ARMY MEDICAL, LIBRARY WASHINGTON Founded 1836 IN1TK1 Section. kSKJSM Number sT2^ Fobm lt3c, W. D.. 8. G. O. (Revised June 13, 1936) yyr/ rr; i'9 THE PATHOLOGY AND TREATMENT VENEREAL DISEASES INCLUDING THE RESULTS OF REGENT INVESTIGATIONS UPON THE SUBJECT. BY FREEMAN J. BUMSTEAD, M. D., r» LECTURER ON VENEREAL DISEASES AT THE COLLEGE OF PHVSICIAXS AND SURGEONS, NEW YORK ; SURGEON TO ST. LUKE'S HOSPITAL ; ASSISTANT SURGEON TO THE NEW YORK EYE INFIRMARY. WITH ILLUSTRATIONS ON WOOD. PHILADELPHIA: BLAN CHARD AND LEA. 1861. )8t>l Entered according to the Act of Congress, in the year 1861, by BLANCHARD AND LEA, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania. PHILADELPHIA : COLLINS, PRINTER. PREFACE. The object in the preparation of this work has been to furnish ili3 student with a full and comprehensive treatise upon Yenereal Diseases, and the practitioner with a plain and practical guide to their treatment. In carrying out this design, theoretical discus- sions have been made subordinate to practical details; and, in the belief that the success of treatment depends quite as much upon the manner of its execution as upon the general principles upon which it is based, no minutiae, calculated to assist the surgeon or benefit the patient, have been regarded as unworthy of notice. The additions to our knowledge of Venereal, during the last ten years, have been numerous, and in the highest degree important. Among the most remarkable, may be mentioned the distinct nature of the two species of chancre; the innocuousness of the secretion of the infecting chancre when applied to the person bear- ing it, or to any individual affected with the syphilitic diathesis; the removal of certain obstacles to a general belief in the conta- giousness of secondary lesions; the fact that syphilis pursues the same course whether derived from a primary or secondary symp- tom, commencing, in either case, with a chancre at the point where the virus enters the system; the definite period of incubation of the true chancre, and of general manifestations; the inefficacy of the * abortive treatment of syphilis; and the phenomena of syphilization and their correct interpretation. Several of these topics are entirely new within the period mentioned, and upon others much clearer views have been obtained; so that our present knowledge of Yene- IV PREFACE. real Diseases may be regarded as far more complete and satisfactory than at any previous time. As yet, however, these results and the investigations which have led to them are, for the most part, scat- tered through the pages of medical periodical literature, in our own and foreign languages. To collect them into one volume, and thus render them more accessible to the American reader, has also entered into the purpose of the author. 162 West 23d Street, New York. July, 1861. CONTENTS. Introduction PART I. GONORRHOEA AND ITS COMPLICATIONS. PAGE 17 CHAPTER I. Urethral Gonorrhcea in the Male . Preliminary considerations Symptoms Causes and nature of gonorrhoea Treatment Abortive treatment Treatment of the acute stage Treatment of the stage of decline Copaiba and cubebs Obstacles to success Treatment of special symptoms CHAPTER II. Gleet Symptoms Pathology Treatment Bougies Injections Deep urethral injections Blisters Separation of the affected surfaces CHAPTER III. Balanitis Causes . Symptoms Treatment 39 39 41 46 55 56 60 64 72 78 80 83 84 85 87 90 92 95 96 97 99 99 100 100 VI CONTENTS. CHAPTER IY. Phymosis Symptoms Treatment Circumcision PAGE 103 104 105 107 Paraphymosis CHAPTER Y, 111 CHAPTER VI. Swelled Testicle Causes . Seat Symptoms Pathological anatomy Treatment CHAPTER VII Inflammation of the Prostate Acute prostatitis Treatment . Chronic prostatitis Treatment . 114 115 117 120 128 130 137 137 139 140 142 CHAPTER VIII Inflammation of the Bladder Treatment 146 147 CHAPTER IX. Gonorrhoea in Women Causes . Symptoms Gonorrhoea of the vulva Gonorrhoea of the vagina Gonorrhoea of the urethra Complications Diagnosis Treatment CHAPTER X. GONORRHCEAL OPHTHALMIA Frequency Causes . Symptoms Diagnosis Treatment 149 149 152 153 157 160 161 163 164 175 177 177 180 183 183 CONTENTS. Vll CHAPTER XI. Gonorrheal Rheumatism Causes . Seat Symptoms Diagnosis Nature . Treatment PAGE 193 195 197 199 211 213 215 Vegetations Treatment CHAPTER XII, 218 220 CHAPTER XIII. Stricture of the Urethra . 222 Anatomical considerations 222 Transitory strictures 240 Permanent or organic strictures 243 Seat . 246 Number . 250 Form . . . 250 Degree of contraction 252 Pathology of stricture . 254 Abscess and fistula , 250 Lesions of the bladder 258 Lesions of the ureters and kidneys 259 Lesions of the genital organs 259 Constitutional effects of stricture 260 Symptoms of stricture . 261 Causes of stricture 266 Diagnosis of stricture 271 Exploration of the urethra 272 Introduction of the catheter 276 Model bougies 278 Treatment 280 Constitutional means 280 Dilatation . 282 Continuous dilatation 287 Rapid dilatation 288 Expansion 290 Rupture 291 Caustics 291 Incisions 295 Internal division 296 Perineal section 299 Consequences of operations upon strict ure 310 Vlll CONTENTS. Treatment of retention of urine Puncture by the rectum Opening of the urethra Puncture above the pubes Puncture through the symphysis Treatment of extravasation of urine Treatment of urinary abscess and fistula PAGE 312 318 321 322 322 323 324 PART II. THE CHANCROID, ITS COMPLICATIONS; AND SYPHILIS. CHAPTER I. Introductory Remarks ....... 327 Syphilitic virus ....... 327 Is there more than one kind of syphilitic virus ? . . 328 Constitutional syphilis very rarely occurs more than once in the same person ........ 348 Classification of the symptoms of syphilis .... 353 CHAPTER II. Chancres ..... 355 Seat of chancres 355 Contagion .... 35S Form of chancres 361 Artificial inoculation 363 Classification of chancres 366 Simple chancre 367 Infecting chancre 369 Mixed chancre .... 382 Inflammatory or gangrenous chancre . 386 Phagedenic chancre 387 Diagnosis of chancres . 390 Treatment of chancres . 394 General treatment . 395 Abortive and destructive treatment 404 Topical applications 417 Special indications from the seat of chancres 421 Chancres of the franum 421 Urethral chancres . 422 Chancres of the vagina and os uteri 424 Chancres of the anus and rectum . 424 Chancres of the mouth 425 CONTENTS. ix CHAPTER III Affections of the Lymphatic Vessels and Ganglia atten mary Sores Simple bubo Virulent bubo . Indurated bubo " Bubon d'emblee" Treatment of buboes General treatment . Counter-irritants Compression Methods of opening buboes Treatment of difficult cases Treatment of indurated buboes dant upon Pri CHAPTER IV. General Syphilis.—Introductory Remarks General syphilis always follows a chancre Period of incubation of general syphilis Classification of general symptoms Some of the symptoms of general syphilis are contagious What constitutional symptoms are contagious ? . Syphilis pursues essentially the same course, whether derived from a primary or secondary symptom; in the latter case, as in the former, the initial lesion is a chancre .... CHAPTER V. Treatment of Syphilis Hygiene Mercurials Fumigation Inunction . Salivation . Duration of treatment Iodine and its compounds Syphilization Is syphilization an efficient and safe method of treating tional syphilis ? . How are the facts of syphilization to be explained ? constitu CHAPTER VI. Syphilitic Fever; State of the Blood; Engorgement of the Lymphatic Ganglia ......•■ Syphilitic fever . State of the blood .....«■ Engorgement of the cervical ganglia . 546 546 547 548 X CONTENTS. CHAPTER VII. * PAGE Syphilitic Affections of the Skin . . . . . .551 Syphilitic erythema 555 Syphilitic papules , p 557 Syphilitic squamae, . . 559 Syphilitic vesicles . 560 Syphilitic bulla? 561 Pemphigus . 561 Rupia 562 Syphilitic pustules 564 Acne . . 564 Impetigo 565 Ecthyma 566 Syphilitic tubercles 568 Ulcers 572 Treatment 572 CHAPTER VIII. Syphilitic Affections of the Appendages of the Skin Alopecia ..... Onychia ..... Paronychia, ..... 575 575 577 578 Mucous Patches Treatment CHAPTER IX. 579 585 Gummy Tumors CHAPTER X. *• CHAPTER XI. 586 Syphilitic Affections of Mucous Membranes ' 590 Erythema . . . ' . 591 Ulcers . . .... 591 Tubercles of the tongue . . . 594 Treatment of the affections of the mouth and throat 596 Stricture of the oesophagus 598 Affections of the stomach and intestines 599 Stricture of the rectum 601 Affections of the nasal passages 603 Affections of the larynx and trachea 605 Aphonia ..... 605 Laryngitis . . 606 Ulceration of tlie trachea . 608 CONTENTS. XI CHAPTER XII. Syphilitic Affections of the Eyes . Affections of the bones of the orbit Affections of the lachrymal passages Affections of the eyelids Affections of the conjunctiva Affections of the cornea Iritis Infantile iritis Retinitis and choroiditis Amaurosis Paralysis of the motor nerves PAGE 611 611 612 614 615 615 617 625 629 631 631 CHAPTER XIII. Syphilitic Affections of the Ear 633 Syphilitic Orchitis Diagnosis Treatment CHAPTER XIV. CHAPTER XV. Syphilitic Affections of the Muscles and Tendons Muscular pains .... Muscular contraction Muscular tumors 635 638 639 642 642 642 644 CHAPTER XVI. Syphilitic Affections of the Nervous System 647 CHAPTER XVII. Syphilitic Affections of the Periosteum and Bones Osteocopic pains .... Nodes ...... Caries and necrosis .... 652 653 654 657 CHAPTER XVIII. Congenital Syphilis .... 660 Etiology ..... 660 Transmissibility .... 663 Abortion ..... 664 Period of development .... 665 Xll CONTENTS. Symptoms ...••• General aspect of syphilitic infants Coryza . Affections of the skin and mucous membranes . Onychia . Suppuration of the thymus gland Changes in the lungs . Changes in the liver . Peritonitis ..•••• Affections of the periosteum and bones Hydrocephalus . Affections of the supra-renal capsules and pancreas Prognosis . Treatment . page 670 670 670 671 672 672 673 674 676 676 677 677 677 678 ON VENEREAL DISEASES. INTRODUCTION. There are three diseases, which, from their origin in sexual intercourse, have been denominated Venereal, viz: Gonorrheu>, to flow; a name which is still in use among American and English writers, notwithstanding the incorrectness of the supposition in which it originated.1 The French call the same affection " blennorrhagie," or a flow of mucus, a name which is also erroneous, since the discharge does not consist of mucus alone, but of a mixture of mucus and pus. In popular language it is termed "clap" by the English, and "chaude-pisse" by the French. The chief mucous membranes subject to gonorrhoea are those lining the genital organs in the two sexes, and the conjunctiva oculi. Gonorrhoea of the anus, mouth, nose, and external ear are, indeed, mentioned by authors, but the existence of all of them is more or less doubtful. Perhaps there is the least question in ad- ■ CocKnr/RNE (The Symptoms, Nature, Cause, and Cure of Gonorrhoea, London, 1715) first established the fact that gonorrhoea is not a flow of semen. 40 URETHRAL GONORRHOEA IN THE MALE. mitting gonorrhoea of the anus and rectum, though it is said to be rare even in countries where unnatural practices are frequent; but we can hardly admit under this head those cases in which the anus is simply excoriated by a discharge flowing from the urethra or vulva, without extension of the disease to the rectum. Reported cases of gonorrhoea of the mouth, nose, and external ear are very few in number, and are all of them open to serious question; as, for instance, the supposed case of gonorrhoea of the nose, reported by Mr. Edwards,1 in which it is very doubtful whether the disease was of this origin and not a simple catarrhal affection. M. Diday relates some experiments which will serve to elucidate this point, though we are surprised, in reading them, that any surgeon should presume to make them, or any patient submit to them. M. Diday says: " Frequently (eight or ten times at least), for the purpose of experiment, I have moistened the end of my finger in the urethral discharge of patients with gonorrhoea, when the disease was in its most acute stage, applied it within the nostrils and rubbed it into the nasal mucous membrane, and there has never resulted the slightest degree of inflammation in the part."2 But when we recollect how frequently a disregard of cleanliness must cause the application of gonorrhoeal matter to the nostrils and lips, and how readily such applications excite inflammation of the ocular conjunctiva, the great rarity of suspected cases of nasal and buccal gonorrhoea must convince us, without the necessity of such experiments as those above mentioned, that certain mucous mem- branes are more apt to contract gonorrhoea than others; and in this we may find an analogy to an extraordinary fact which has recently excited much attention, viz., that all parts of the body are not equally susceptible of the two varieties of chancre; the chancroid never being met with upon the head or face, although it may be implanted there by artificial inoculation. The reason of the preference of these diseases for certain localities escapes us, but they are not the only instances of the kind met with. The symptoms and the treatment of gonorrhoea vary according as the disease affects the male or female, and according also to the portion of mucous membrane attacked; it will be convenient, therefore, to consider this affection under corresponding heads. 1 London Lancet, Am. ed., June, 1857. 2 Annuaire de la syphilis, annee 1858. SYMPTOMS. 41 URETHRAL GONORRHOEA IN THE MALE. Men are more liable to contract gonorrhoea than women; and of a given number of cases of this disease in the former, in a large proportion it is the urethra which is affected. Cases of urethral discharge in the male outnumber all other forms of gonorrhoea in the two sexes combined. The explanation of this fact will appear when we come to consider the causes and nature of gonorrhoea. Symptoms.—The symptoms of urethral gonorrhoea in the male first appear, as a general rule, between the second and fifth day after exposure; though, in exceptional cases, as late as the seventh, tenth, or fourteenth day; but their occurrence after this time, as alleged by some authors, is, I believe, to be explained on the ground that the earliest manifestations of the disease have been overlooked. At first, the symptoms are very slight, consisting only of an uneasy or tickling sensation at the mouth of the canal, which, on examination, is found more florid than natural, and moistened with a small quantity of colorless and viscid fluid, which glues the lips of the meatus together. This moisture of the canal gradually increases in amount, until on pressure a drop may be made to appear at the orifice. At the same time it begins to lose its clear, watery appearance, and assumes a milky hue. Examined under the microscope, it is found to consist of mucus with the addition of pus-globules; the number of the latter being proportioned to the depth of color of the discharge. Meanwhile, some smarting is felt by the patient in the anterior portion of the canal during the passage of the urine. Such are the symptoms of the early stage of gonorrhoea. The exciting cause of the disease has been applied to that portion of the canal which lies near the orifice of the meatus and which was chiefly exposed to contagion, and the ensuing inflammation is gradually lighted up in this part, and has not yet extended beyond that portion of the urethra known as the fossa navicularis. This early stage of gonorrhoea is often called "the stage of incubation," a name which is objectionable because the inflammatory process is doubtless set up at the time of the application of the exciting cause. Time is required for it to produce its full effect, and the earliest symptoms are but slowly and gradually ushered in. A more 42 URETHRAL GONORRHOEA IN THE MALE. appropriate name is the first or preparatory stage. It is important to recollect the symptoms of this stage and the fact that the disease is as yet confined to the external portion of the urethra, since, as we shall see hereafter, a more rapid method of cure may now be resorted to than is admissible in the subsequent stages. The first stage of gonorrhoea usually lasts from two to four days. The symptoms gradually increase in intensity, until, in about a week after exposure, the second or inflammatory stage may be said to commence. If we examine the penis during this stage, we find the mucous membrane covering the glans, reddened and with an angry look. The whole extremity of the organ is swollen so that the prepuce fits more tightly than natural. In some cases the latter is puffed out by oedema in its cellular tissue, and phymosis may exist, rendering it impossible to uncover the glans. The inflammatory blush is especially marked in the neighborhood of the meatus, the lips of which are swollen so as to contract the calibre of the orifice. The discharge has now become copious, so much so in some instances as to drop from the meatus as the patient stands before you. It is thick, of a yellowish cream color, and not unfrequently tinged with green. This greenish hue, as in the sputa of pneumonia, is due to the admixture of blood-corpuscles, which may be sufficiently numerous to produce the characteristic color of blood. The penis generally, and especially upon the under surface over the course of the canal, is sensitive and tender on pressure. While passing his urine, the patient complains of intense pain, which is now not confined to the anterior part of the canal, but is felt in all that portion of the organ anterior to the scrotum, or is even more deeply seated. The severity of the suffering during the act is in some instances very great. The pain is compared to the sensation of a hot iron introduced within the canal, and the popular name, chaude-pisse, given to the disease by the French, is fully justified. This pain is excited in part by the irritation produced up«n an abnormally sensitive membrane by the salts contained in the urine, but chiefly, I am inclined to think, by the distension of the contracted and sensitive canal by the passage of the stream. Hence, during the act, the patient involuntarily relaxes the abdomi- nal walls, forces the air from his lungs, and keeps the diaphragm elevated, in order to diminish the pressure upon the bladder and lessen the size and force of the stream of urine. In consequence SYMPTOMS. 43 also of the urethra being contracted and more or less obstructed by the discharge, the stream is forked or otherwise irregular. Another source of suffering in this stage of gonorrhoea is the nocturnal erections, which are apt to come on after the patient is warm in bed. The' genital organs are in a highly sensitive con- dition, and are readily excited by lascivious dreams, the contact of the bedclothes, or a distended bladder; or, independently of such exciting cause, they assume a state of erection which even in health is more apt to occur during sleep. When thus excited, it will often be found that the penis is bent in the form of an arc with its concavity downward. This condition is known as chordee. Its explanation is very simple. The urethra, the chief seat of the inflammation, runs along the under surface of the penis. Plastic lymph is effused around this canal, gluing the tissues together and rendering this portion of the penis less extensible than the remain- ing portion composed of the corpora cavernosa. Hence, in a state of erection, the corpus spongiosum surrounding the urethra, not being able to yield to the distension, acts like the string of a bow, and chordee is produced. The stretching of the parts thus ad- hering together excites pain, which is often very severe. The sufferer, awaking from sleep, instinctively grasps the penis in his hand, and bends it in a still smaller curve, so as to remove the strain from the under surface and thus ease the pain. It not unfre- quently happens that during one of these attacks of chordee, the mucous membrane of the urethra becomes lacerated, and hemor- rhage takes place from the canal. In this way nature may produce local depletion, and, if the flow be not excessive, the effect is often beneficial. The above explanation of the mechanism of chordee is the one usually received, though it is proper to state that it is rejected by Mr. Milton, who believes that chordee is due to spasm of the mus- cular fibres, which Mr. Kolliker and Mr. Hancock have shown to exist around the whole course of the urethra.' I am not convinced that the generally received opinion should thus be laid aside, though it is highly probable that spasmodic muscular action plays some part in the production of the frequent erections and chordee which take place in gonorrhoea. During the inflammatory stage of gonorrhoea abscesses sometimes 1 Miltox on Gonorrhoea, p. 75. 44 URETHRAL GONORRHOEA IN THE MALE. form in the cellular tissue covering the urethra, either anteriorly to the scrotum, or in the perineum; and may attain a very con- siderable size. If left to themselves, they are liable to break internally within the canal and give rise to urinary abscess and fistula. It is also chiefly during the second stage of gonorrhoea that buboes are met with, if they occur at all; for they are rare compared with the number of patients afflicted with this disease. They are at once recognized by the physician and patient by the enlargement and tenderness of one or more glands in the groin, occasioning consider- able pain and uneasiness in walking and standing. Buboes attend- ant upon gonorrhoea, uncomplicated with chancre, are sympathetic buboes; of which a fuller description will be given hereafter, when speaking of buboes in general. They may generally be made to disappear in a few days by keeping the patient quiet and producing a little counter-irritation by painting the skin over them daily with tincture of iodine. It is only in scrofulous subjects, or in conse- quence of violence, excessive fatigue or general depressing influ- ences, that they ever exhibit a tendency to suppurate. I have known of one instance of a man suffering from gonorrhoea, who after exposure to great hardship upon a wreck, had a suppurating bubo that confined him to his bed for six months. Inflammation of the lymphatic vessels running along the dorsum of the penis is still another complication of the acute stage of gonor- rhoea, and one which is also met with in connection with simple chancres. It is to be carefully distinguished, as we shall see here- after, from the induration of these vessels which often attends an indurated chancre. " It occupies the same vessels and the same situation, and presents the same forms as the latter; but is distin- guished from it in several ways: 1. By its feel, which is like that of an hypertrophied cord, elastic but not cartilaginous. 2. By the fact that the cellular tissue uniting the vessels generally participates in the inflammation, and thus binds together in a large cord the dorsal vein, the lymphatics and the artery, rendering it difficult to distinguish the inflamed lymphatics from the bloodvessels. 3. By the pain, generally severe, which it excites, and by the swelling and redness visible over the course of the inflamed vessels, caused by the extension of the inflammation to the skin."1 This inflammation 1 Bassereau : " Affections de la peau symptomatiques de la syphilis," p. 160. SYMPTOMS. 45 of the lymphatics on the dorsum of the penis sometimes gives rise to chordee, with the concavity of the arc looking upward. The second stage of gonorrhoea, which we have now described, is variable in its duration in different subjects. As a general rule, it lasts from one to three weeks, being influenced by the constitution of the individual, his mode of life and the number of his previous attacks. It is succeeded by the third stage or stage of decline. This final stage of acute gonorrhoea is marked by no peculiar symp- toms, and is characterized only by the disappearance of the more acute symptoms and a gradual return to a condition of health. The discharge runs through the same phases, in an inverse order, which it did at the outset of the attack. It gradually becomes less and less purulent, and finally is almost wholly mucous, before completely disappearing. Perhaps the most valuable indication of the ushering in of this stage of gonorrhoea is the marked diminution or entire cessation of the pain in passing water. The painful erections and chordee may continue after the acute inflammation has subsided, since it takes time for the plastic matter effused around the urethra to be ab- sorbed. We have reason to believe that in the course of an attack of gonorrhoea, the disease gradually extends from the outer to the deeper portions of the canal, and it is in this latter situation that it is prone to lurk for an indefinite period. After the discharge has lasted for several weeks, we may evacuate the whole of the spongy portion by pressure from behind forward in front of the scrotum, and thjen, when no further discharge can be made to appear, we can still produce it by the exercise of similar pressure on the perineum. In some instances, the inflammation extends to the mucous mem- brane of the bladder. The duration of the final stage of gonorrhoea is, as a general rule, longer than either of the preceding. It may be cut short by treat- ment, but, if left to itself, commonly lasts for weeks or even months. Gonorrhoea is a disease which, independently of treatment, rarely terminates in less than three months. Thus far I have said nothing of the reaction of this disease upon the general system. This varies greatly in different individuals and in different attacks in the same person. In some rare cases there is considerable febrile excitement during the inflammatory stage, marked by the usual symptoms of headache, dry skin, full pulse, 46 URETHRAL GONORRHOEA IN THE MALE. furred tongue, etc. As a general rule, however, there is but little constitutional disturbance, and after the acute symptoms have passed, the invariable tendency of the disease is to depress the general health. This fact should be remembered in the treatment. A first attack of gonorrhoea is usually more acute than subsequent ones; the latter often being subacute or chronic from the first. They are also more difficult to be influenced by remedies, and show a decided tendency to run into gleet. Cases of gonorrhoea have been reported, in which it has been said there was no discharge whatever—all the other symptoms of gonor- rhoea being present, and the disease following impure coitus. These have been called cases of dry gonorrhoea. I doubt whether there be a total absence of all secretion in these cases throughout their whole course, but can readily conceive of an inflammation of the mucous membrane of the urethra, resembling that of erysipelas upon the skin, in which the secretion is for a time but slight, and incapa- ble of detection except by a careful examination of the urine. As. the inflammation subsides, however, I should expect to find distinct traces of a discharge. We have analogous symptoms occasionally in inflammations of the pituitary membrane of the nose. Two cases of this variety of gonorrhoea are reported by Dr. Beadle in the New York Journal of Medicine and Surgery, for October, 1840. Causes and Nature of Gonorrhoea.—Every one is aware that urethral gonorrhoea in the male often proceeds from direct conta- gion, or, in other words, from intercourse with a woman affected with the same disease. But there is another mode of origin, ad- mitted by nearly every writer, as of at least occasional occurrence, but with regard to the frequency of which some difference of opinion has been expressed. I refer to gonorrhoea originating in coitus just before, after, or during the menstrual period, or with a woman suffering from leucorrhoea, and, in a few instances, when nothing whatever abnormal can be discovered in the female genital organs, and the disease in the male can only be attributed to the irritant character of the vaginal or uterine secretions. I have been convinced, by a somewhat extended observation, that gonorrhoea originating in this mode is of very frequent occur- rence. Of one thing I am absolutely certain, that gonorrhoea in the male may proceed from intercourse with a woman with whom coitus has for months, or even years, been practised with safety, causes and nature of gonorrhoea. 47 and this, too, without any change in the condition of her genital organs, perceptible upon the most minute examination with the speculum. I am constantly meeting with cases in which one or more men have cohabited with impunity with a woman both before and after the time when she has occasioned gonorrhoea in another person; or, less frequently, in which the same man, after visiting a woman for a long period with safety, is attacked with gonorrhoea without any disease appearing in her, and after recovery resumes his intercourse with her and experiences no farther trouble. The frequency of such cases leaves no doubt in my mind, that gonor- rhoea is often due to accidental causes, and not to direct contagion. In many of the instances referred to, the woman is suffering from a frequent combination of symptoms met with in practice, viz., general debility, engorgement of the cervix uteri, and more or less leucorrhoea; but her previous history, and the impunity with which her favors have been bestowed for a long period, preclude the idea that her discharge is the remains of a previous attack of gonorrhoea to which it owes its contagious property. Moreover, such an ex- planation fails to cover other instances, in which there is no appear- ance whatever of leucorrhoea, and the genital organs, so far as we can discover, are in a state of perfect health; although intercourse about the time of the menstrual period has given rise to gonorrhoea in the male. An attempt is sometimes made to evade the issue of this ques- tion, by asserting that in the cases referred to, the disease has been contracted from another source than the one alleged, and the pro- verbial mendacity of venereal patients is appealed to in support of this assumption. Argument is of course useless with any one assuming this ground; but to a candid mind, the opinion of such men as Ricord, Diday, and others, who fully sustain the position above assumed, and who are certainly not ignorant of the sources of error surrounding the etiology of venereal diseases, is sufficient to carry great weight, and lead to an impartial investigation of facts which can be followed but by one conclusion. For my own part, I desire to state that while pursuing the investigation which has led me to believe in the frequency of gonorrhoea, independent of con- tagion, I have not entertained a single case in which the moral grounds of certainty have not been irresistible; and that a number of my patients have been medical men, and intimate acquaintances, whose sins against morality were fully known to me, who could 48 URETHRAL GONORRHOEA IN THE MALE. therefore have had no motive for concealment, and with whom mis- take or deceit has been either in the highest degree improbable, or, in repeated instances, impossible. Moreover, it is a mistake to sup- pose that in investigations of this nature we are entirely at the mercy of the patient's honor and truthfulness, since to one practis- ing in a large city there are a thousand sources of circumstantial evidence and remarkable coincidences in the testimony of persons wholly unknown to each other, which in many cases preclude all possibility of error. The greatest obstacle to the admission of gonorrhoea independent of contagion appears to be the rarity of urethritis in married men compared with the frequency of leucorrhceal discharges in their wives. As proved by unquestionable cases occurring in my own practice and in that of my medical friends, husbands do not always escape. That they are not more frequently affected is sufficiently explained by the immunity conferred against all simple irritants by constant and repeated exposure, whereby " acclimation"—to use a term adopted by the French—is acquired. The same fact is observed when neither the church nor the state has sanctioned marital relations; since it is not generally the habitual attendant upon a kept mistress affected with leucorrhoea who suffers, but some fresh comer who shares her favors for the first time. Most cases of gonorrhoea from leucorrhoea or the menstrual fluid present no characteristic symptoms by which they can be distin- guished from those originating in contagion. The contrary is frequently asserted, and it is said that the former class may be recognized by the mildness of the symptoms, the short duration of the disease, and the absence of contagious properties. I am familiar with the slight urethral discharge unattended by symptoms of acute inflammation, and disappearing spontaneously in a few days, which sometimes follows intercourse with Women affected with leucorrhoea; but such instances are far less frequent than thosflAki which the disease is equally as persistent and as exposed to com^ications as any case of gonorrhoea from contagion. Some of the most obstinate cases of urethritis I have ever met with have been of leucorrhceal origin, and have terminated in gleet of many months' duration. Those who maintain.the non-contagious characl^ of urethral discharges of leucorrhoeal origin have failed to adduof the slightest proof in favor of their assumption, and it may safely-Jbe asserted that none of them would venture to make a practical application CAUSES AND NATURE OF GONORRHOEA. 49 of their principles. The contagious character of the leucorrhceal secretion is already proved by the existence of the disease in the male; why should not the same property be continued another, still another, and any number of removes from its origin ? This supposition is sustained by analogy, since no fact is better established than that catarrhal conjunctivitis may be communicated from one person to another until all the members of a family, school, or asylum have become affected. At our public institutions for diseases of the eye such instances are very common and the phy- sicians of our children's asylums are well aware of the difficulty of eradicating muco-purulent conjunctivitis which has once sprung up among the inmates. At an orphan asylum, under the charge of my friend, Dr. Learning, this disease was introduced by a single child, brought from Randall's Island, and spread to twenty-two others before it could be arrested. Again, the leucorrhoea of pregnancy is sufficient to give rise to ophthalmia neonatorum: would any one, presuming upon its leucorrhceal origin, dare to apply a drop from the infant's eyes to his own ? Several instances are recorded in which physicians have lost the sight of an eye with which the discharge of ophthalmia neonatorum has inadvert- ently been brought in contact. The views which I have here advocated relative to the frequency of gonorrhoea independent of contagion, are by no means novel, and are entertained by many of our most eminent authorities, especially among the French, who possess unequalled advantages for investigating the etiology of venereal diseases. The importance of the subject will fully justify me in making the following quota- tions from other authors. Ricord says: " If we investigate with the greatest care the exciting causes of gonorrhoea—and I am now speaking of the most charac- teristic cases of the disease — we cannot help admitting that a gonorrhoeal virus is absent in the majority of cases. Nothing is more common than to find women, who have occasioned gonorrhoea unsurpassed in intensity and persistency, and attended by the most serious complications, and who are yet only affected with uterine catarrh which is sometimes hardly purulent. In many cases, inter- course during .the menstrual period appears to be the only cause of the disease; while, in a large number, we can discover nothing, unless perhaps errors in diet, fatigue, excessive sexual congress, 4 50 URETHRAL GONORRHOEA IN THE MALE. the use of certain drinks, as beer, or of certain articles of food, as asparagus. Hence the frequent belief of patients, which is very often correct, that they have contracted their gonorrhoea from a perfectly sound woman. "" I am most assuredly familiar with all the sources of error in such investigations, and I will presume to say that no one is more guarded than I am against the various forms of deceit which are strown in the path of the observer; yet I confidently maintain the following proposition: Gonorrhoea often arises from intercourse with women who themselves have not the disease. Any one who studies gonorrhoea without preconceived notions, is forced to admit that it often originates from the same causes that give rise to inflammation of other mucous membranes."1 The "preconceived notions" that Ricord here speaks of, have been the greatest obstacle to the admission of the truth in ques- tion. To a surgeon making up his mind beforehand that every patient utters a falsehood who says that he has contracted his gonorrhoea from a woman in whom no evidences of disease can be found, any amount of proof is valueless. Diday, in speaking of the prophylaxis of venereal diseases, says : " A man should never forget that gonorrhoea may be contracted from any woman; and I say any woman, and not any prostitute, for I do not except from this uncivil remark, any member of the gen- tler sex. No matter how great her cleanliness, her apparent health, her supposed or real virtue, or even her virginity, or how recently she has been examined, a woman may, from some cause or other, have the whites—often of a very innocent character, as from metritis, chlorosis, dysmenorrhcea, catarrhal inflammation, or as a result of confinement, and also, on the other hand, from a gonorrhoea which she has contracted; and from the very fact that she has a discharge—no matter what its origin—she is liable to give a discharge to a man."z Fournier arrives at the same result from an investigation rela- tive to the classes of women from whom gonorrhoea is derived. It appears from his statistics that gonorrhoea was contracted from in- tercourse with 1 Lettres sur la Syphilis, 2d ed., p. 29. 1 Nouvelles Doctrines sur la Syphilis, p. 515. The Italics are in the original. CAUSES AND NATURE OF GONORRHOEA. 51 Women of the town Clandestine prostitutes Kept women, actresses, etc Working girls Domestics Married women Total 387 Fournier adds: " This result is easily explained, and might even have been predicted. In fact, gonorrhoea is, I think, much less frequently contracted from contagion than from excessive coitus, repeated or prolonged sexual congress, or peculiar excitement dur- ing the act; and in most cases of intercourse with public women, all these causes are absent, and intercourse is generally very short, without much excitement, and not frequently repeated.'" Again, Mr. Henry Thompson says: " It is a fact too well estab- lished to render it necessary to adduce evidence respecting it here, that urethritis in the male is sometimes caused by contact with the other sex, from discharges which are not venereal in their origin."2 Finally, from many other writers whose testimony is equally strong in favor of the leucorrhceal and menstrual origin of gonor- rhoea in many cases, I will quote the remarks of Mr. Skey:— " I cannot entertain a doubt that a very considerable proportion of cases of gonorrhoea are not the product of a specific poison. The opinions I entertain on this subject are not the product of mere speculation, and still less of a desire to differ with other and more experienced authorities. They are deduced from, what appeared to my judgment, positive facts, and those by no means few or far between. I may venture to say it is notorious that leucorrhoea will produce gonorrhoeal discharge; and if a poison be essential to gonorrhoea, whence comes it? Leucorrhoea is not supposed to contain the elements of gonorrhoeal poison. Again, gonorrhoea is by no means an infrequent result from intercourse about the period of menstruation; and it also follows intercourse with women under circumstances of mechanical violence."3 The importance of the truth laid before the reader in the above remarks and quotations, whenever a physician in the exercise of his 1 De la Contagion Syphilitique, p. 118. 2 Stricture of the Urethra, p. 120. s Lectures on the Venereal Disease, London Medical Gazette, vol. xxiii. (1838-9) p. 439. Cases. 12 44 138 126 41 26 52 URETHRAL GONORRHOEA IN THE MALE. profession incurs the fearful responsibility of passing judgment upon the virtue of a woman, and thus affecting her reputation and happiness (and often that of many others with whom she is con- nected) for life, cannot be overrated. In all such cases, the accused should receive the benefit of any doubt which may exist; and the physician who withholds it from her out of a morbid fear that he may be imposed upon,1 and thus runs the risk of convicting an in- nocent person, is unworthy of his calling. His province is to decide from the symptoms taken in connection with the known facts of the case, and unless these are sufficient to establish guilt beyond the shadow of a doubt, humanity demands at least a verdict of "not proven." The following cases will illustrate this point:— Case 1. A gentleman of the city, six weeks after marriage, applied to his physician to be treated for gonorrhoea, which he solemnly declared he had contracted from his wife, and his known probity was such as to render his statement in the highest degree probable. Under the supposition that his disease could only have arisen from contagion, he had already ac- cused his wife of unchastity, her friends had been informed of the charge, and a separation and action for divorce were imminent. His physician examined the wife, whom he found perfectly healthy, and ascertained, on farther inquiry, that the disease in the husband was due to the continu- ance of coitus during a menstrual period. Case 2. The following case is reported in a work entitled " Sur la non- existence de la maladie venerienne," which was published in Paris in 1826:— A young man became attached to a young female friend, " a peine sortie de l'enfance," and married her after some years of mutual attachment. Some months after this " hymen fortune! " the young man was compelled to take a journey to some distance, and, while travelling, he experienced pain in making water, and shortly perceived a discharge from the urethra. On arriving at a town, he consulted an eminent surgeon, who assured him he had a gonorrhoea. " Mais, monsieur, je suis nouvellement mariey and he assured the learned surgeon, that he had never known any woman but his wife from the hour of his birth. "Comment," repond le chirurgien, en souriant, " vous voudrez me cacher la cause de votre mal: de quel pays etes-vous ? Vos jennes gens rougiroient; je vous certifie, monsieur, que vous avez une belle et bonne chaude-pisse." The youth continued to 1 In a discussion upon the origin of gonorrhoea independent of contagion, which I once held with the writer of a work on venereal, the final argument of my op- ponent was, "I do not like to feel that I am imposed upon by patients." CAUSES AND NATURE OF GONORRHOEA. 53 protest his innocence. Some days after the testicle swelled. The sur- geon now assured him that if his wife were virtuous, he must have had " une affaire" with other women, and that the pox remained in his blood from that period. Between the two alternatives of his own or his wife's purity, of course he could not entertain a doubt. He wrote to her an in- dignant and passionate letter, and then blew out his brains. The un- fortunate woman submitted to an examination, which proved her free from disease, never uttered another word—shortly miscarried, and died. So much for the honor of our noble profession I * Case 3. A few years since, in one of the New England States, a clergy- man came very near being deposed from the ministry, and convicted of adultery, on the testimony of his physician, that a urethral discharge for which he had treated him could only have arisen from impure inter- course 1 Other causes, in addition to those already mentioned, may give rise to urethral gonorrhoea in the male. Thus, unquestionable in- stances are reported in which a gouty or rheumatic diathesis with- out exposure in sexual intercourse has occasioned a discharge from the urethra. Ricord relates a remarkable case of tubercular deposit in dif- ferent portions of the urethra of a strumous subject with sympto- matic urethral discharge;2 and a scrofulous diathesis is generally a strong predisposing, if not an active cause of inflammation of the urethra as well as other mucous canals. Mr. Harrison reports the case of a medical practitioner who suffered from a puriform discharge, heat and pain along the course of the urethra, attended with frequent micturition, chordee, and sympathetic fever, after eating largely of asparagus.3 Among other causes of urethritis are free indulgence in fermented liquors, terebinthinate medicines, paraplegia inducing changes in the urine, the use of bougies, stricture, masturbation, prolonged excitement of the genitals, vegetations within the urethra, ascarides in the rectum, dentition, epidemic influences, etc. M. Latour, editor of the Union Medicale, vouches for the truth of the following history: A physician, thirty years of age, had been continent for more than six weeks, when he passed an entire day in the presence of a woman whose virtue he vainly attempted to 1 Quoted by Mr. Skey, loc. cit. 1 Bulletin de l'Acad. de Med., vol. xv. p. 565. 3 London Lancet, Am. ed., Jan., 1860. 54 URETHRAL GONORRHOEA IN THE MALE. overcome, and who resisted all his approaches. From ten o'clock in the morning until seven in the evening, his genital organs were in a constant state of excitement. Three days afterwards he was seized with a very severe attack of gonorrhoea, which lasted for forty days. A chancre within the urethra is attended with more or less thin and often bloody discharge, which will be more particularly de- scribed in a subsequent portion of this work under the head of concealed chancre. I will merely remark at present that inoculation of the secretion upon the person affected cannot determine the presence of a primary sore, unless it be a chancroid, since the infecting chancre is not auto-inoculable. Again, urethral discharges are sometimes due to changes in the mucous membrane lining the canal, induced by infection of the constitution with the syphilitic virus. In several instances I have observed a muco-purulent discharge coinciding with the first out- break or a relapse of secondary symptoms, and so long after the last sexual act that it could not be attributed to the ordinary causes of gonorrhoea. Bassereau speaks of similar cases.1 There is no more frequent seat of early constitutional manifestations than the mucous membranes in general; and in the cases referred to changes probably take place in the urethral walls similar to the erythema, mucous patches, and superficial ulcerations which are found within the buccal and nasal cavities. These cases are very rare, and can only be distinguished from ordinary gonorrhoea by the previous history and coexisting symptoms of the patient. For instance, if there has been no exposure for a long period, and especially if secondary symptoms have recently made their appear- ance upon other mucous membranes, the urethral discharge is probably symptomatic of the constitutional diathesis. Since the secretions of secondary lesions are now known to be contagious, the discharge in these cases is doubtless so, also; but it is not susceptible of inoculation upon the person from whom it is derived nor upon any other affected with the syphilitic diathesis, and, if communicated to a healthy individual under the requisite conditions, will give rise to an infecting chancre. The inferences from what has now been said of the etiology of gonorrhoea relative to its nature, are so obvious that they require little more than mere mention. If in a large proportion of cases 1 Affections Syphilitiques de la Peau, p. 356. TREATMENT. 55 the disease can be traced to no other cause than leucorrhoea, the menstrual fluid, or, in less frequent instances, to excessive coitus, intercourse under circumstances of special excitement, inattention to cleanliness, the abuse of stimulants, etc., and if, when thus ori- ginating it is undistinguishable either by its symptoms, course, complications, or termination from the same affection due to con- tagion, it is evident that it should be ranked among the ordinary catarrhal inflammations of mucous membranes, or, in other words, that it is a simple urethritis, the connection. of which with sexual intercourse is a merely accidental, or at all events, not a necessary circumstance. But—it may be asserted—the possibility of contagion proves the presence of a poison. Granted: but it does not follow that it is a specific poison, or one incapable of being produced by simple inflammation. Such a conclusion would be contrary to the facts adduced in the preceding pages, and, moreover, is not required by the analogy of inflammations of other mucous membranes; since, in muco-purulent conjunctivitis—the true analogue of gonorrhoea— we have precisely the same order of events, viz., inflammation originating in simple causes, and giving rise to a secretion which is contagious and capable of transmission through an indefinite series of individuals. The discharge from the two mucous surfaces just mentioned would even appear to be transferable, since that from the urethra applied to the eye gives rise to purulent ophthalmia, the secretion of which, if we may rely upon a few experiments by Thiry, of Brussels, will, when brought in contact with the lining membrane of the urethra, produce urethritis. In the first chapter of the second part of the present work I shall take occasion to institute a comparison between the poisons of gonorrhoea, the soft and the hard chancre. I have no space to discuss the untenable theory of a "granular virus" of gonorrhoea advanced by M. Thiry, according to which, the presence of granulations upon the mucous membrane is neces- sary to render the discharge contagious.1 Treatment.—The treatment of gonorrhoea must be adapted to the general condition of the patient, and especially to the stage of 1 M. Thiey's views have been published in a series of lectures in the Presse Med. de Bruxelles, and are also advocated by Guyomar, These de Paris, 1858 (No. 282). 56 URETHRAL GONORRHOEA IN THE MALE. his disease. In the great majority of cases met with in practice, acute inflammatory symptoms have already set in at the time the patient first applies to the surgeon; but in those exceptional cases which are seen at an early period, we may often succeed in cutting short the disease by means of the treatment termed abortive. Abortive Treatment of the First Stage.—During the first few days after exposure, varying in number from one to five in different cases, before the symptoms have become acute, when the discharge is but slight and chiefly mucous, and while as yet there is no severe scalding in passing water, we may resort to caustic injections with a view of exciting artificial inflammation which will tend to subside in a few days, and supplanting the existing morbid action which is liable to continue for an indefinite period and is exposed to various complications. This is known as the " substitutive," or more com- monly as the "abortive treatment" of gonorrhoea. This method has been inordinately praised and as violently attacked; its true merit is probably to be found between these two extremes. It is certainly liable to be greatly abused, and, if so, is both unsuccessful and capable of producing the most unpleasant consequences; but when limited to the early stage of gonorrhoea and used with proper caution, it is a highly valuable method of treatment, unattended with danger, and undeserving the censure sometimes cast upon it. In employing the abortive treatment, there are several points which it is important to recollect: 1. The disease, in the stage to which this treatment is applicable, is limited to the anterior portion of the urethra, known as the fossa navicularis, or extends but a short distance beyond it; it is not necessary, therefore, that the injection should reach the deeper portions of the canal. 2. For the treatment to be successful, the whole diseased surface should receive a thorough application of the injection, for if any portion remain untouched, it will secrete matter that will again light up the disease. 3. When once a sufficient degree of artificial inflam- mation is excited, the caustic has accomplished all that can be expected of it, and should be suspended. Since a solution of nitrate of silver, which is commonly used in the abortive treatment, is readily decomposed by contact with metallic substances, metal syringes should be avoided. Glass sy- ringes, if well made, answer every purpose; but as found in the shops, they are apt to be unequal in calibre in different parts of the cylinder, the wadding of the piston contracts in drying, and a TREATMENT. 57 portion of the fluid fails to be thrown out, as is seen by its overflow when the syringe is filled a second time. For these reasons, I never advise a patient to purchase a glass syringe, knowing that it will probably give him much annoyance, and perhaps prevent his de- riving benefit from treatment. Fortunately, we have a very excel- lent substitute in the hard-rubber syringes which can be obtained at the druggists'.1 The solution of nitrate of silver, in the abortive treatment of gonorrhoea, may be of considerable strength, when only one injec- tion will be required; or it may be weak, and in that case should be repeated at short intervals until the effect produced be deemed sufficient. I much prefer the latter course, especially with patients who apply to me for the first time, since it enables me to graduate the effect according to the susceptibility of the urethra, which varies in different persons. The following is the formula for the weak form of injection:— fy. Argenti nitratis crystalli gr. j-iss. Aquse destillatae 5jvj. M. With this, as with all injections in gonorrhoea, it is essential to success that the surgeon should administer the injections to his patients, or see, by actual observation, that they know how to use them. Verbal directions cannot be relied upon. The patient should be made to pass his water immediately be- fore injecting, or, better still, a quarter of an hour before. We wish to clear the urethra of matter, and to have the bladder empty, so that the injection may have some time to act before it is washed away by another passage of the urine, and yet a short interval 1 An excellent series of urethral syringes is manufactured by the American Hard Rubber Company. In these instruments, the diameter of the cylinder is in all parts the same ; the piston works with great accuracy ; the material is not acted upon by ordinary medicinal agents, and the different sizes and forms of the in- strument are adapted to the various purposes for which it is required. The size most generally applicable to the treatment of gonorrhoea is called "No. 1, B." It holds half an ounce, which is not too much for injections in the latter stages of the disease ; if used in the abortive treatment of the first stage, it should be only half filled. " No. 1" holds two drachms, and is well adapted for the abortive treatment. The " Urethral Syringe with extra long pipe," is, in fact, a syringe united to a catheter, and is adapted for injections of the deeper portions of the canal or the bladder. The catheter portion may be bent to any curve desired, by first heating it over a spirit-lamp. 58 URETHRAL GONORRHOEA IN THE MALE. between the last act of micturition and the injection is advisable, in order that as much of the urine as possible may have drained from the canal and little be left to decompose the nitrate of silver. The prepuce should now be fully retracted, and the glans penis exposed. The latter should be wiped dry, so as to afford a firm hold to the thumb and forefinger of the left hand, applied to its opposite sides, and firmly compressing it around the point of the syringe, introduced to its full extent within the meatus. If this pressure be properly made, not a drop of the solution will be lost, as the piston of the syringe is slowly forced down by the forefinger of the right hand holding the instrument, and the whole contents will be discharged into the canal. The syringe should now be withdrawn, and the fluid still retained for a few seconds by con- tinuing the compression of the glans. When the injection is allowed to escape, it will be found to be of a milky-white color. This is due to the partial decomposition of the contained salt by the remains of the urine and the muco-pus in the canal. As this decomposition has prevented the application of the injection in its full strength to the urethral walls, a second syringeful should be thrown in, and retained for two or three minutes. During this time, a finger of the disengaged hand should be run along the under surface of the penis from behind forwards, so as to distend the portion of the canal occupied by the injection, and insure the thorough application of the fluid to the whole mucous surface. This description of the method of using the syringe is, in the main, applicable to all the injections which may be required in the course of a gonorrhoea; but we are now speaking of the abortive treatment, by means of weak injections of nitrate of silver. We will suppose that this first injection has been administered by the surgeon, who, at the same time, has explained the various steps of the operation to the patient. The directions with regard to diet, etc., that will presently be mentioned in speaking of the second stage, should now be given; the patient should be ordered to repeat the injection every three hours, and, for the present, it is best that he should be seen by the surgeon twice a day. It is also well at this time to prescribe an active purge. The first effect of the caustic injections is manifested in a few hours; the discharge becomes copious and purulent, and consider- able scalding is felt in passing water. In the course of twenty-four or thirty-six hours, however, the discharge grows thin and watery, TREATMENT. 59 and, very likely, is tinged with blood. It is now time to stop the injection and omit all medication for a few days, until we see how much good has been accomplished. If the treatment meets with its usual success the discharge will gradually diminish, and finally disappear in from three to five days. Sometimes, however, after growing less, it again increases, showing a tendency to relapse. In that case, I usually advise weak injections of sulphate of zinc, as recommended in the third stage of the disease. Some surgeons prefer to resume the caustic injections in the same manner as at first, if, after a week has elapsed, any traces of the discharge remain. The chief objection to this modification of the abortive treatment is, that it is necessary to leave the administration of most of the injections to the patient, who may be prevented by ignorance, or the requirements of his occupation, from using them as thoroughly or as often as is necessary. If we have reason to fear this, we may resort to a stronger solution, and inject it once for all, with our own hands. It was this method of employing the abortive treatment that was recommended by Debeney of France, and Carmichael of England, by whom this treatment was first introduced to the profession. The same method is also still employed and highly recommended by many surgeons, and especially by M. Diday of Lyon. The strong injection should not contain less than ten grains of the nitrate of silver to the ounce of distilled water, and more than fifteen grains are objectionable, unless with patients who have been under treatment before, and in whom the urethra has been found to be quite insensible. R. Argenti nitratis crystalli gr. x-xv. Aquae destillatae §j. M. The mode of using this injection is identical with that already described. Two small syringefuls should be thrown in; the first to clear the urethra of urine and muco-pus, the second to exercise a curative effect; and the surgeon should feel that the success of the treatment depends, in a great measure, on the thoroughness of its application. As an additional precaution against the fluid extending further back than is necessary, the patient may compress the penis anteriorly to the scrotum, while the surgeon is adminis- tering the injection. There is still another mode of employing a strong solution of 60 URETHRAL GONORRHOEA IN THE MALE. nitrate of silver, by means of an instrument introduced by Dr. F. Campbell Stewart, of this city, and called by his name. This instrument consists of a straight canula inclosing a sponge, which can be made to protrude from its extremity. The sponge is first soaked in a solution of nitrate of silver, and concealed within the canula. The instrument is then introduced for about two inches within the urethra, when the canula is to be partially withdrawn; the sponge is thus exposed to the contact of the urethral walls, in which position it is to be allowed to remain for a minute or two, and then withdrawn by slowly twisting it on its long axis. By the use of Dr. Stewart's instrument, the extent of the application can be limited at will, and it is perhaps owing to this fact that we can employ with safety a much stronger solution than when using a syringe. I have thus applied a solution of twenty, and even thirty grains to the ounce, without exciting an undue amount of inflammation, or other unpleasant symptoms. Care should be taken that the instrument be of sufficient size. Some of those found in the shops are too small, not exceeding a No. 7 bougie in diameter. I have had one manufactured for my own use of the size of No. 10. I cannot leave this subject of the abortive treatment of gonor- rhoea, without again expressly stating that I recommend it only in the first stage of the disease, and not after acute inflammatory symp- toms have set in, or the patient suffers from scalding in passing water. Taking the usual run of cases as met with in practice, probably not more than one out of ten is seen at a sufficiently early period to admit of the abortive treatment. Its employment in the acute stage, as recommended by its inventors, is generally unsuccessful, and dangerous and even fatal results have been known to ensue. Prudent practitioners have limited the use of caustic injections to the early stage of gonorrhoea, except in some instances in the decline of the disease; but, in the latter case, the mode of injecting must be modified so that the fluid may reach the deeper portions of the canal. Treatment of the Acute Stage.—The proper regulation of the diet, exercise, and mode of life of the patient, is of the first importance in every stage of gonorrhoea. In the treatment of the inflamma- tory stage, as well as in the abortive treatment of the first stage, if the patient can keep his bed for a few days, the battle is half won. The advantages of absolute repose and quiet should be placed TREATMENT OF THE ACUTE STAGE. 61 prominently before him, and every inducement be offered to lead him to avail himself of them. Yet in practice, we find that very few will submit to this constraint. It is very well to say that every patient that puts himself under the care of a physician, should follow his advice implicitly in all things; but we must take the world as we find it, and the calls of business, or the necessity of secrecy, often render the insistence upon such stringent rules impossible. When life is in danger, men absorbed in business will stay at home, but not merely for an attack of gonorrhoea. This indeed should not prevent our doing our best to persuade them, but we shall succeed in but a small minority of cases. Exercise of all kinds should be avoided as much as possible; walking, dancing, riding on horseback, and standing—in the street, at the desk, at a party—are all injurious. Eiding is certainly less objectionable than walking, and yet a long ride, even in a rail-car, often aggravates a gonorrhoea or induces a relapse when it is appa- rently cured. At home, and at the store or office, the recumbent posture should be maintained as much as possible. It is highly important, also, that the genital organs should be well supported by a suspensory bandage. The kind of bandage is immaterial, provided it fit well and do not chafe the parts; and of these condi- tions the surgeon should satisfy himself by actual observation. While the more acute symptoms continue, the diet should be exclusively farinaceous; and meat, stimulants, asparagus, coffee, and acids be forbidden. The perusal of all books calculated to excite the passions, and the company of lewd women, even if no improprieties be committed, should be strictly interdicted. The last-mentioned caution is not generally given without good reason. At the commencement of the treatment of a case of gonorrhoea in the acute stage, it is well to administer an active purge, as five grains of calomel combined with ten of jalap, a full dose of Epsom salts, or three or four compound cathartic pills of the TJ. S. P. If the inflammatory symptoms be severe, marked benefit will be de- rived from the application to the perineum of half a dozen leeches, which, however, are rarely absolutely necessary. Care should be taken to keep the head of the penis free from any collection of matter, lest balanitis be excited or the disease aggravated by its presence. A pair of triangular-shaped drawers, like ordinary swim- ming drawers, worn next the skin, affords the best protection to the patient's linen. Water, as hot as can be borne, is the most grateful 62 URETHRAL GONORRHOEA IN THE MALE. local application that can be used. I have found that it generally affords great relief to the scalding in micturition and the local pain and uneasiness, and can fully indorse Mr. Milton's statement with regard to it. " The only direct application which I can safely say has never disappointed me, which is at once safe, simple, and useful, is that of very hot water to the penis. But to obtain the really good effects it offers, the water must be hot, not lukewarm. In fact, we seldom see so much good ensue as when it is carried to the extent of producing some excoriation and faintness; thus applied, and especially in the early stages of the disease, the weight felt about the testicles soon disappears, the pain on making water and using injections is soothed, and the prepuce and glans rapidly regain a more normal temperature and color."1 After the operation of the cathartic, we may, in most cases, commence at once with copaiba or cubebs, rules for the exhibition of which will presently be given at length. If, however, the penis be still much swollen, and the scalding on passing water severe, we may defer the exhibition of the anti-blennorrhagics for a few days, and administer alkalies or diuretics, either alone or combined with sedatives, for the purpose of rendering the urine less irritating by diminishing its acidity, or diluting its contained salts by increasing its quantity. Again, both these classes of remedies may be given at the same time. From one to two drachms of the chlorate, acetate, or nitrate of potash, or two or three drachms of liquor potassae, may be added to a pint of flaxseed tea; and the patient be directed to take this quantity in the course of twenty-four hours. The following is also an excellent formula:— R. Potassse bicarbonatis 5ij> Tincturae hyoscyami ^j. Mucilaginis 3 V. M. A tablespoonful every three hours. Do not mix tincture of hyoscyamus and liquor potassas in the same prescription, since the effect of the former is destroyed by the presence of a caustic alkali.2 In this stage of the disease, Mr. Milton highly recommends the following:— ' Milton on Gonorrhoea, p. 21. * See Paris's Pharmacologia, Ninth Edition, p. 512. This fact has recently been brought forward as new, and confirmed by actual experiment, by Dr. Garkod ; Medico-Chirurgical Transactions, Second Series, vol. xxiii. London, 1858. TREATMENT OF THE ACUTE STAGE. 63 fy. Pulv. potassae chloratis Jij. Aquae bullientis §v. Misce et adde— Liquoris potassae giij. Potassae acetatis 3iij ad 3v. Misce et cola. One ounce three times a day. If the bowels be not freely open, Mr. Milton adds powdered rhu- barb to each dose of this mixture, in sufficient quantit}r (gr. v ad 9j) to produce two or three loose stools daily. The following is another formula recommended by Mr. Milton:— R. Potassae acetatis £j. Spiriti aetheris nitrici 3iij- Aquae camphorae 3" vj. M. One ounce three times a day. An elegant and convenient method of administering an alkali is by means of Brockedon's wafers of bicarbonate of potassa, of which two may be given after each meal. The only objection to them is their expensiveness. If the penis be much swollen and florid, the meatus contracted by the distension of its walls, and the urethra in a state of great sensibility, the above general measures should constitute the only treatment, and no local remedies, with the exception of hot water, be resorted to, until the inflammation has somewhat subsided. In the majority of cases, however, especially when the patient has had go- norrhoea before, the local symptoms are not severe, even in the acute stage, and the point of a syringe can be gently introduced within the canal without exciting much pain. When this is the case, an injection containing glycerin and strongly opiated, will be found to afford great relief to the local pain and uneasiness, and hasten the subsidence of the inflammatory symptoms, and the diminution of the discharge. I can speak very decidedly in favor of this appli- cation and of its perfect safety; but the opium must not be added in the form of tincture, or the alcohol, which is an irritant, will counteract its effect; and the fluid is to be injected with gentleness, and not with such force as to painfully distend the canal. The following is the formula that I use:— B. Extracti opii Qj. Glycerin |j. Aquae ^iij. M. Injection to be used after every passage of urine. 64 URETHRAL GONORRHOEA IN THE MALE. In many cases of a subacute form, half a grain or a grain of sul- phate or acetate of zinc may be added to each ounce of the mixture, even at the outset, and there are but few cases in which it is not admissible in the course of twenty-four or forty:eight hours, when the inflammation, local pain, and scalding are generally found to be much improved. If the case continue to progress favorably, the quantity of the astringent may be gradually increased, and that of the opiate diminished; and the treatment should be continued according to the rules laid down for the third stage, to be mentioned presently. While pursuing the treatment of the acute stage of gonorrhoea, care should be taken that antiphlogistic measures be not too long persevered with. It should be remembered that the natural tend- ency of the disease is to lower the tone of the system, and a con- dition of debility in turn reacts on the disease and prolongs its duration. We often meet with patients who have treated them- selves with low diet and daily purging for weeks, and yet who are no better of their gonorrhoea. An antiphlogistic course alone may relieve the more acute symptoms, but it will not cure the complaint; and so soon as the pain in passing water has diminished and the local inflammation in a measure subsided, the patient should no longer be confined to his room, and should have a more liberal diet; nor, under any circumstances, should his confinement and abstinence be prolonged, if, after a reasonable time, they are found to produce no change for the better, or the pulse becomes feeble, the skin clammy, and the strength exhausted. Indeed, in some cases, in which the constitution is enfeebled by disease, debauch, or previous attacks of venereal, it is necessary to abstain from all measures calculated to lower the tone of the system, and resort to good living and even quinine, iron, and other tonics, from the very outset of the disease. It is, therefore, to be expressly understood that the antiphlogistic treatment here recommended, is intended to apply, in its full force, chiefly to the disease as it appears in first attacks in men of full habit. Those patients who have had nume- rous previous attacks will rarely require such active treatment in any stage of the disease. The judgment of the surgeon must determine the indications of each individual case. Treatment of the Stage of Decline.—A marked diminution of the scalding in making water, and of the painful sensations in the penis, is, I believe, a better index of the subsidence of the inflammatory TREATMENT OF THE STAGE OF DECLINE. 65 action, than the character of the discharge, which, independently of treatment, often continues copious and purulent after the third stage has fairly commenced. In giving directions as to the regimen of a patient in the third stage of gonorrhoea, some regard should be paid to his usual mode of life. As a general rule, all indulgence in spirituous or malt liquors should be strictly forbidden, and total abstinence be prac- tised until the cure is complete, and for at least a fortnight afterward. You will meet with some patients, however, who have been free drinkers for years, and who will not well bear the total loss of their stimulus, without becoming so debilitated that their gonorrhoea is thereby prolonged and more difficult to cure. In these exceptional cases, it is better to allow a glass of claret, sherry, or even brandy and water, to be taken with the dinner. In any case, malt liquors should be avoided, since they are decidedly more injurious than other liquors which contain a larger amount of alcohol. The patient may now return to a more generous but simple diet, though salt meats, highly seasoned food, asparagus and cheese should still be avoided. The bowels are not to be allowed to become consti- pated, and this should be prevented so far as possible by regulating the diet. One or two free stools a day are desirable. If the patient have been confined to the house during the acute stage, he may now be allowed to go out, but should be cautioned against walking or standing more than is necessary, and the genital organs should be well supported by a suspensory bandage. Patients often inquire whether the use of tobacco is injurious; I believe that it is, and that either smoking or chewing, especially in excess, relaxes the genital organs and tends to keep up a urethral discharge. I have frequently been told by patients subject to spermatorrhoea, that smoking during the evening would invariably be followed by an emission during the night, and I am satisfied that many cases of gonorrhoea are prolonged by the excessive use of tobacco. I there- fore recommend entire abstinence, or, at least, great moderation, both in smoking and chewing, to persons suffering with this dis- ease.1 The chief remedies adapted to the third stage of gonorrhoea are 1 Dr. Shipley has recently published two cases of gonorrhoea in which the dis- charge repeatedly disappeared on leaving off smoking, and returned on resuming it. (Boston Med. and Surg. Journal, Nov. 22, 1860.) 5 66 URETHRAL GONORRHOEA IN THE MALE. injections, and copaiba and cubebs. By far the more important of these are injections, which constitute our chief reliance in the treatment of this affection, when it has arrived at this stage; and, in spite of all that has been written and said against them, I do not hesitate to say, that the surgeon who voluntarily renounces injec- tions, deprives himself of his best weapon in contending with gonorrhoea, and is comparatively impotent in his attempts to con- quer it. The objections that have been raised against this mode of treat- ment need not long detain us. They are chiefly the following: 1. It is asserted that the injected fluid carries before it the muco- pus within the urethra, and thus extends the disease to the deeper portions of the canal. Supposing this possible in any case, it cannot take place, if the patient pass his water before injecting, as he should always be directed to do. 2. It is said that injections may excite swelled testicle and other complications of gonorrhoea. This is only possible, when they are used of too great strength or with undue violence. 3. The chief objection that has been alleged against injections is, that they are a frequent cause of stricture of the urethra. This the opponents of injections have endeavored to prove, by showing that most persons, with stricture preceded by gonorrhoea, were treated for the latter disease by injections. This is clearly a mode of reasoning, post hoc ergo propter hoc, and by no means proves the ground assumed. I have heard of some one, who, to show its fallacy, instituted some inquiries among patients with stricture, as to whether they had taken flaxseed tea for their pre- vious gonorrhoea, and was able to prove, if such reasoning be relia- ble, that flaxseed tea is a very fruitful source of stricture.. As Ricord justly states, it is much more probable that strictures are due to the chronic inflammation, which, in cases of gonorrhoeal origin, has usually preceded them for a long period, than to any influence exercised by injections. The well known effect of chronic inflammation of a mucous membrane in producing an effusion of plastic material in the sub-mucous cellular tissue which by its con- traction diminishes the calibre of the canal, is a strong argument in favor of this view. The objections to the use of injections are, I believe, founded on their abuse, or on false reasoning, and will not stand the test of examination. When properly used, they con- stitute the most valuable means within our reach for the cure of gonorrhoea, and are employed in the practice of all surgeons, with TREATMENT OF THE STAGE OF DECLINE. 67 very few exceptions, who have had the opportunity of testing their value. Injections are particularly adapted to the treatment of the first stage by the abortive method and to the treatment of the third stage of gonorrhoea; although, as already stated, in very many cases they may be used with safety and benefit in a weak form, even in the second or acute stage. These remarks in favor of injections do not of course imply that they are infallibly successful, nor that they can be used indiscrimi- nately in all cases. Under certain circumstances, their effect is found to be injurious. If in the course of treatment the patient complain of a frequent desire to pass his urine, and other symptoms indicating inflammation of the neck of the bladder or prostate, in- jections should be at once suspended. Continuous pain in the penis, or any considerable amount of tumefaction of its tissues also contra-indicates the use of irritant or astringent injections, although the formula containing glycerin and extract of opium, which was recommended in the acute stage, may still, in many cases, be em- ployed with advantage. Moreover, it should not be forgotten that injections will sometimes keep up a discharge through the irrita- tion which they excite, however simple may be their composition. After the force of the disease has been subdued, they should there- fore be used at gradually increasing intervals, or, from time to time, be altogether omitted, until the necessity of their continuance again becomes apparent. The manner of using the syringe in the third stage is essentially the same as in the abortive treatment of the first stage. A larger syringe, however, should be employed, one, for instance, holding three or four drachms; since there is now no necessity of limiting the action of the injection posteriorly, and, on the contrary, it is desirable to extend it as far back as possible, in order that it may reach the whole diseased surface. For this purpose the finger may be run along the under surface of the urethra from before back- wards, as well as in the opposite direction (from behind forwards), as previously recommended, in order to insure complete distension of the canal and exposure of its lacunae. The patient should always pass his water before injecting, and throw in two syringefuls at each application. A great variety of substances have been recommended as the active principles of injections. A choice, to a certain extent, is 68 URETHRAL GONORRHOEA IN THE MALE. doubtless desirable, since the same injection does not always suc- ceed equally well in all cases. For instance, one of my patients, whom I have repeatedly treated for gonorrhoea, is always made worse by an injection of sulphate of zinc, and is benefited by a weak solution of nitrate of silver. Peculiarities of this kind are occasionally met with, but I believe that much time is wasted by young practitioners in changing from one to another of the many varieties of injections proposed in books, under the supposition that some specific effect is to be obtained from the contained ingredients, whereas, in most cases, success depends upon the thoroughness of the application, and attention to the general health and any existing complications. My own preferences for an astringent as the active principle of injections in the third stage of gonorrhoea, are very strongly in favor of the sulphate of zinc; which is also the favorite injection of Sigmund of Yienna, Mr. Milton, and many other eminent surgeons. I have already spoken of the addition of a small quantity of this salt to the sedative injections of the acute stage, after the more in- flammatory symptoms have been subdued.. The proportion of the sulphate may be increased and that of the opiate diminished, as the case progresses, and the latter finally omitted altogether. The strength of the injection should be such that it may excite a slight uneasy sensation in the urethra for about ten minutes, but it must not be strong enough to cause severe or long-continued pain. As the case approaches a cure, the injection will cease to excite any un- pleasant feeling whatever, and its strength need not be further increased. In most cases, we need not at any period exceed the proportion of the sulphate in the following formula:— R. Zinci sulphatis gr. xij. Aquae Jiv. M. Glycerin may be substituted for half an ounce or an ounce of the water. As to the frequency with which the injection is to be used, I usually direct the patient to inject after each passage of his urine, with the expectation that he will take four or five injections in the course of the twenty-four hours. It is better that the last injec- tion should be applied an hour or two before retiring, since if used directly before going to bed, it favors the occurrence of erections and chordee during the night. If the discharge do not materially diminish under the use of these TREATMENT OF THE STAGE OF DECLINE. 69 injections, combined, in most cases, with the internal administration of copaiba or cubebs, I usually resort to a solution of nitrate of silver, of the strength of from two to five grains to the ounce of water, and inject it myself for the patient, daily, or every two or three days, while at the same time he is directed to continue his injection of sulphate of zinc. The effect of an irritant like nitrate of silver should be closely watched, and its administration should not, there- fore, be left to the patient himself. The acetate of zinc is nearly, if not quite as valuable a remedy as the sulphate, and the remarks above made in favor of the latter are equally applicable to the former. Indeed, if I were asked to name the simplest treatment of gonorrhoea, and the one best adapted to the largest number of cases, I should reply: a weak injection of the sulphate or acetate of zinc, containing from one to three grains to the ounce of water. Many men about town constantly carry in their pockets a prescription of this kind (generally with the addition of a little morphine or a few grains of powdered opium), with which they almost invariably succeed in arresting their frequent attacks of gonorrhoea, without resorting to the nauseous anti-blennorrhagics, or finding it necessary to consult a surgeon. A great reputation has been acquired for a reddish powder sold by an irregular prac- titioner of this city, who tells his patients that the ingredients are entirely unknown to the profession. This powder, subjected, to chemical analysis, is found to contain as coloring matter Armenian bole, and as an active ingredient acetate of zinc. The sulphate of zinc was a favorite with Dr. Graves, who was in the habit of combining it with the impure carbonate of zinc, as in the following formula:— ty. Zinci sulphatis gr. iij. Calaminae gr. x. Mucilaginis 3ij- Aquae 3vj. M. With regard to the addition of calamine, Dr. Graves says: " How the lapis calaminaris acts, unless on a mechanical principle, it is difficult to explain; but of its utility I am certain, having long used this combination, as recommended in Thomas's Practice of Physic."1 The chloride of zinc is a powerful caustic and irritant which fulfils, although in a much less perfect manner, the same indications 1 Clinical Lectures, London Med. Gaz., new series, vol. i., 1838-9, p. 438. 70 URETHRAL GONORRHOEA IN THE MALE. as nitrate of silver, and may, therefore, be used under similar circumstances. It is a favorite injection with some practitioners, and especially with my venerable friend, Dr. J. P. Batchelder, who employs a very strong solution in all stages of gonorrhoea, and states that but few cases resist more than a week. Dr. B. dissolves 3ij of the chloride in 3iij of water, and directs the patient to com- mence with three drops of the mixture to a tablespoonful of water, and inject three times a day; to add a drop at a time (rarely exceeding eight drops) until a smarting sensation is produced; and then gradually to diminish the strength until the discharge disap- pears. In several trials which I have made of this method. I have been disappointed in the results; and, in general, I regard the action of the chloride of zinc as much inferior to the nitrate of silver, and not without danger, and would limit its use to certain cases of gleet in which it is desired to set up acute inflammation. Of the numerous other formulae for injections sometimes employed in the treatment of gonorrhoea, the following are among the best:— #. Cupri sulphatis gr. xij. Aquae ^iv-vj. M. ty. Liq. plumbi subacetatis §ss-j. Aquae q. s. ad §iv. M. R. Aluminis gr. xij-xxx. Aquae 3*iv. M. Mr. Milton says of alum: " The absence of pain which follows its use, and its feeble curative power, have led me to assign to it only a secondary rank. I am, indeed, extremely doubtful if it possess any superiority over very mild injections of nitrate of silver or sulphate of zinc, and would, therefore, confine its exhibition to those cases accompanied by severe pain, where it may, during a day or two, serve as a pioneer to the others." In the following we have a combination of alum and sulphate of zinc:— ty. Liq. aluminis comp. §j. Aquae §iij. M. The two following are excellent formulae much employed by Ricord:— TREATMENT OF THE STAGE OF DECLINE. 71 R. Zinci sulphatis, Plumbi acetatis, aa gr. xxx. Aquae rosae 3*vj. M. B,. Zinci sulphatis gr. xv. Plumbi acetatis gr. xxx. Tincturae catechu, Vini opii, aa 3j. Aquae rosse 3VJ. M. Yegetable astringents may also be employed either alone or in combination with the salts of the metals. R^. Vini rubri §vj. Acidi tannici gr. xviij. M. R. Zinci sulphatis, Acidi tannici, aa gr. xij. Aquae §iv. M. Tannate of zinc is formed by decomposition of the sulphate. Injections of tincture of aloes are recommended by Gamberini1 of Bologne, who states that they excite only a momentary smarting sensation, and are very efficacious. I£. Tinct. aloes Jss. Aquae §iv. M. The subnitrate of bismuth has recently come into favor. It acts as a local sedative, or, when deposited upon the walls of the ure- thra, may possibly serve to protect the diseased surfaces from con- tact. Of 52 patients treated exclusively with injections of subnitrate of bismuth, 36 recovered after an average treatment of twenty-two days.2 I have found only one difficulty attending its use, viz., that it clogged up the urethra, and by its mechanical presence excited an uneasy sensation, which was only relieved by the passage of the urine. As it is not soluble in water, it should be suspended by means of mucilage, and the bottle be shaken before using. R. Bistnuthi subnitratis Jij. Mucilaginis §ss. Aquae 3iijss. M. 1 Rev. de Ther. Med.-Chir., Jan. 1, 1860, p. 13. 2 Victor db Meeic ; Report to the Medical Society of London, April 30, 1860. 72 URETHRAL GONORRHOEA IN THE MALE. Finally, in many cases of gonorrhoea, simple iced-water injected after each passage of the urine, is very serviceable in allaying pain and irritation, and not inefficacious for the cure of the discharge. Copaiba and Cubebs.—Certain drugs which appear to possess a peculiar power in arresting inflammation of the urethral mucous membrane, are called anti-blennorrhagics. The chief of them are copaiba and cubebs. Some interesting investigations made by Ricord to determine the mode of action of these agents, are given in Ricord and Hunter on Yenereal. It had already been observed in practice that copaiba and cubebs had but little curative effect upon gonorrhoea of any portion of the male or female genital organs, except the urethra; and it was hence suspected that they acted chiefly by their presence in the urine, and not through the general circulation; but this fact had not been demonstrated. A man with gonorrhoea chanced to enter Ricord's ward at the Hopital du Midi, who had a fistulous opening communicating with the ure- thra a short distance in front of the scrotum, produced by a liga- ture which had been applied around his penis when a child. He could at will, by separating or approximating the two edges of the fistula, either make his urine emerge from the artificial orifice, or cause it to traverse the whole extent of the urethra. Both portions of the canal were affected with gonorrhoea. Ricord administered copaiba to this patient, and directed him to pass his water entirely through the fistula. In the course of a few days, the disease was cured in the posterior portion of the canal, behind the artificial opening through which the urine had passed, while it remained unchanged in the anterior portion. He was now directed to make his water pass through the whole length of the canal, and in a few days more the anterior portion was also cured. By a singular coincidence, two other cases, of a similar character, soon after presented themselves in Ricord's wards, in one of which copaiba, and in the other cubebs, was given in the same manner, and the result in each was the same as in the case just described. From these experiments, Ricord concludes that copaiba and cubebs have but little influence upon gonorrhoea, unless directly applied to the diseased surface, and hence that we cannot expect decided benefit from their administration in any form of gonorrhoea, except that of the urethra in the two sexes. In gonorrhoea of the vagina or vulva, or in balanitis, they are comparatively useless. The presence of these drugs in the urine is still further evinced COPAIBA AND CUBEBS. 73 by the odor which they impart to this fluid, and which is often suf- ficient to pervade the bedchamber occupied by the patient. It must not, however, be inferred that copaiba and cubebs have no effect except by way of the kidneys. They are often used with benefit in other diseases than those of the urinary organs, and cannot therefore be entirely destitute of action through the gene- ral circulation. Moreover, they sometimes act as revulsives by producing copious evacuations from the bowels, and the urethral discharge is diminished as after the administration of a purge; their chief action, however, is in the manner described, by their presence in the urine. Such being the case, it might naturally be supposed that an emulsion of copaiba injected into the urethra would have the same effect, and that thus the internal administration of so nauseous a drug might be avoided. The experiment has been tried in nume- rous instances, but the result has always been unsatisfactory. As stated by Ricord, both copaiba and cubebs, in passing through the digestive organs or kidneys, undergo some modification of an un- known character, upon which their curative power depends, and which cannot be imitated by art. Dr. Hardy, of Paris, is said to have effected a cure in several cases of vaginal gonorrhoea by giving the patients copaiba, and directing them to inject their urine into the vagina after each act of micturition. This course, however, is more interesting as an experiment than worthy of imitation in practice. It was formerly supposed that copaiba could be used with safety only in gleet, and even then in very small doses, and that it was inadmissible in gonorrhoea, especially in its acute stage, having a tendency, as was thought, to excite inflammation of the neck of the bladder and swelled testicle. In the latter part of the last century, however, it was discovered that the natives of South America were in the habit of administering copaiba in large doses in all stages of gonorrhoea, and this, too, with very great success. This led to a bolder method of administering it, and it was soon ascertained that its curative effect is much greater in the acute than in the chronic form of urethritis, and that it is rarely, if ever, productive of those complications which were once attributed to it.1 In short, it would 1 For an interesting history of the remarkable change in medical opinion with regard to the administration of copaiba, see Trousseau, Traite de Therapeutique, vol. ii. p. 592. 74 URETHRAL GONORRHOEA IN THE MALE. appear that copaiba can be administered with safety and to much greater advantage in the acute stage of gonorrhoea, or at an early period of the stage of decline than afterward, and the same is true of cubebs. Still, when a case of this disease presents itself with marked inflammatory symptoms, it is usual to wait for a day or two until these have been somewhat subdued, by the means already mentioned, before commencing with copaiba or cubebs, and I do not think that any time is thus lost; and, in all cases, the effect of the remedy is promoted by the previous exhibition of a cathartic. The diuretics and alkalies, spoken of in connection with the acute stage, may be combined with these drugs, as in some of the formulae to be mentioned presently, or may be given separately. The dose of copaiba is from twenty minims to one or even two drachms, repeated three times a day. It may be given in its pure state upon coffee, wine, or milk, but it is so disagreeable to the pa- late, and so likely to excite nausea, eructations, and even vomiting, that few persons can tolerate it in this form. To render it more acceptable to the taste and stomach, it is generally given in combi- nation ; and other ingredients are often added for the purpose of assisting its action upon the urethra. A very common and excel- lent formula is the following, which is known as the Lafayette mixture:— $. Copaibae, Spiriti aetheris nitrici, aa §j. Liquoris potassae 5'j- Spiriti lavandulae comp. 3*ij. Syrupi acacise 3VJ. M. Dose.—From a teaspoonful to a tablespoonful after each meal. The following are also useful formulas:— B* °le* copaibae, " cubebae, aa gj. Aluminis :jij. Sacchari albi 3iv. Mucilaginis 3iij- Aquae §ij. M. Dose.—A teaspoonful three times a day. ty. Copaibae, Liquoris potassae, aa jjiij. Mucilaginis acaciae Jj. Aquae menthae viridis q. s. ad §vi. M- (Milton.) Dose.—One ounce three times a day. COPAIBA AND CUBEBS. 75 R. Copaibae 3x. Tincturae cantharidis, Tincturae ferri chloridi, aa 3U- M. Dose.—From half a teaspoonful to a teaspoonful. But in whatever way combined, many stomachs will not tolerate copaiba in a liquid form; hence I commonly prescribe the solidified mass, formed by the addition of magnesia, and known in the U. S. Dispensatory as Pilulse Copaibae. It requires some little tact to pre- pare this mass; or, rather, difficulty is met with, unless the proper kind of copaiba be used. Two kinds of the balsam are found in commerce, one of which, the best, is solidifiable with magnesia, and the other not. The solidified mass should be divided into pills, each of which may contain five grains; and it is desirable to coat them with sugar, both for the purpose of preventing their ad- hering together, and to render them more acceptable to the palate. This is to be accomplished in the following manner: Put the pills into a vessel with sufficient water to moisten them; then turn them out upon a pan and sprinkle over them finely powdered sugar, at the same time rolling them about by shaking the pan, so that they may be entirely and equally coated. This process may be repeated after they are dry, as many times as is necessary to give them a thick coating of sugar. The dose is from four to eight pills three times a day. Thus prepared, they leave no taste in the mouth, and, being slowly dissolved in the stomach, are much less likely to ex- cite nausea than the liquid article. We have another anti-blennorrhagic, but little if at all inferior to copaiba, in the powdered berries of the Piper Cubeba. Cubebs possess the advantage over copaiba of being far less disagreeable to the taste, and less likely to excite nausea, eructations, vomiting, and diarrhoea; and, on this account, are often to be preferred in the treatment of gonorrhoea. They cannot be relied upon, how- ever, unless freshly powdered, and preserved in a glass vessel; since the essential oil which they contain is rapidly absorbed by any porous material. Cubebs are conveniently taken, mixed in sweetened water, in the proportion of one to two drachms of the powder to half a glassful of the liquid; and this dose should be repeated three or four times a day. Cubebs are often advantageously combined with iron, especially for persons of weak habit, thus:— 76 URETHRAL GONORRHOEA IN THE MALE. R. Pulveris cubebae 5U« Ferri carbonatis 3ss. M. et ft. pulv. To be taken three times a day. Cubebs and copaiba may be combined together in the same pre- scription. R,. Copaibae 3*ij. Pulveris cubebae §j. Aluminis 5iss« Magnesiae q. s. ut fiat massa. To be divided into pills containing five grains each, of which from four to eight are to be taken three times a day. ty. Pulveris cubebne §iij. Copaibae 3iss. Aluminis 3'j- Sacchari albi §j. Magnesiae 3iss< Olei cubebae, Olei gaultheriae, aa 3j« M. This mixture forms a paste, of which the patient may be directed to take a piece the size of a walnut, after each meal. The following prescription is particularly adapted to delicate stomachs:— R. Copaibae §ij. Magnesiae 3J. Olei menthae piperita gtt. xx. Pulveris cubebae, Bismuthi subnitratis, aa 3*ij. M. To be divided into pills of five grains each, and coated with sugar. R. Copaibae §j. Magnesiae 3ss. Pulveris cubebae §iss. Ammoniae carbonatis 3U- Ferri sulphatis £)j. M. (Meot.) To be divided into pills of five grains each: dose, three, three times a day. Copaiba and cubebs may also be obtained enveloped in capsules of gelatin, and this is a popular form of administration. I am not, however, partial to these preparations. The capsules do indeed obviate the disagreeable taste of these drugs, but they do not pre- vent nausea arid eructations, when their contents are suddenly dis- charged into the stomach, by the solution of the envelope. I very much prefer the French dragees which have been introduced within COPAIBA AND CUBEBS. 77 the last few years, and of which there are several varieties; some containing copaiba alone, others cubebs, and others still both these drugs combined with iron; I have found them all to be very reli- able. The dose is from four to six, three times a day. In my own practice, I usually prescribe these dragees, or one of the above for- mulae for pills of the solidified copaiba with cubebs, or simple cubebs in powder. I am also in the habit of prescribing some form of iron, either alone or in combination with the anti-blennor- rhagics, in the majority of cases, after the more acute symptoms have passed. Injections of an emulsion of copaiba into the rectum, in cases where it is not borne by the stomach, have been recommended, especially by Yelpeau. I have never tried this method of adminis- tering copaiba, and should have but little faith in its efficacy. It is acknowledged that a much larger quantity must be used than when it is given by the mouth. A simple injection should first be employed to clear the rectum of fecal matter, when the following mixture may be thrown in:— R. Copaibae 3^. Ovi vitelli No. j. Extracti opii gr. j. Aquae gviss. M. The nausea, eructations, and diarrhoea, which are often excited by copaiba, have already been referred to, and sometimes render it impossible to administer this remedy in any form to a delicate sto- mach. The diarrhoea may often be controlled by the 'combination of alum or an opiate, but more frequently requires the drug to be suspended, and afterward resumed in smaller doses. Copaiba sometimes, also, gives rise to a cutaneous eruption, be- longing to the class of exanthemata, as roseola, erythema, or urti- caria. Such eruptions should be carefully distinguished from those of secondary syphilis, as may readily be done by the absence of coexisting syphilitic symptoms, by the itching that usually attends them, and by their disappearance in a few days after the copaiba is suspended. The administration of copaiba should never be con- tinued, if it produce this effect. Another unpleasant symptom not unfrequently occasioned by copaiba, is pain in the region of the kidneys, dependent upon con- gestion of those organs. A few years ago, a patient was under my 78 URETHRAL GONORRHOEA IN THE MALE. care for gonorrhoea, who had previously had several attacks of haematuria. Contrary to my advice, he took copaiba, which in- duced a return of the blood in his urine, and I afterward learned that the administration of this drug had already produced a similar effect in a former attack of gonorrhoea. I always consider the presence of pain in the kidneys an indication that the copaiba should be omitted; for we have no right, in these days Avhen renal disease is so common, and a healthy kidney so rarely met with at a post-mortem examination, to subject our patients to the risk of permanent injury. Cubebs may occasion, though much more rarely, any of the unpleasant symptoms just mentioned as likely to occur from co- paiba. Both of these drugs, in large doses, will, in rare instances, excite severe headache, giddiness, and even more serious symptoms connected with the nervous centres. Ricord mentions a case of temporary hemiplegia, and another of violent convulsions, produced by copaiba; in both instances, these serious symptoms were followed by the outbreak of a cutaneous eruption, also dependent on the drug. The anti-blennorrhagics now mentioned, are of undoubted efficacy in the treatment of many cases of gonorrhoea, but in others they utterly fail; nor have we any means of distinguishing these two classes of cases beforehand. As I have already stated, I think they hold a second rank to injections in the cure of this disease. As a general rule, if they are likely to prove successful, their good effect will be apparent in a fortnight or three weeks from their commencement, and if, by this time, the disease continue unabated, they should be omitted and other means employed to effect a cure. When long continued, they produce disorder of the digestive func- tions, impair the appetite, and induce general malaise and debility; a condition of the system highly calculated to prolong the duration of gonorrhoea. Though often of marked benefit, they are by no means indispensable in the treatment of every case of gonorrhoea. Obstacles to Success.—A mistake, generally committed by patients who treat themselves for gonorrhoea and by some physicians, espe- cially in the early years of their practice, is over-medication, and a neglect of the general health. Nothing is more common than to meet with a patient, suffering from gonorrhoea of several months' standing, who has been kept on low diet, and been taking various preparations of copaiba and cubebs, using a variety of injections OBSTACLES TO SUCCESS. 79 often exceedingly irritant in their composition or strength, and who is now run down, weak in body and despairing in mind. His digestion is impaired, his appetite gone, and his clap as bad as ever. Let such a man lay aside his capsules, pills, powders, mixtures and irritant injections; give him substantial food, and a tonic, as quinine or iron; limit the special treatment of his disease to a weak astrin- gent injection, as from one to three grains of sulphate of zinc to the ounce of water, and his disease will probably begin to improve at once, and subside entirely in the course of a few days or weeks. Under any circumstances, you will have removed one great obstacle to a cure, and if the discharge do not entirely disappear, it is pro- bably kept up by some local complication, which can now be attacked with a prospect of success. The following is a type of this class of cases. Case. P. A., aged 19, applied to me on May 5th, 1857, for a gonor- rhoea which he contracted about the middle of January. He had been under the care of several physicians, and had treated himself a portion of the time ; had taken copaiba in almost every form, and cubebs in large quantities; and had used strong injections of nitrate of silver, sulphate of zinc, alum and acetate of lead. He was now much debilitated, and complained of general malaise and loss of appetite, and the discharge was still copious. I passed a bougie to ascertain if he had stricture, but could discover none. I then directed him to abstain from all anti-blen- norrhagics and to live well, and prescribed five grains of citrate of quinine and iron to be taken with each meal, and an injection of sulphate of zinc, three grains to the ounce. In one week from the time I first saw him, the discharge had disap- peared. There was a slight return of it a few days afterward which lasted only for a day or two, and did not again appear. In the large class of cases of which this is a type, the disease is kept up by a debilitated condition of the system, and requires for its removal general hygienic measures, and in most cases tonics. I have found the citrate of iron and quinine, and the tincture of the chloride of iron, most serviceable. Independently of debility, the chief causes of the continuance of a gonorrhoeal discharge are the existence of stricture and irritation of the neck of the bladder. It is desirable in every obstinate case to ascertain if the former be present by the passage of a full-sized bougie, and if any obstruction be met with, appropriate treatment should at once be adopted. 80 URETHRAL GONORRHOEA IN THE MALE. It sometimes happens that a case of gonorrhoea has been going on well for a week or ten days under the use of the anti-blennor- rhagics and injections—the discharge has almost entirely ceased and the patient considers himself nearly well, when suddenly a relapse takes place; the discharge is once more thick and purulent; the scalding in making water returns; the injection, which has scarcely been felt for a number of days, excites considerable pain, and at the same time the patient has a frequent desire to pass his urine, and suffers from an uneasy sensation in the perineal region. The latter symptoms denote that the disease has extended to the deeper portion of the urethra, and that there is irritation or inflam- mation of the neck of the bladder. Under these circumstances, the case requires to be very carefully watched and judiciously treated. Unless great care be used, the inflammation may extend through the vas deferens to the scrotal organs, and swelled testicle ensue; or the prostate gland may become involved. If irritant injections now be used, they will prove inefficient and will aggra- vate the symptoms. It is best to suspend the use of injections altogether, and to resort to the exhibition of alkalies and sedatives, as recommended in the inflammatory stage, until the subsidence of the symptoms shall enable us to resume direct treatment; the patient should also be particularly careful with regard to exercise. Canada turpentine, the product of the Abies Balsamea, will also be found of essential service in these cases, in place of the anti-blennorrhagics, which should be omitted. It may be made into pills containing five grains each, of which from six to twelve should be taken daily. Still another remedy of value is blistering the penis or perineum, in the manner which I shall describe in connection with gleet. Treatment of Special Symptoms.—It remains to speak of the treat- ment of certain special symptoms which may attend a case of gonorrhoea, and one of the most annoying of these is chordee. Yarious sedatives are employed for the relief of this symptom, among which camphor holds the first rank. This may be given in the form of a pill, combined with extract of lettuce or opium, as in the following formulas:— R^. Lactucarii, Pulveris camphorae, aa 9ij. M. ft. pil. No. xx. Dose.—Two at bedtime. (Ricord.) TREATMENT OF SPECIAL SYMPTOMS. 81 R. Pulveris camphorae j^iss. Pulveris opii gr. x. M. ft. pil. No. x. Dose.—One or two. (Ricord.) Mr. Milton prefers camphor in a liquid form in large doses. He directs the patient to take one drachm of the tincture in water on going to bed, and every time he wakes up with chordee, to repeat the dose. He states that after the continuance of this treatment for two or three nights all tendency to chordee disappears. Lupulin is another .remedy of undoubted power in allaying the excitability of the genital organs, and possesses the advantage over opium that it does not constipate the bowels. It may be given in doses of fifteen grains, triturated in a mortar with sugar. This quantity is to be taken before going to bed, and may be repeated one or more times in the night if required. Of the above means of relieving chordee, I regard Mr. Milton's method of giving camphor, if it do not disagree with the stomach, and the administration of lupuline, as the best; yet none of the remedies mentioned can be relied upon with certainty of producing the desired effect, for they all fail in many instances. Much may be accomplished by directing the patient to avoid eating or drink- ing for some hours before going to bed, to be careful to empty his bladder and rectum, and to sleep on a hard mattress, with but few bedclothes over him. The position in bed is also of importance, since erections are much less likely to take place when lying upon the side than upon the back. I have sometimes directed a suppo- sitory of hyoscyamus and belladonna to be introduced into the rectum with good effect. Another means of relief which I have found highly successful is bathing the genital organs in very hot water directly before going to bed. The reaction after the application of heat has a sedative effect, and in this respect has exactly an opposite influence to that of the cold lotions which are sometimes advised. Hemorrhages from the urethra, occurring during erections, if slight, require no treatment. When copious, they are to be arrested by quiet, the horizontal posture, the application of ice externally, and the injection of ice-water into the canal; and severe cases may require compression effected by the introduction of a bougie within the urethra, and a bandage around the penis, or a compress to the perineum. 6 82 URETHRAL GONORRHOEA IN THE MALE. If abscesses form along the course of the urethra, they should be opened at an early period, for fear that they may break inter- nally, and thus give rise to urinary abscess and fistula. As an attack of gonorrhoea is passing off, it not unfrequently happens that the discharge assumes an intermittent character, entirely disappearing for a few days, and then, without apparent cause, reappearing for a day or two. This may occur several times in succession, and in some cases that I have witnessed, it has assumed great regularity. The surgeon should, of course, assure himself that the return of the symptoms is not due to imprudence, and, if satisfied of this, is generally safe in telling the patient that his disease will soon cease entirely to annoy him. It is important to continue treatment for some days after all traces of the disease have passed away, since relapses are very readily induced. They are usually brought on by the patient's neglecting the rules with regard to exercise, diet, etc., already laid down, or by his indulging in sexual intercourse. He should be particularly cautioned on these points, and should be directed to continue his medication, both external and internal, in decreasing doses, for at least ten days after the lips of the meatus have ceased to be glued together in the morning. Until every symptom of gonorrhoea has disappeared for this length of time, the patient cannot consider himself as securely well, and should still be cautious in his habits for a fortnight longer. The reader may be interested to know what is the average duration of treatment required in the hands of the best surgeons for the cure of gonorrhoea, laying aside those cases which are seen in the first stage, and which are speedily cured by the abortive method. This may be estimated at three or four weeks. Greater success, on the average, is probably not attainable by any means with which we are at present acquainted. GLEET. 83 CHAPTER II. GLEET. The term "Blennorrhoea," or, in common parlance, "Gleet," is applied to a slight and chronic discharge from the male urethra, unattended by symptoms of acute inflammation. Gleet generally follows without interval an attack of gonorrhoea,- as a consequence of the neglect or unsuccessful treatment of the latter; and, as the acute gradually subsides into the chronic disease, it is impossible clearly to define a line of demarcation between them, and to say when the former ceases and the latter begins. In many cases, however, gonorrhoea runs through its successive stages and is apparently cured; when, after an interval of several weeks or even months, the patient returns with the report that he has recently noticed in the morning on rising that the lips of his meatus adhere together, and, on separating them, that the urethra contains a small amount of matter; he suffers no pain or inconvenience, but is still anxious about his discharge and desires to be free from it. In such instances, it is probable that the cure of the preceding urethritis was only apparent, and that a slight degree of inflam- mation was left in the deeper portions of the canal, not manifesting itself externally until aggravated by some exciting cause, as coitus, alcoholic stimulants, fatigue, etc. Or, again, it is not improbable that there is a stricture of the urethra, which is the most frequent cause of the continuance of a gleety discharge following an acute attack of gonorrhoea. Other organic changes may exist within the canal and be productive of gleet, as vegetations similar to those met with upon the internal surface of the prepuce, and in rare instances, polypoid growths.1 Idiopathic gleet, or gleet not preceded by acute urethritis, may be dependent upon various affections of the prostate, and espe- cially upon the hypertrophy of this gland so common in old men. 1 See Thompson on Stricture, p. 73 et seq. 84 GLEET. It may also arise from disorder of the digestive function, and from disease of the bladder or kidneys, whereby the urine is rendered abnormally irritant. Gleet is often maintained by a state of general debility, or by a strumous, rheumatic, or gouty diathesis. That general debility is a fruitful source of the persistence of gleet, is evident from the fre- quency of this disease in persons of broken-down constitutions, and from the beneficial influence of tonics and general hygienic mea- sures in its treatment. Again, gleet is peculiarly frequent and obstinate in persons of a strumous diathesis who are subject to chronic inflammation of other mucous membranes, and under such circumstances is benefited by the administration of anti-strumous remedies. The influence of rheumatism and gout in the production of discharges from the urethra has already been mentioned in con- nection with gonorrhoea. Symptoms.—In many cases of gleet, the discharge is the only symptom. There is an entire absence of pain in the part, of red- ness and tumefaction of the lips of the meatus, and of scalding in passing water. In some instances, however, the patient experiences a feeling of uneasiness in the penis or perineum, or an itching about the glans, or in the deeper portions of the canal, which may either be constant or attendant only upon the passage of the urine. Again, at the first act of micturition in the morning, the obstruction offered to the exit of the stream by the matter which has dried around the meatus, and glued its lips together, often gives rise to forcible dis- tension of the canal, and a sharp momentary pain in the urethra, which may be avoided by previously separating the lips of the orifice. The discharge in gleet varies in its character, quantity, and in the time of its appearance. In some cases it is evidently purulent, especially when the gleet has followed a recent attack of gonor- rhoea. In other instances, it is perfectly transparent, and, examined under the microscope, is found to consist of a clear fluid, containing epithelial cells and free nuclei, either with or without a few pus- globules. Again, coagulated masses, like the white of an egg, are sometimes forced from the canal. In some cases, the discharge is constant, and sufficiently copious to stain the linen; but in the majority it is perceptible only in the morning on risin°\ When dependent upon inflammation of the deeper portions of the canal, SYMPTOMS —PATHOLOGY. 85 or of the prostate, it may only appear during the efforts of the patient at stool, or be mingled with the last drops of urine in mic- turition. The small amount of the discharge in most cases of gleet, and the frequency of this disease among soldiers, has given rise to the name, "goutte militaire," employed by the French. The symptoms of gleet now described are liable to be aggravated by any cause which produces urethral or vesical irritation. In other words, a gleet is readily transformed into a clap. A hearty meal, alcoholic stimulants, free sexual indulgence, violent exercise, a long ride, or exposure to sudden changes of temperature, may bring on a copious purulent discharge, attended by tumefaction of the parts, scalding in micturition, and all the symptoms of acute gonorrhoea. Only a few hours are required for this change to take place, and, hence, we may explain the sudden reappearance of some attacks of gonorrhoea—often supposed to be due to fresh contagion —when patients, too confident that they are well, are hasty in in- dulging in drink or coitus. Hunter, in his work on Yenereal, states that "a gleet is perfectly innocent with respect to infection," and that in the relapses which so frequently occur, "the virus," in his opinion, "does not return." This statement, although often refuted, still finds place in many elementary works, which are in the hands of medical students. A doctrine more dangerous to the peace of families could scarcely be promulgated. It is, indeed, true, that men are occasionally met with who have for years suffered from gleet, and who have yet had frequent connection with their wives with impunity, but where contagion ceases and immunity begins, no one can tell; and even if we were able to pronounce a discharge of a certain degree of purity innocuous, we could not foresee the effect upon it of a few hours' sexual indulgence. It may at the present moment be wholly mucous, and entirely innocent of contagious properties, and yet a short time hence be purulent, and in the highest degree dangerous. The fact is, no one can pronounce sexual congress safe, so long as a urethral discharge exists, and in replying to the frequent ques- tions of patients on this point, the surgeon should not only avoid incurring the responsibility of allowing it, but do all in his power to dissuade from it. Pathology.—Our knowledge of the pathology of gleet is some- what imperfect, since the urethra is beyond the reach of direct 86 GLEET. observation, and opportunities for making post-mortem examina- tions of persons affected with this disease are very rare. There can be no doubt, however, of the general truth of the law that, while the straight or anterior portion of the urethra is affected in gonorrhoea, the posterior and curved portion is the most frequent seat of gleet, as evidenced by the extension of the inflammation in many cases to the testicle, the uncomfortable sensations experienced by the patient in the perineum, and the difficulty of curing the dis- ease by means of injections, unless the fluid be made to enter the deeper portions of the canal; moreover, after the spongy urethra has been freed of its discharge by pressure along the under surface of the penis, an additional quantity may generally be forced out from the bulbous and membranous portions by pressure upon the perineum. In the few post-mortem examinations which have been made of persons affected with urethral discharges, sufficient attention has not been paid to the duration of the disease nor to the symptoms during life. The most minute description of the pathological appearances of gonorrhoea and gleet is the one given by Rokitansky, who says: " We find the anatomical characters to be those belonging to catarrh generally; in the acute stage there is, according to the violence of the process, redness, injection, tumefaction of the urethral mucous membrane, or secretion of puriform mucus; in the chronic stage there is tumefaction of the mucous membrane, enlargement of the follicles, relaxation of the sinuses, and a white or colorless secretion. The inflammation is either uniformly diffused over the urethra, or is limited to one or more spots. The latter is especially the case in genuine gonorrhoea of the male urethra; we here find not only the navicular fossa, but every point as far as the prostatic portion, and especially the vicinity of the bulb of the urethra liable to become the se*at of the disease. When the gonorrhoea is very violent and obstinate, a small tubercular swelling, which results from the deposition of fibrous matter in the spongy tissue of the urethra, is found at these points."1 Mr. Thompson has found nearly the same appearances: "Ob- servation demonstrates that the two spots which suffer most from gonorrhoeal inflammation, are the fossa navicularis and the bulb; I have had opportunities of observing this two or three times in the dead-house, on the bodies of patients who had been suffering from 1 Pathological Anatomy, Sydenham Society's Translation, vol. ii. p. 233. PATHOLOGY— TREATMENT. 87 gonorrhoea shortly before death. Unusual vascularity is found in the latter situation, particularly if the affection have been chronic, while the intermediate part appears comparatively very little affected. There is a preparation in the Museum of St. George's Hospital, which exhibits the urethra of a patient who died while suffering from gonorrhoea, in which an ulcer exists (the only one to be seen) in the commencement of the membranous portion."1 It is impossible to determine whether the ulcer in the case referred to by Mr. Thompson was a chancre, or a superficial erosion such as is met with in balanitis; it was probably the former, since gonorrhoeal inflammation rarely produces ulcerations involving the whole thickness of the mucous membrane and capable of detection in a preparation that has been preserved for a long time in spirit. The lacuna magna upon the superior wall of the fossa navicularis is probably, in some instances, the source of the discharge in gleet, since it is peculiarly exposed from its situation to participate in the inflammation of gonorrhoea, and its internal surface is not readily accessible to injections. Dr. Phillips states that he has succeeded in curing four obstinate cases of gleet by introducing a director along the upper surface of the urethra until its extremity entered the lacuna magna, and slitting up the wall of the follicle with a narrow bistoury. When the disease is situated in the deeper portions of the canal, we may sometimes determine its seat by the introduction of a bulbous pointed sound or bougie. The patient flinches when the affected part of the canal is reached, and the enlarged extremity of the instrument meets with slight obstruction from the thickened mucous membrane. It appears, therefore, that the pathological changes of gleet are similar to those met with in chronic inflammation of other mucous membranes, as the conjunctiva, tear passages, and the external meatus auditorius, and the extension of the inflammatory process to the membrane lining the follicles and the ducts which open into the deeper portions of the urethra, may account for the well-known persistency of the disease, which is almost proverbial. Treatment.—The treatment of gleet should be addressed to the general condition of the patient as well as to the local disease. It may be laid down as a rule to which there are but few exceptions, 1 Stricture of the Urethra, p. 84. 88 GLEET. that in gleet the tone of the general health is more or less reduced. Not that all patients with gleet are necessarily weak and emaciated; on the contrary, many appear to be robust and hearty; but it is almost always the case that they are not capable of the same amount of exertion as formerly; they are sensible that they have lost a portion of their animal vigor; and the benefit of general hygienic measures and tonics in their treatment is unmistakable. The diet should be plain but substantial, consisting of fresh meat, vegetables, eggs, etc., to the exclusion of salt meats, cheese, and highly-seasoned articles; and secretion from the skin should be promoted by means of frequent sponging or bathing. With regard to exercise, although a long walk or ride, especially when carried to fatigue, will be found to aggravate the discharge, yet when commenced with moderation, and gradually and steadily increased in proportion to the strength, it is found to be highly beneficial. Healthy exercise of the mind is no less important than that of the body, and the attention of the patient should be distracted as much as possible from his disease, and all books and associations calculated to excite the passions be avoided. The bowels should be opened daily, if possible by selecting such articles of food as are laxative, and by regularity in the hour of going to the closet, or, if required, by the administration of medicine. One of the following pills taken at bedtime, will usually insure a free stool in the morning. R. Strychniae gr. ss. Pil. colocynth. comp. 5s3. M. Divide into thirty pills. In the tincture of the chloride of iron, we have a most valuable combination of a tonic and an astringent; which, in most cases of disease of the generative organs in the male and female, is unequalled by any of the more modern and elegant preparations of this mineral. It may be given in doses of from five to twenty drops, largely diluted with, water, three times a day, directly after meals. If the dose be properly graduated, it less frequently excites headache in the male than the female;.should this unpleasant symptom occur, iron reduced by hydrogen may be'substituted for it, in doses of three grains, three times a day. Where the constitutional debility is marked, the union of quinine with iron may be desirable, as in the following:— TREATMENT. 89 R. Ferri et quiniae citratis 3J-ij. Aquae |j. Syrupi limonis ^ij. M. A teaspoonful after each meal. I£. Tincturae cantharidis 5j. Quiniae sulphatis ^ss. Tincturae ferri chloridi 3ij. Acidi sulphurici diluti xxx. Aquae destillatae 5 viij. M. One ounce three times a day. (Childs.) Other salts of iron, as the tartrate of iron and potassa, or the pyro-phosphate of iron, may be substituted for the citrate, in the first of the above prescriptions. In the administration of iron I have always found a rule laid down by Trousseau, a good one, viz., not to stop the medicine suddenly; after the object for which it is administered has been attained, it may be omitted for a fortnight, when it should again be resumed for a few weeks; in this way its effect is rendered much more permanent. With patients of a strumous diathesis, cod-liver oil, the syrup of the phosphates, or Blancard's pills of iodide of iron, may often be used with advantage. I have found that the iodide of potassium has a tendency to increase the discharge from the urethra, as it often does the secretion from other mucous membranes, and I do not therefore administer it. This effect of the iodide may frequently be observed, when we are giving it for tertiary syphilis to patients, who, at the same time, are affected with gleet. From what has already been said of copaiba and cubebs, it is evident that but little good can be expected from their administra- tion in cases of chronic urethral discharge. Moreover, most pa- tients, whose disease has arrived at this stage, have already taken them ad nauseam for the preceding gonorrhoea; hence, we are rarely called upon to administer them in pure gleet. In those cases, how- ever, in which the gleet has relapsed into a clap, they may be given with benefit, especially when combined with a tonic, as in the dragees of copaiba, cubebs, and citrate of iron; in Meot's pills, the formula for which has already been given; and as in the following pre- scription :— 90 GLEET. I£. Copaibae §ss. Tincturae cantharidis §ss. Tincturae ferri chloridi §j. M. Dose.—Thirty drops three times a day. The reader will observe that the tincture of cantharides is an ingredient of several of the above prescriptions. Experience has shown that this drug exerts a decidedly curative action in many cases of gleet, and in gonorrhoea also, in the chronic stage. It is a favorite remedy with the homoeopaths, in doses of a drop of the tincture every few hours, in the acute stage of clap, and is con- sidered by them to be indicated by scalding in micturition, chordee, and a greenish or bloody discharge. I- have used it, however, only in the chronic stage. The tincture may be given in doses of three or five drops three times a day, or it may be combined with iron, as follows:— R. Tincturae cantharidis 5'j- Tincturae ferri chloridi 5VJ- M. Ten drops in water, three times a day. In some cases of gleet there is considerable irritability of the neck of the bladder, as shown by a frequent desire to pass the urine and unpleasant sensations in the perineum. In these cases benefit will be derived from the administration of the salts of potash, com- bined with hyoscyamus, as in the prescriptions already given when speaking of the acute stage of gonorrhoea. Canada balsam is also an excellent remedy under these circumstances. R. Abietis balsameae sjij. Div. in pil. No. xxiv. Two. three times a day. Bougies.—In all cases of gleet, the urethra should be carefully examined with a full sized bougie or sound, in order to detect the presence of stricture; and if the slightest contraction be discovered, it should at once receive appropriate treatment, since upon its removal will probably depend the cure of the discharge. Dr. Charles Phillips, whose name is little known to the American pub- lic, but who in Paris has acquired an enviable reputation in diseases of the genito-urinary organs, states that gleet is almost invariably dependent upon slight stricture, which may be detected by means of bulbous-pointed and knotted bougies, but which is frequently BOUGIES. 91 overlooked from the want of careful exploration with proper instru- ments.1 Whatever may be the truth of this statement, which, to say the least, requires confirmation, the frequent passage and retention of bougies is one of the best means known for the treatment of gleet, even when no stricture can be discovered by the ordinary mode of examination. The manner in which bougies effect a cure of chronic urethral discharges is somewhat obscure, but is probably to be ex- plained on the ground that they distend the canal, expose lacunge in which matter would otherwise lodge, and separate for a time the diseased surfaces; or, again, they may serve to stimulate the vessels of the part, and thus change their action. . Bougies tapering towards the extremity and terminating in an olive-shaped point, are best adapted for the purpose. They are introduced easily and with little inconvenience to the patient, and the contraction near their point facilitates the introduction of medi- cated ointments into the deeper portions of the canal. The instru- ment should be large enough fully to distend the canal but not to stretch it, and should be smeared with cerate, lard, olive or castor oil, or glycerin. The bladder should previously be emptied and the patient placed in the recumbent posture. However gently it may be introduced, the first passage of a bougie usually excites a more or less disagreeable sensation, which sometimes gives rise to syncope, and which generally renders it advisable to withdraw the instrument in a few minutes; but after two or three insertions it ceases to give annoyance, and may be retained for half an hour or an hour. It sometimes happens that the bougie aggravates the discharge, and revives the acute inflammation which has for a time disap- peared. In such cases it is best to suspend the treatment and resort to injections, which will often effect a permanent cure. This ag- gravation of the symptoms, however, according to my experience, takes place in a minority of cases only. With this exception, the passage of the bougie may be repeated every second or third day at first, and afterwards every day, or in some instances as often as twice a day. The length of time requi- site for a cure by means of bougies varies in different cases. As examples of their successful employment I may mention one case 1 Traite des Maladies des Voies Urinaires, Paris, 1850, p. 33. 92 GLEET. recently under my care, a gleet of four years standing, which was treated with the tincture of the chloride of iron internally, and the introduction of bougies every second day, and in which a cure was effected in two weeks. In another case, a gleet of nine months, the discharge disappeared in three weeks under the use of the same means. Other cases of a like character might be mentioned, but such satisfactory results cannot by any means be expected in every instance. In many, this treatment must be continued for several months, or other measures, as injections and blisters, be resorted to. Bougies may be medicated in various ways. Calomel rubbed up with sufficient glycerin or oil to cover it, forms a very cleanly and excellent mixture with which to anoint the bougie, and I think materially assists the curative action. Mercurial ointment may also be used, either alone or combined with extract of belladonna, the latter being added in case the urethra is irritable. R. Unguenti hydrargyri ^ss. Extracti belladonnae 5SS- M. For the purpose of stimulating the mucous membrane, we may employ the diluted ointment of red oxide of mercury, or an oint- ment containing a few grains of nitrate of silver, but such applica- tions should not be continued for any length of time, lest they keep up the discharge. R. Ung. hydrarg. oxidi rubri 3J. Adipis 5iij. M. R. Argenti nitratis gr. v-x. Adipis sj. M. Injections.—Injections have been so fully discussed in the preced- ing chapter, that little remains at present to be said of their com- position, or the ordinary mode of their administration. In gleet as in gonorrhoea, weak solutions of the sulphate or acetate, of zinc (containing from two to three grains to the ounce of water) are in most instances to be preferred; and the injection should be made to permeate the urethra as deeply as possible, in order that it may be applied to the whole extent of the affected surface, but care should be taken not to distend the canal with too much force, the sensations of the patient being the best indication when a sufficient amount has been employed. So far as inflamma- INJECTIONS. 93 tion of the testicle and prostate have any connection with the use of injections, I believe they are more frequently due to violent manipulation than to the irritant character or strength of the solu- tion. Hence, injections should always be used with gentleness, while at the same time the canal should be entirely filled, that none of the folds, into which the urethral walls are naturally thrown ex- cept during the passage of the urine, may escape coming in contact with the astringent fluid. With this precaution, a weak injection may be employed to advantage every two or three hours; a degree of frequency which will often prove successful when a less degree has failed. In addition to the formulae for injections given in the chapter upon gonorrhoea, the following may be added:— I£. Hydrargyri bichloridi gr. j. Aquae Jviij-xij. M. R. Gallae gj. Aluminis £)ij. Aquae 3 viij. M. R. Acidi nitrici gtt. xvj-xl. Aquae 3*viij. I have recently employed with very satisfactory results the solu- tion of persulphate of iron prepared by Dr. Squibb, as in the fol- lowing :— R. Liq. ferri persulphatis (Squibb) 3ss. Aquae 3*vj. M. The strength of the above solution may, in some instances, be increased. Ricord advises solutions containing iodine in scrofulous subjects, and although the injection of this mineral into the urethra cannot be supposed to affect the constitutional diathesis, yet it may exert a beneficial action upon the mucous membrane as when applied to the fauces. ]$.. Tinct. iodinii gtt. viij. Aquae ^viij. M. (Ricord.) R. Ferri iodidhgr. viij. Aquae 3viij. M. (Ricord.) 94 GLEET. I will here repeat a suggestion previously given, that the use of any medicated injection, and especially one containing insoluble ingredients, will prevent even a sound urethra from exhibiting its normal dryness. Without due caution, therefore, a patient may go on injecting long after his disease is cured. Hence, after the dis- charge has for some time been reduced to a very minute quantity, and especially if it appear to consist of little more than the insolu- ble deposit of the solution, the injection should be omitted for a few days, in order that the exact condition of the urethra may be de- termined ; or, again, it may be administered only once in the twenty- four hours, selecting for the purpose the early part of the day, and the appearance of the meatus the following morning will indicate what progress has been made towards a cure. Substitutive medication is sometimes employed in gleet as in the abortive treatment of the first stage of gonorrhoea. Thus, highly irritant or caustic injections are used with the intention of exciting acute inflammation, upon the subsidence of which the chronic affection may perhaps disappear. Nature accomplishes the same result in- the same manner, when, as sometimes happens, after the cure of a fresh attack of gonorrhoea no traces remain of a preceding gleet. Substitutive treatment, however, is less successful in gleet than in the early stage of gonorrhoea, since the seat of the disease is less accessible and the mucous membrane more deeply affected; moreover, it is less safe, since an irritant injection extended to the deeper portions of the canal is more liable to induce swelled testicle than when limited to the fossa navicularis. Either nitrate of silver or chloride of zinc is most frequently employed in the substitutive treatment of gleet, and, as in the abortive treatment of gonorrhoea, the solution may be a strong one and injected but once, or weak and repeated a number of times. For instance, the surgeon may thoroughly and once for all inject with his own hands a solution of ten or fifteen grains of nitrate of silver, or five grains of the chloride of zinc to the ounce of water; or a weaker solution of either (from one to five grains of the nitrate, and from half a grain to two grains of the chloride) may be injected by the patient several times a day until the discharge becomes copious and purulent, when the injections should be suspended until their effect upon the gleet can be determined. Sometimes, as previously stated, the pain excited in a certain portion of the urethra by a bulbous pointed bougie and the slight DEEP URETHRAL INJECTIONS. 95 obstruction presented by the thickened mucous membrane, will indicate the probable source of a gleety discharge; and in such instances, having first measured its distance from the meatus, the affected surface may be cauterized with Lallemand's porte-" caustique. Deep Urethral Injections.—In the ordinary method of injecting the male urethra, it is impossible to make the fluid pass through the whole extent of the canal into the bladder. After a certain portion (about half an ounce) of the contents of the syringe has been injected, the remainder escapes above the piston, or, however tightly the glans may be compressed around the point of the in- strument, flows from the meatus. The obstruction to the entrance of the fluid is due to the contraction of muscular fibres (the com- pressor urethras muscle) which surround the membranous portion and serve as a sphincter to the urinary canal ;l and this is the posterior limit of the application of the fluid to the urethral walls by the more common method of injecting. In order to reach the deeper portions of the canal, which are involved in many cases of gleet, it becomes necessar}- to resort to injections through a catheter, or by means of the "urethral syringe with extra long pipe," manu- factured by the American Hard Rubber Company. The length of the urethra should be measured by introducing a catheter and marking the point in contact with the meatus when the urine first commences to flow; upon withdrawing the instru- ment the distance between its eye and the mark upon the stem will be the measurement required. On again introducing the catheter for the purpose of injecting (the patient having first passed his water), it is an easy matter to carry its point within half an inch of the vesical neck without entering the bladder, when the fluid may be thrown in by means of a syringe as the instrument is slowly withdrawn. If the catheter be sufficiently large to moderately distend the canal, none of the injection will escape from the meatus so long as the eye of the instrument is in the prostatic or membranous portion of the urethra, since the contraction of the same muscle which prevents the entrance of fluid from without, also prevents its exit from within, and obliges it to flow backwards towards the bladder; hence we may, if we choose, limit the appli- cation of the injected fluid to the deeper portions of the canal 1 See the section on the Anatomy of the Urethra in the chapter on Stricture. 96 GLEET. exclusively, and the pain excited will be found to be less than when a solution of the same strength is thrown into the external portion, since the urethra, like other mucous passages, is most sensitive near its outlet. The chief disagreeable sensation follow- ing an injection thus confined to the portion of the urethra- lying between the compressor urethras muscle and the neck of the bladder, is an urgent desire to pass water, which, however, should be resisted as long as possible, that the fluid may have time to act upon the urethral walls before it is washed away or neutralized by the urine. During the succeeding twenty-four hours, micturition is somewhat more frequent than usual, but is not particularly painful; and the discharge is slightly increased for a day or two. The efficacy and safety of these injections in affections of the deeper-seated portions of the urethra is attested by MM. Diday1 and Bonnet, of Lyons, Mr. Langston Parker,2 of Birmingham, and my own experience. The same formulas may be employed that have been recommended for injections by the more common method, and the application may be repeated once or twice a week. Blisters.—Blisters were long ago recommended for the cure of obstinate cases of gleet, but had almost fallen into disuse, when they were revived by Mr. Milton, in his work on the treatment of gonorrhoea. This author speaks of them in the following terms: " I have seen two blisters, with a mild injection or two, at once cure a clap which had defied the most energetic treatment; and as I never found a case which resisted blistering and injections together, that was not complicated with stricture or affection of the testicle, lam slowly arriving at the conviction, that every case of clap or gleet, however ob- stinate, may, if uncomplicated, be cured by blistering, singly or com- bined^ It is to be feared, however, that this remedy has proved less successful in the hands of other surgeons than in Mr. Milton's. Recent writers who have spoken favorably of them, appear to have done so chiefly on Mr. Milton's authority; others, as Mr. Langston Parker, have given their testimony decidedly against them, and in 1 Des Injections circonscrites a la partie profonde de l'uretre, de leur mode d'exe- cution et de leur efficacite curative ; Annuaire de la Syphilis, annee 1858, p. 61. Diday's method of employing deep urethral injections has been followed in the above description. 2 Syphilitic Diseases, page 82. Mr. Parker injects the fluid into the bladder, lets it remain for a few minutes, and desires the patient to force it out. This method is not so good as the one above recommended. 3 Milton on Gonorrhoea, p. 90. The Italics are in the original. SEPARATION OF THE AFFECTED SURFACES. 97 my own practice they have not been attended with such success as to lead me to prefer them to other and less disagreeable modes of treatment. Still, they may be worthy of a trial in obstinate cases which have resisted the use of bougies and injections. The manner of applying them is of considerable importance. The hair should be shortened around the root of the penis, and a piece of paper be wrapped around the organ, and cut in such a manner as to form a pattern of its surface from the pubis to within half an inch of its extremity. The blister, corresponding in shape and size to the pattern, should be applied to the penis, and tied or fastened in its place, that it may not slip, and coming in contact with the scrotum, produce a troublesome sore. It should not be retained longer than two hours, during which the patient must remain quiet. The morning is the best time for its application, since, if applied at night, it is likely to prevent sleep. On remov- ing it, the surface is found to be reddened, but not vesicated, un- less, perhaps, at a few points; and the penis should now be covered with a rag spread with simple cerate, and be protected from friction by an external layer of cotton wadding. On examining the parts after a few hours, it will be found that numerous bullae have formed on the surface, which at first appeared to be only reddened. These may be pricked, and the serum which they contain evacuated, but the epidermis should be carefully pre- served. I have sometimes found the extremity of the prepuce beyond the site of the blister, puffed out with an effusion into its cellular tissue, which may be left to take care of itself, or, if exces- sive, be evacuated by a few punctures with a. lancet. Cantharidal collodion is" a more convenient application than the unguentum lyttas, but its effect cannot be limited like that of the latter, which should therefore be preferred. When applied for a few hours only, I can confirm Mr. Milton's statement, that blisters do not excite severe pain, nor produce a troublesome sore. The first effect of their application is to increase the urethral discharge, which can only be expected to be benefited in the course of five or six days. The blister may be repeated at the end of a week, if any discharge still remain. The perineum may be blistered in a simi- lar manner, but this will require the patient to be kept in bed until the vesicated surface has healed. Separation of the Affected Surfaces.—Contact of the diseased sur- faces doubtless assists in keeping up the discharge in gleet, as it is 7 98 GLEET. well known to do in balanitis. Hence it has been proposed, by means of a probe and a gum-elastic bougie open at the extremity, to introduce a strip of lint, either dry or soaked in some astringent fluid, within the urethra, and thus maintain its walls apart, renew- ing the application after each passage of the urine. This method, in which I have had no experience, has been successful in some instances, but is very troublesome and inconvenient, and would appear to be attended with danger of the lint slipping entirely into the urethra, and entering the bladder. Civiale mentions a case in which this accident occurred, but does not give the ultimate result.1 Mr. Milton2 states that it has happened to him in several instances, and that the lint has always found its own way out, but the danger of its retention is too great to be incurred. Finally, in obstinate cases of gleet in which the discharge ap- pears to come from the anterior portion of the urethra, laying open the lacuna magna, as recommended by Dr. Phillips, is worthy of a trial.3 1 Maladies des Organes Genito-urinaires, vol. i. p. 444. 2 On Gonorrhoea, p. 31. 3 See page 87. BALANITIS —CAUSES. 99 CHAPTER III. BALANITIS. If the prepuce be retracted, a mucous surface of considerable extent is exposed, a portion of which covers the glans penis, and the remainder consists of the internal reflection of the prepuce. This surface may be the seat of inflammation, similar to that which has been described as affecting the urethra. If the disease be con- fined, as it sometimes is, to the membrane covering the glans, it should, strictly speaking, be called balanitis; if to the internal sur- face of the prepuce, posthitis, and if it involve both, balano-posthi- tis; all these varieties, however, for the sake of convenience, are commonly included under the one name, balanitis. Gonorrhoea spuria, balano-preputial gonorrhoea and external blennorrhagia are other terms by which it is sometimes known. Causes.—Men in whom the prepuce is very long, or who are affected with congenital phymosis, are peculiarly exposed to bala- nitis, since the mucous membrane covering the glans, and lining the prepuce, is maintained in so sensitive a condition, from its want of exposure to the air and friction, that inflammation is readily set up by the least cause of irritation. In persons with congenital phy- mosis, the mere collection of sebaceous matter, the removal of which is prevented by the occlusion of the preputial orifice, is suf- ficient to give rise to balanitis; and I have known of several in- stances in which, from inattention, the discharge was supposed to come from the urethra, and was mistaken for gonorrhoea. The diagnosis can readily be made by exposing and wiping the meatus, and then observing whether upon pressure the matter comes from the urethra, or the balano-preputial fold. In general, the exciting causes of balanitis are the same as those of urethral gonorrhoea. Thus it may arise from exposure to gonor- rhoeal or leucorrhceal discharges, or from intercourse about the 100 BALANITIS. time of the menstrual period; and, even more frequently than gonor- rhoea, from coitus with a healthy woman, particularly under cir- cumstances of special excitement, from violence, masturbation, excessive exercise, the want of cleanliness, errors in diet, and atmos- pheric influences. To these should also be added the presence of a chancre, vegetation, or an eruption dependent upon syphilis or other causes, upon the mucous membrane of the glans or prepuce. Symptoms.—The symptoms of balanitis are tenderness of the extremity of the penis, an itching sensation beneath the prepuce, and scalding during micturition if the urine comes in contact with the affected surface. The inflamed mucous membrane is sensitive on pressure, reddened, and often denuded of epithelium in irregular patches, which are of a darker red than the surrounding surface where the epithelium is but partially detached. These superficial excoriations are generally multiple, and are similar to the ulcera- tions frequently met with upon the cervix uteri. The affected surface secretes a muco-purulent fluid, varying in quantity and consistency, as in gonorrhoea. If phymosis exist and the preputial orifice be so contracted as not to afford free exit to the discharge, the matter may collect at the base of the glans and form an abscess. An effusion of serum takes place in the cellular tissue of the pre- puce, rendering it more or less cedematous, and sometimes occasion- ing accidental phymosis. The general system sympathizes but little with the local affection, which is in most cases of short duration, and very amenable to treatment. The inguinal ganglia may, in rare instances, become slightly enlarged and sensitive, but they never suppurate. One attack of balanitis predisposes to another. Men with a long prepuce or congenital phymosis, are often met with who have lived thirty or forty years without suffering inconvenience from their malformation, but who, after one attack of balanitis, are constantly subject to others, following intercourse with the most healthy woman, or even mere imprudence in diet. Treatment.—When the prepuce can be retracted, the treatment of balanitis is exceedingly simple. All that is necessary, in most eases, is to free the parts from any collection of matter by gently washing them with tepid water, and then to cut a piece of lint or soft linen into pieces about an inch square, and laying them upon treatment. 101 the glans with their upper margin well up in the corona, to draw the prepuce over them. In this manner the inflamed surfaces are isolated from each other, and speedily take on a more healthy action. The frequency with which this application should be repeated depends upon the copiousness of the discharge; generally from two to four times in the twenty-four hours is sufficient, and a cure is usually attained in a few days or a week. In severe cases, however, other measures than those mentioned may be desirable. If the surface be excoriated, it is well to pencil it over lightly with a crayon of nitrate of silver, or to apply a solution of this salt, of the strength of a drachm to the ounce of water. Again, instead of using the lint dry, it may be moistened in either of the following mixtures:— R. Liquoris plumbi diacetatis 3j. R. Liquoris sodae chlorinatse 3HJ. Aquae 3* ij. AquaB 3* v. M. M. R. Acidi tannici 5Jj. R. Extracti opii 9j. Glycerin 5J. Zinci sulphatis gr. vj. M. Glycerin 3*j. Aquae 3* ij. M. When phymosis, either congenital or acquired, exists, the parts are less accessible to treatment. In this case the nozzle of a syringe holding several ounces and filled with tepid water, should gently be inserted between the glans and prepuce, and its contents be discharged into this cavity, in order to free it from all collection of matter. A few drachms of a solution of nitrate of silver, or of one of the lotions just mentioned, may then be thrown up, and this should be repeated several times in the course of the day. In these cases, Mr. Langston Parker highly recommends the following pre- paration, introduced between the glans and prepuce by means of a camel's-hair pencil:— R. Cerati simplicis, vel mellis, Olei olivaB, aa §j. Hydrargyri chloridi jss. Extracti opii 3J. M. If balanitis be attended by much infiltration into the cellular tissue of the prepuce, the fluid should be evacuated by several punctures with a lancet. If the patient can keep his bed, the penis may also be enveloped in a single thickness of linen, wet with cold 102 BALANITIS. water or diluted Goulard's extract, and exposed to the air. If, however, he continues his daily occupation, no benefit can be ex- pected from such applications, which, when confined by the clothes, act like poultices, and favor rather than prevent oedema. In all cases the cure of balanitis will be accelerated, if the patient be kept quiet and the parts elevated. When this disease is dependent upon the presence of a chancre, secondary eruptions or vegetations, these should receive their appropriate treatment. With persons who have repeated attacks of balanitis it becomes an important object to take measures to prevent them. To accom- plish this the strictest cleanliness should be enjoined. The parts should twice a day be cleansed of all accumulation of their natural secretion, and afterwards moistened with an astringent lotion, as a mixture of equal parts of brandy and water with the addition of alum, a solution of tannin, or any of the astringent washes already mentioned. It is also desirable to attend to the digestive functions, and to regulate the diet. The influence of a long prepuce in pro- ducing relapses of this disease has already been referred to. I have sometimes succeeded in remedying this malformation by directing the patient to keep his prepuce constantly retracted by means of a narrow bandage applied around the penis, posterior to the glans. If this be worn for a few weeks, the prepuce will often remain retracted without further assistance, and the mucous surface of the glans becomes hardened by exposure and friction. If this attempt prove unsuccessful, the superfluous integument should be removed by circumcision. PHYMOSIS. 103 CHAPTER IV. PHYMOSIS. The term Phymosis is applied to that condition of the penis in which it is impossible to retract the prepuce behind the glans. In the majority of cases phymosis is a congenital malformation due to unnatural narrowness of the preputial orifice, and may be associated with adhesions, varying in position and extent between the glans and its covering. A remarkable instance of this kind is recorded in the Surgical Register of the N. Y. Hospital: Joseph Smith, of Prussia, aged 49, was admitted into this institution Oct. 19,1832, with congenital phymosis. Dr. Stevens removed the free portion of the prepuce, which was found to be attached to the mar- gin of the meatus instead of the base of the glans, and formed a tubular prolongation of the urethra nearly an inch in length. Congenital phymosis is a source not only of great inconvenience to the subject of it, but of increased exposure to venereal diseases in promiscuous intercourse, and is sometimes the cause of serious disturbance in the genito-urinary and nervous systems. Mr. Jonathan Hutchinson1 has shown by statistics that syphilis is much less common among Jews than among Christians, probably on account of the practice of circumcision among the former. At the Metropolitan Free Hospital, situated in the Jews' quarter, London, in 1854, the proportion of Jews to Christians among the out-patients was nearly one to three; yet the ratio of cases of syphilis in the former to those in the latter was only one to fifteen; and that this difference was not due to their superior chastity was evident from the fact that the Jews furnished nearly half the cases of gonorrhoea that were treated during the same period. Mr. Hutchinson's ob- servations also lead him to believe that hereditary syphilis is much rarer amono- the children of Jews than Christians; and the experi- 1 Medical Times and Gazette, Dec. 1, 1855. 104 PHYMOSIS. ence of most surgeons will confirm the fact that persons with a long prepuce, and especially those affected with congenital phymo- sis, are peculiarly subject to venereal diseases. The size of the preputial orifice in congenital phymosis varies in different cases. In some, it is large enough to permit of the partial exposure of the glans and the removal of the natural secretion of the part, at least with the assistance of a syringe and injections of warm water; while in others, it is so contracted that it is difficult or even impossible to uncover the meatus; whence it happens that the entrance of the urine at each act of micturition beneath the prepuce, and the collection of sebaceous matter, maintain a constant state of irritation and even chronic inflammation, to which most of the adhesions met with between the opposed surfaces are undoubt- edly attributable. Daily observation proves that congenital phymosis is not incon- sistent with a state of perfect health; and yet when we reflect upon the sympathy existing between different portions of the genito- urinary apparatus, and between the latter and other organs, we might reasonably expect to meet with at least occasional instances in which irritation of the head of the penis due to this cause gives rise to disturbance in other parts of the body. These anticipations are realized in practice; but, according to Fleury,1 who has ably investigated this subject, such disturbance is to be attributed more to the extreme sensitiveness of the balano-preputial membrane con- stantly protected from friction and exposure to the air, than to the irritation of collections of sebaceous matter; since it is often present even when the condition of the parts admits of the most perfect cleanliness. Among the symptoms which have been ascribed to congenital phymosis are: balanitis, constant itching and even pain at the head of the penis, inordinate excitability of the genital organs, frequent erections, erotic dreams, seminal emissions, imperfect development of the penis and testicles, incomplete and painful ejaculation of the sperm, vesical tenesmus, incontinence of urine, gastralgia, neural- gias, and general lassitude and prostration. Probably no one will be disposed to call in question the occasional connection between the milder of the above affections and phymosis. With regard to the others, some doubts might be legitimately entertained, were it 1 Gaz. des Hop., Oct. 30, 1851. TREATMENT. 105 not for the circumstantial report of the symptoms, and the fact l.hat simple excision of the elongated prepuce has in most cases "brought complete and permanent relief.1 Accidental phymosis may depend upon any cause enlarging the glans penis to such an extent that it will not pass through the pre- putial orifice, or occasioning such an amount of thickening or con- traction of the prepuce that it cannot be retracted; in other words, the seat of the difficulty may be either in the glans or its covering. In some cases the obstruction is simply mechanical, as from vege- tations within the balano-preputial fold, the induration surrounding an infecting chancre, or the cicatrization of any primary sore situ- ated Lpon the margin of the prepuce. More frequently it originates in inflammatory action, as idio- pathic balanitis or posthitis, or the same affections excited by the presence of chancres, secondary eruptions, vegetations, etc., either of whica may occasion swelling of the glans or infiltration in the lax cellu'iar tissue of the prepuce. There is still another cause of phymosis which, strictly speaking, cannot be included among those just mentioned; I refer to a peculiar thickening of the mucous membrane and submucous tissue, obseived both in men and women after the cicatrization of a chancre, and which consists neither in specific induration nor oedema, but in hypertrophy of the normal tissues of the organ. Gosselin believes that this effect is peculiar to primary sores, and ranks it among the consecutive symptoms of syphilis. It is most frequently found in the labia minora in women, and in the prepuce in men. In the latter the envelope of the glans may become so thickened that its retraction may be very difficult and give rise to fissures of the preputial orifice, or may be quite impossible. Treatment.—In congenital phymosis attended by any of the unpleasant effects alluded to at the commencement of this chapter, circumcision is the only sure means of relief; but if, from any cause, an operation be impracticable, the patient should be directed at each act of micturition to expose the meatus as perfectly as 1 Fledry's observations have been fully confirmed by Borelli (Maladies genito- vhicales, Gaz. des Hop., Dec. 1851); Anagnostaxis relates a cure of amblyopia by excision of the prepuce (Rev. de Thf'r. M'd.-Chir., No. 4,1860) ; and Tkopsseao one of incontinence of urine by the same operation (Gaz. des Hop., No. 9, 1860). 106 PHYMOSIS. possible in order to prevent the retention of the urine beneath the prepuce. In accidental phymosis, the rule is to avoid an operation if pos- sible, unless congenital phymosis has previously existed; but when due to vegetations beneath the prepuce, or to contraction of toe preputial orifice from the cicatrix of a chancre which has entirely healed, an operation may be necessary to gain access to the abnormal growths or to restore the opening of the prepuce to its original size. Phymosis dependent upon a large mass of specific induration, of which I have met with several instances, disappears under the internal administration of mercurials. An operation should, if possible, be avoided or deferred when the phymosis is due to acute inflammation, which may in most cases be subdued by rest in the horizontal posture, low diet, ca- thartics, leeches to the groin or perineum (not upon the prepuce), a lead and opium wash, and, if it be certain that no chancre is present, by scarifications; but if gangrene threaten, ddlay is no longer justifiable. In some instances, we are certain that a chancre is concealed between the prepuce and glans, where it may have been seen either by the patient or surgeon before the phymosis supervened; in others, its existence is highly probable, from the fact that the patient has been exposed in promiscuous intercourse. Kow the mere suspicion of a chancre within the hidden folds of mucous mem- brane is sufficient to induce great caution in resorting to an ope- ration which may be followed by inoculation of the edges of the wound. It is indeed true, that if the primary sore be of the infect- ing species, auto-inoculation will not be likely to take place; but the chancre may be of the mixed variety, or there may be both a true chancre and a chancroid; hence the fact that a mass of induration can be felt beneath the prepuce is not sufficient of itself to justify an operation. A case in point has fallen under my own observation: A medical friend was called to treat a case of phymosis dependent upon a chancre, surrounded by a cartilaginous mass of induration which could be felt beneath the prepuce. Relying upon the fact that an infecting chancre cannot be inoculated upon the person bearing it, he resorted to an operation; in a few days the edges of the wound assumed the appearance of a soft chancre. The original chancre was undoubtedly of the mixed variety. CIRCUMCISION. 107 Under some circumstances, however, and especially with gan- grene threatening, an operation cannot be avoided; but the incisions should be carefully protected from contact with the virus, and, if inoculated, should be cauterized with nitric acid. The thickening of the substance of the prepuce, already described as a sequela of primary sores, is rarely so great as to produce com- plete phymosis; but the difficulty attending the exposure of the glans and the frequent rents which the act occasions, often justify the removal of the hypertrophied tissues. Circumcision.—Partial operations for phymosis, as, for instance, slitting up the prepuce along the dorsum, or excision of a triangular portion, often fail to afford permanent relief, and leave the organ in a misshapen condition. The purposes of elegance and utility can best be subserved by circumcision. Before describing this operation, let me remind the student that the prepuce is composed of two layers, separated by cellular tissue of such lax texture as to admit of an almost indefinite amount of motion between them. The internal or mucous layer is firmly attached to the penis posterior to the corona glandis, and hence is incapable of being drawn forwards to any great extent in front of the glans. The external or integumental layer, on the contrary, is continuous with the flaccid skin of the body of the penis, and may be elongated almost indefinitely; its anterior portion doubling in upon itself as the posterior is drawn forwards.' It follows from this anatomical arrangement, that a section of the prepuce in front of the glans can only include the integumental together with an insignificant portion of the mucous layer. Of the various methods of performing circumcision recom- mended by different authors, I prefer the following:— The patient should be upon the bed where he is to lie until cica- trization is accomplished, in order after the operation to avoid unne- cessary motion and hemorrhage, which would interfere with speedy union; and if he is incapable of self-control, he should be etherized. The requisite instruments are a pair of long-bladed forceps, a sharp- pointed bistoury, blunt-pointed scissors, and sutures of iron or sil- ver wire, or serresfines. Allow the penis to hang without traction in its natural condition, and with a pen and ink trace a line upon the skin corresponding to the corona glandis, to serve as a guide for the incision. Next draw the prepuce forwards, until this line is in front of the glans, and 108 PHYMOSIS. grasp it between the long blades of the forceps (somewhat more obliquely than is represented in the adjoining cut, so as to include a larger portion of the prepuce above than below), which should be intrusted to an assistant; the external part is now to be excised in front of, and close to the blades of the forceps, having first been put upon the stretch by the left hand of the operator. Any at- tempt to cut from either margin of the fold will be attended with Fig. l. some difficulty, since the several layers of the skin and mucous membrane oppose an amount of resistance to the knife that is not readily overcome; hence, it is better to transfix the centre of the flap (the blade of the knife parallel to, in front of, and in contact with the forceps), cut downwards, and complete the section by turn- ing the knife, and cutting upwards. The assistant should now remove the forceps, when the integu- ment will retract, carrying its cut edge back to the base of the glans, and exposing the raw external surface of the mucous membrane which still covers the glans. If the mucous membrane be in a healthy condition, it may be divided with scissors along the dor- sum, and turned back to be united to the integument; but if thick- CIRCUMCISION. 109 ened by chronic inflammation, vegetations, or the cicatrix of a chancre, more or less of it should be excised. The parts should not be brought into coaptation until the bleeding has been arrested by exposure to the air, and torsion of the small vessels. Union may be effected by means of sutures of iron wire, or serres-fines, which should be removed as soon as the edges of the wound are securely glued together with lymph, or within twenty-four or forty- eight hours. I prefer simple exposure to the air, and protection by means of a cradle from contact with the bedclothes, to the water- dressing commonly employed, unless union by first intention fails to take place, and suppuration ensues. The patient should remain in bed until the parts have entirely healed, and, if the contact of the urine with the wound cannot be otherwise prevented, should micturate with his penis immersed in a basin of tepid water. In favorable cases, confinement to the house for two or three days is sufficient. It would hardly seem necessary to caution the surgeon not to excise too large a portion of the integument, were it not for the following case reported by Nelaton :l A patient appeared at the cli- nique who had been operated upon for phymosis eleven days before by the usual method. The physician, forgetting that the integu- ment of the penis is very lax and extensible, had, before making the incision, drawn it forwards to its utmost limits; the consequence was that, after the operation, the penis was denuded nearly to the abdominal wall. An extensive suppurating surface had remained, which was torn and made to bleed by frequent erections. The case does not appear to have been followed to its termination, but Nela- ton remarks upon the rigidity and malformation of the organ, pro- vided cicatrization should take place, and adds that "this case shows the importance of marking the limits of the incision before the operation." The American editor of Erichsen's Surgery states that the favorite operation for phymosis at the Pennsylvania Hospital, Philadelphia, consists in simple division of the mucous layer of the prepuce, by means of fine scissors, one blade of which is sharp, and the other probe-pointed. The former is made to penetrate between the two layers of the prepuce along the dorsum of the organ, while the latter passes between the glans and its envelope, and thus the inter - ' Pathologie Chirurgicale, t. v. p. 663. 110 PHYMOSIS. nal layer may be divided as far as the corona glandis. The pre- puce should be retracted several times each day, especially during micturition, both in order to prevent contact of the urine with the wound, and also immediate union, which would thwart the purpose of the operation. Faure accomplishes the division of the mucous layer in a simpler manner, as follows: The skin of the penis is forcibly drawn towards the abdomen, when an incision is to be made with blunt-pointed scissors upon the dorsum of the retracted preputial orifice, impli- cating the mucous membrane, but sparing the integument. This allows of a still farther retraction of the prepuce, bringing into view an additional portion of mucous membrane, which, by a suc- cession of the above procedures, may be divided to the base of the glans. These methods, unattended by any loss of substance, may suffice when it is desired simply to relieve uncomplicated phymosis; but when the mucous membrane is in a diseased condition, as is generally the case when an operation is required, circumcision should be preferred. PARAPHYMOSIS. Ill CHAPTER V. PARAPHYMOSIS. In paraphymosis the extremity of the penis is strangulated by a narrow preputial orifice retracted behind the prominent corona glandis, which forms the chief obstacle to reduction. After the lapse of a few hours or days, the parts behind and especially in front of the stricture become swollen from infiltration of serum and fibrine; the constricting "ring is concealed in a deep furrow between . them, and is still farther retained in its abnormal position by adhesion to the deeper textures—the result of inflammatory action. Ulceration or gangrene may finally supervene, and perhaps relieve the stricture, but with an unnecessary loss of tissue. Paraphymosis is frequently met with in boys, as the result of their first attempt to expose the glans. It may also follow the injudicious retraction of the prepuce when previously, affected with phymosis, and while the parts are still in an inflamed condition. Treatment.—When called to a case of paraphymosis, it may not be advisable to attempt reduction until the oedema has first been diminished by rest in the horizontal posture, elevation of the penis, and a saline cathartic, assisted in some cases by scarification of the swollen tissues in front of the stricture, the application of ice or a stream of cold water directed upon the part. Reduction may often be facilitated by placing the patient under the influence of an ansesthetic. The difficulty is frequently increased by the vicious manner in which the attempt is made. The swollen glans and mucous layer of the prepuce are to be passed through a narrow preputial orifice. Mere pressure from before backwards will increase their transverse diameter and augment the difficulty of reduction; this can be best accomplished by compressing, and, if necessary, elongating them, and drawing the constricting ring and integumental layer over them. 112 PARAPHYMOSIS. To effect this purpose, let the parts in front of the stricture be well oiled, and the glans enveloped in a thin rag, that it may afford a firmer hold to the fingers. The surgeon steadily compresses the glans for ten or fifteen minutes in its transverse diameter, with the thumb and fingers of his right hand, and endeavors to relieve its distended vessels of a portion of their contents. He then encircles the body of the penis with the thumb and fingers of his left hand, and draws the integument forwards, attempting at the same time to insert the right thumb nail beneath the stricture, and elevate it above the corona glandis, which is most pro- minent upon its superior aspect. Steady perseverance in the above method will rarely fail of success, when reduction is possible; but the following modes, recommended by different authors, are perhaps worthy of description. In an ingenious method proposed by M. Garcia Tcre'sa, the centre of a piece of tape is placed upon the dor- sum of the corona glandis, the oppo- site ends passed round the sides of the glans, crossed beneath the frenum, and wound around the little finger of each hand; the glans is then compressed by flexing the middle and ring fingers, and exercising traction in opposite direc- tions, while the other fingers remain free to draw the prepuce for- wards, and accomplish its reduction.1 Dr. Yan Dommelen effects compression of the glans by winding around it a strip of adhesive plaster half a yard long, and about a quarter of an inch wide, commencing at its base, and terminating near the orifice of the urethra.2 M. Seutin, of Brussels, has invented a pair of forceps with spoon- shaped extremities, to maintain compression of the glans until the constricting ring can be drawn over them. The three preceding methods are designed for the purpose of ' Rev. de Ther. MOd.-Chir., Feb. 15, 18G0. 2 Med. Times and Gaz., Jane 4, 1859. TREATMENT. 113 compressing the glans during reduction; in the following, which is said to be employed with great success at the Children's Hospital, in Pesth, compression of nearly the whole organ precedes the attempt to restore the preputial orifice to its normal position:— The penis is first well cleansed and dried, when a strip of adhe- sive plaster, about three lines broad, is applied longitudinally from the middle of its under surface, over the swollen prepuce and glans, avoiding the meatus, to the middle of the upper surface. Another strip is carried in a similar manner from side to side over the glans, and in large boys a third, and even a fourth strip, may be required to cover the whole organ. Finally, still another strip is firmly ap- plied transversely over the preceding, commencing just behind the meatus, and continued by successive turns to the middle of the body of the penis. The application is said to be well borne, and the swelling so diminished within twenty-four hours, that the plaster must be renewed; reduction can usually be effected within forty- eight hours.1 The late Abraham Colles, Prof, of Surgery at the Royal College of Surgeons of Ireland, succeeded, after other means had failed, in relieving two severe cases of paraphymosis, by passing a director beneath the stricture from before backwards, and elevating it upon the point of the instrument, while the stem was made to compress the swelling in front, and gradually force it back beneath the stric- ture. This process was repeated on each side of the penis, after which reduction was quite easy.8 When reduction is impossible, and ulceration or gangrene threat- ens, it becomes necessary to relieve the stricture, by dividing the preputial ring, which—as should not be forgotten—is situated at the base of the furrow between the swollen folds of mucous membrane and integument. This may be done by entering a narrow, sharp- pointed bistoury flatwise, and from before backwards, upon the dorsum of the penis, turning its edge upwards, and dividing the stricture. In some cases, this procedure must be repeated in several places, and the swollen prepuce freely scarified, before reduction can be effected. 1 Schmidt's Jahrbiicher. ' Dublin Quart. Journ. of Med. Sci., May, 1857. 8 114 SWELLED TESTICLE. CHAPTER VI. SWELLED TESTICLE. The most frequent complication of gonorrhoea is an affection of the scrotal organs, variously known by the names of swelled testicle, hernia humoralis, orchitis, and by the more correct term, gonorrhoeal epididymitis. In order to understand the mode in which this complication supervenes upon gonorrhoea, it is desirable to recall to mind the canal which connects the testicle and the urethra, and which is designed for the passage of the seminal fluid. Tracing this canal from before backwards, we have first the aperture of the ejaculatory duct, near the anterior extremity of the veru montanum in the prostatic portion of the urethra; following this duct, we find that it merges into the vas deferens, which passes round the bladder, through the spermatic canal in the abdominal muscles, and finally descends within the scrotum, where it terminates in the numerous and intricate convolutions of the epididymis. We thus have a passage, lined with mucous membrane, which is continuous with the mucous membrane of the urethra, and connecting the deepest portion of this canal with the epididymis. In the early stages of urethral gonorrhoea, the inflammation is generally confined to the neighborhood of the fossa navicularis. At a later period, however, the deeper portions of the canal are involved, and the disease thus gains access to the ejaculatory duct, and, under the influence of any exciting cause, may extend along the spermatic canal to the epididymis, or even beyond this, to the testicle and the tissues which envelope it. The patient's own sensa- tions will sometimes indicate that in this mode has originated the affection of the testicle. He has felt a dull pain in the perineum and in the groin, along the course of the spermatic vessels, for a day or two before he observed the tenderness and swelling of the testis. Again, we may find additional evidence in the fact that the cord corresponding to the inflamed testicle can be felt externally to be swollen and hard, and can be traced from the testicle through CAUSES. 115 the inguinal canal, even into the iliac fossa. Post-mortem exami- nations, also, have exhibited the ordinary appearances of inflamma- tory action throughout the whole of the canal connecting the testicle and urethra. There can be but little doubt, therefore, that in many, and probably in most cases, swelled testicle owes its origin to the extension of the inflammation along a continuous mucous surface. In some cases, however, no evidence of such extension can be found either in the sensations of the patient, or in any abnormal condition of the cord, which appears to be entirely unaffected. These cases are analogous to the inflammation of a lymphatic ganglion in the groin or axilla, in consequence of a wound of the foot or hand; the lymphatic vessel connecting the two exhibiting no symptoms of inflammation. It may be that the inflammation has traversed this vessel, but that its passage has been so rapid as not to excite notice, and to leave no traces behind it; or it may be that particles of irritant matter have been conveyed along the duct, and lodged in the ganglion. A similar explanation is given in cases of swelled testicle without appreciable lesion of the cord, by those who refuse to admit any other origin for this disease than the direct extension of the inflammatory process. Most authorities, however, admit that swelled testicle may be excited through sym- pathy alone, without any inflammation, however slight, of the spermatic tract, or any passage of irritant matter; and the subsidence of the swelling in one testicle, and its subsequent appearance in the other, as is observed in some cases, renders this view probable. Causes.—Gonorrhoea of the urethra is the only form of gonor- rhoea which gives rise to swelled testicle, which is never met with as a complication of balanitis. The following table, drawn up by M. de Castelnau,1 exhibits the times of its appearance in the course of the gonorrhoea, in 239 cases, collected from different sources:— Gaussail. Despinb. Aubrey. Db Castelnau. Total. 1st week . 3 2 8 3 16 2d . . 4 6 17 7 34 3d • . 5 2 9 8 24 4th " . 16 2 15 6 39 5th " . 39 2 8 5 54 6th " and later . 6 15 43 8 72 Total, 73 29 100 37 239 1 Annates des Maladies de la Peau et de la Syphilis, May, 1844. 116 SWELLED TESTICLE. In the experience of most surgeons, swelled testicle is even rarer during the first fortnight of a gonorrhoea, than would appear from the above statistics. As a general rule, it may be said to supervene after the third week, and most frequently after the sixth week. Cases are reported in which it has occurred after the discharge had entirely disappeared, and in one as late as three months. A patient once came to me with swelled testicle, five weeks after I had treated him for a clap, and had dismissed him as cured, and he assured me that he had not perceived any discharge in the mean- while, nor could I discover any upon examining the penis. It is probable, as stated by Yelpeau, that in these cases there still remains, in the prostatic portion of the urethra or at the neck of the bladder, a small amount of inflammation, but not sufficient to manifest itself externally. Instances are recorded in which the swelling of the testicle is said to have appeared before the discharge from the urethra. In one case reported by M. Castelnau, the epididymitis was developed a week after coitus, and the urethral running was first seen five days afterwards. M. Yidal (Ann. de Chir., 1844) gives a similar case, and Yelpeau (Diet, de Med., art. Testicule) admits such an occur- rence. It is not improbable that a gonorrhoea really existed, but was overlooked, in these cases ; still it is possible that the prostatic portion of the urethra alone received the irritation from coitus, and that the effect produced was insufficient to manifest itself by a dis- charge until after the swelling of the testicle had taken place. In some instances we are able to trace an attack of swelled tes- ticle directly to some exciting cause, which has aggravated the urethral disease. Thus the patient may have been imprudent in ex- ercising or in exposing himself to cold, or he may have indulged in a debauch or in sexual intercourse. Strongly irritant injections, or any violence done to the canal by a large bougie, or by forcible distension when using a syringe, may also occasion it. One of the most severe cases of this disease that I ever met with had been induced by the forcible introduction of a large bougie in the treatment of a gleet of several years' duration. In other instances, however, the exciting cause of epididymitis is not apparent, in- dependently of the fact that the inflammatory action has had time to involve the prostatic portion of the urethra and gain access to the spermatic ducts. It has been supposed by some surgeons, that the use of copaiba and cubebs, is occasionally the cause of epididy- SEAT. 117 mitis; while others Tiave not only denied this, but have even re- commended these drugs in the treatment of this affection. I have already referred to this subject in speaking of the antiblennorrha- gics, and will only say at present that evidence is wanting in favor of both these assertions. We have no reason to believe that copaiba and cubebs ever occasion this disease, and still less reason to believe that they can be used with benefit in its treatment. It should not be forgotten that wearing a well-fitting suspensory bandage during an attack of gonorrhoea is the best protection against swelled testicle. The patient is thus relieved of the weight of the scrotal organs, the flow of blood from the part is facilitated, and the liability to inflammatory action is consequently much diminished. Seat.—Gonorrhoeal epididymitis more frequently attacks the left testicle than the right. Of 1,342 cases observed by Prof. Sig- mund, of Yienna, the left testicle was affected in two-thirds.1 The greater frequency of this disease on the left side has been attributed by some authors to the fact that men usually "dress" on this side, and that the left testicle consequently receives less support than the right. This explanation, however, is very questionable. The dif- ference is doubtless to be found in that cause, as yet not explained in a perfectly satisfactory manner, which renders the left testicle more prone than the right to take on various forms of morbid action. Both testicles rarely become inflamed simultaneously, but not un- frequently one is attacked after the other. This usually occurs only after the lapse of several weeks, though I have seen the two attacks separated by only a few days' interval. Sigmund states that both testicles were affected in seven per cent, of his hospital patients, and in five per cent, of his private cases. Occasionally, the inflammation, after leaving one testicle and attacking the other, will return to the first; to this form of the disease Ricord has given the expressive name of see-saw epididymitis. The best authorities, with but few exceptions, agree in the state- ment that it is the epididymis, of all the scrotal organs, which is first and chiefly involved in most cases of this disease. It is here 1 British and Foreign Medico-Chirurgical Review, Oct. 1856. Mr. Curling denies that the left testicle is most frequently affected (Diseases of the Testis, p. 22t>). but his statement is founded on 138 cases only, which are far inferior in number to the above statistics of Prof. Sigmund. 118 SWELLED TESTICLE. that the vas deferens terminates, and we may* suppose that the in- flammatory action is retarded in its progress by the innumerable and intricate convolutions which compose this appendage to the tes- ticle. At an early stage of the inflammation, and also after the swelling has somewhat subsided, the epididymis can be felt en- larged to several times its natural size. The normal position of the epididymis is posterior and external to the body of the testicle, and pressure upon this part excites more pain than elsewhere. The epididymis, not being enveloped, like the testicle, in a fibrous cap- sule, is susceptible of an indefinite amount of tumefaction, and fre- quently enlarges to such an extent as to partially surround and encase the body of the testis. It should be recollected, however, that the position of the epi- didymis, relative to the testicle, may be abnormal; in which case the seat of the greatest tenderness and swelling will differ from the description just now given. Such malpositions are called by the French inversions du testicule. They have recently been thoroughly investigated for the first time by M. Eugene Royet,1 who admits the five following varieties:— 1. The epididymis may be anterior to the body of the testicle. 2. It may be on one side, either the external or internal. 3. It may be superior; the long axis of the testis being antero- posterior, and the epididymis resting upon its upper surface. 4. In the fourth variety, the epididymis and vas deferens form a loop or sling, wnich surrounds the testis from before backwards. 5. In the fifth variety, the relative position of the epididymis and testis varies from day to day, without appreciable cause. All these varieties are rare, with the exception of the first, which, according to Royet's researches, is met with in one out of every fifteen or twenty persons. The abnormal position of the epididymis in front of the testicle is, therefore, the only one possessing much practical importance. The possibility of this malposition should be borne in mind both in operating for hydrocele and when forming a diagnosis of scrotal tumors. In cases of epididymitis, when the in- flammation is not general, the epididymis may be recognized by its hardness to the touch and its sensibility to pressure. When all the scrotal organs are involved in the inflammatory process, Royet states that the chief means of recognizing an anterior position of the 1 De l'Inversion du Testicule; Paris, 1859, pp. 55. SEAT. 119 epididymis, are a want of mobility in the skin anteriorly, and the fact that the vas deferens can be felt in front instead of behind the other vessels of the cord. Next to the epididymis, the tunica vaginalis is most frequently involved in gonorrhoeal epididymitis. M. Rochoux has advanced the idea that inflammation of this membrane is the chief and con- stant lesion in swelled testicle; but this is a mistake. Yaginali- tis, although a very frequent, is not a constant symptom, and is always consecutive to the inflammation of the epididymis. There is commonly an effusion varying in quantity and character, within the tunica vaginalis. This may consist only of serum and be ap- parently due to simple obstruction of the circulation; or it may contain fibrin and other products of inflammation. Sometimes bands of lymph bind the two opposed surfaces together, as in pleu- risy. The sub-scrotal cellular tissue also participates in the inflam- matory action, and is thickened by oedema or fibrinous deposit. The frequency with which the tunica vaginalis is involved in swelled testicle, while the body of the testicle is unaffected, has been explained by Gendrin,1 who states that when the cellular tissue of an organ is continuous with that underlying a neighboring serous membrane, it becomes a ready means of communicating in- flammatory action; but when a contiguous organ is not thus con- nected with the original seat of the disease, the passage of the inflammation is less easy. The connecting link between the epi- didymis and tunica vaginalis is found in the areolar tissue which penetrates the former and underlies the latter, while the testicle is surrounded by the fibrous tunica albuginea, and, being thus isolated, generally escapes. Following the tunica vaginalis in the order of frequency, the spermatic cord is next found to be the seat of inflammatory action in gonorrhoeal epididymitis. The body of the testicle is rarely affect- ed ; and even when involved, the fibrous tunic which invests it limits the amount of swelling of which it is capable, although it greatly increases the suffering of the patient by constricting the inflamed tissues. # Some idea of the comparative frequency with which the different tissues now mentioned are attacked in this disease may be formed from the statistics of Prof. Sigmund, already referred to. In 1342 1 Histoire Anatomique des Inflammations, t. i. p. 143. 120 SWELLED TESTICLE. cases, the epididymis was alone affected in 61; the epididymis and tunica vaginalis in 856; the epididymis and cord in 108, and these three parts together in 317. The propriety of the name, gonorrhoeal epididymitis, will now be evident. It is no objection to this term that the epididymis, in many cases, is not the only part involved. As in diseases of the eye, we call a certain inflammation iritis, though other parts besides the iris are involved, so in swelled testicle, the principal seat of the disease should determine its scientific name. The term orchitis, which is adopted by Yidal, Yelpeau, and most English authors, is less correct, and is moreover objectionable, because it is calculated to confound this disease with that affection of the testicle which is produced by constitutional infection, and which is totally distinct in its character and symptoms. Symptoms.—There are generally no marked premonitory symp- toms preceding an attack of swelled testicle. Sometimes, however, we find that the patient has suffered from malaise for several days; that he has had slight fever, perhaps a chill, and a dull pain or heavy sensation in the perineum, cord, and scrotal organs, attended with a frequent desire to pass water. His attention is soon attracted to the testicle by pain, felt especially on motion, and on examination he finds this organ swollen, and tender on pressure. The swelling and tenderness rapidly increase, and the pain extends to the correspond- ing thigh, to the groin, and to the lumbar region. In the course of twenty-four or forty-eight hours, the affected side of the scrotum may have attained the size of the fist; the skin is tense and in some cases of a dark red or almost purplish hue; the pain is very severe, especially at night, preventing sleep; the least pressure upon the part, even from the bedclothes, is almost unendurable; partial ease only can be attained by keeping perfectly quiet in the horizon- tal posture with the addition of some support to the genital organs. If the cord be involved, the pain, swelling, and tenderness are found to extend upwards to the inguinal canal. There is generally more or less febrile disturbance of the system at large. The skin is hot, the tongue coated, the pulse increased in force and frequency, and the patient extremely nervous and agitated. Cases are reported in which the swelling of the cord was so excessive as to produce stran- gulation at the abdominal ring, attended by symptoms resembling those of strangulated hernia, such as abdominal tenderness and symptoms. 121 vomiting. It must not be supposed, however, that the symptoms are always so severe as those now described. Such severity is more apt to be met with in persons of a nervous temperament, in whom this disease is one of the most distressing that can occur. In other cases, however, the suffering is comparatively slight, and I have known patients to attend to their daily occupation during its whole course. Between these two extremes we may have every shade of variation. While the inflammation is at its height it is impossible to distin- guish the different portions of the scrotal organs. Judging from mere inspection of the swelling, we might be led to suppose that it was chiefly made up of the body of the testicle. This, however, is not so. It is composed, for the most part, of the swollen epididy- mis, of an effusion into the tunica vaginalis, and of oedema of the subscrotal cellular tissue. The hydrocele is often, but not always, sufficient to enable us to detect distinct fluctuation, and rarely, if ever, is the tumor transparent; but on gently touching it, the surface is found to yield for a short distance before the fingers come in con- tact with the firmer body of the testicle beneath. This yielding is due to the displacement of the oedema of the scrotum and of the fluid in the sac. If the tumor be punctured with a lancet, bloody serum, varying in amount from a few drops to several drachms, will escape. Resolution begins to take place in a few days, commencing in the anterior portion of the tumor. The oedema of the scrotum and the hydrocele disappear, and the different portions of the testis can now be distinguished from each other—the epididymis, still swollen and hard, behind; and the body of the testicle, preserving, in most cases, its normal elasticity, in front. The whole duration of the attack varies from one to three weeks. In a discussion on the treat- ment of this disease before the Academy of Medicine in Paris, in 1854, Yelpeau stated that its duration under ordinary methods of treatment averaged 16 or 18 days. In some cases'of swelled testicle, after the more acute symptoms have subsided, the parts still remain engorged and the disease shows a tendency to become chronic. This is most likely to occur in patients of weak habit, and while this condition lasts the least ex- citino- cause may induce a return of the acu$e inflammation. Most cases of swelled testicle terminate favorably. In some rare instances, however, abscesses form in the cellular tissue underlying 122 SWELLED TESTICLE. the scrotum, or in the epididymis or body of the testicle. Mr. Edwards1 has recently reported a case in which the whole testicle protruded through an opening formed by an abscess in the scrotum, the skin being drawn in around the orifice. Mr. Edwards " pared the edges, drew them asunder, making with the handle of the scalpel a sufficient separation of the deeper tissues, and the testicle was at once drawn, as it were, back into the scrotum, the wound closing over it. Three hare-lip pins were inserted; the wound closed by first intention, and the patient was walking about perfectly well on the seventh day." If suppuration takes place in the testicle, the pus generally burrows in various directions, forming sinuses, and destroying a portion of the parenchyma; sometimes a cir- cumscribed abscess is formed, which may become encysted, and, the more fluid portion being absorbed, the solid portion may re- main in a concrete state for an indefinite length of time, and closely resemble a tubercular deposit. The presence of the cyst will clear up the diagnosis, since true tubercular matter is always found in direct contact with the parenchyma of the testis, and is never met with encysted. The swelling of the testicle attendant upon gonorrhoea may, however, be the exciting cause of true tubercular deposit, in per- sons of a strumous diathesis.2 As the epididymis was the first part attacked, so it is the last to recover its normal condition, and in some cases it retains, for months or years, an irregular and knotty mass of induration, which may obstruct the passage of the semen and render the affected testis useless. If this induration exist on both sides, or if the opposite tes- ticle be undeveloped, as is often the case with an undescended testis, the patient will probably be impotent. In a few rare cases gonor- rhoeal epididymitis has been known to terminate in atrophy; of the testicle. The condition of the urethral discharge preceding and during an attack of swelled testicle has been the subject of considerable dis- cussion. It was at one time supposed that this complication of gonorrhoea was usually preceded by a diminution of the running, and hence that it might be attributed to the use of active measures which were supposed to drive the disease from the urethra to the ! Edinb. Med. Journal, Nov. 1860, p. 455. 2 A case of this kind was recently exhibited at a meeting of the Anatomical Society of Paris. Bulletin de la Soc. Anat. de Paris, 2d serie, t. iv. p. 2. SYMPTOMS. 123 testicle. On this supposition has been founded the theory that swelled testicle may be caused by metastasis. A proper apprecia- tion of the facts in the case, however, does not warrant this conclu- sion. It is, indeed, true as a general rule, that the urethritis has passed the acute stlge and that the discharge has consequently diminished before the epididymis becomes inflamed,1 but, this is the natural course of the disease when no complication whatever takes place. To prove a metastatic origin of the epididymitis, it would be necessary to show that there is a sudden disappearance or diminution of the running, just preceding the swelling of the testicle; such, however, does not occur. On the contrary, as stated by Ricord, there is often an exacerbation of the urethral disease and a slight increase of the discharge for a day or two preceding. When the disease of the testicle is fairly es- tablished, the discharge diminishes as a consequence of revulsive action. These phenomena coincide with what is seen in affections of other parts when acute inflammation is estab- lished in their neighborhood. The induration of the epididymis, which frequently remains for some time after an attack of swelled testi- cle, or which may even become per- manent, requires farther mention. This induration is commonly situated in the lower part of the epididymis, in or near the globus minor. It will be recollected that the upper portion, or globus major, is composed of the con- volutions of the vasa efferentia, which Vortical section of the testis and epididy are from ten to thirty in number, but mis. (After gray.) 1 Gaussail's statistics relative to the discharge are as follows: In 67 of 73 cases the discharge and the other symptoms of the gonorrhoea had diminished more or less__in other words, the acute stage of clap had passed—when the swelling of the testicle took place ; in 6 cases, the gonorrhoea was still at its height. In 30 of the 73 cases, the discharge gradually diminished and disappeared entirely during the treatment of the epididymitis; in 43 cases, some discharge remained after the disease of the testicle was cured. 124 SWELLED TESTICLE. that these minute vessels unite into a single duct, before leaving this portion. Hence the globus major of the epididymis consists of several seminiferous tubes, any one of which would be sufficient to convey the semen, in case the others were obstructed; while the body and globus minor contain but one tube, the obliteration of which must completely cut off the communication between the testis and the penis. But it is in this latter portion, viz., the globus minor, that the induration left by an attack of swelled testicle is almost invari- ably found; and, as we shall presently see, it generally effects the obliteration of the single duct of the part, and renders the patient impotent upon the affected side. It now becomes an interesting subject of inquiry, what effect this obliteration has upon the testis, whether it becomes atrophied, or whether it remains in a normal condition, and continues to secrete sperm. Again, in those cases in which epididymitis has occurred on both sides, an induration may be left in each testicle, totally ob- structing the passage of semen; in such cases does the patient still retain sexual desires; is he capable of sexual intercourse; and if so, how does his semen differ from that of a perfectly healthy indi- vidual ? These questions have been ably answered in a paper by Dr. L. Gosselin, published in the Archives Generates de Medecine, for Sept. 1853. Dr. Gosselin's conclusions are based upon experiments upon the lower animals, and upon the observation of nineteen patients af- fected with double induration of the epididymis following gonor- rhoea. The spermatic cord of one side was exposed in two dogs, the vas deferens isolated from the spermatic vessels, and a portion of it excised. The animals were killed several months after, when it was found that the testicle of the side operated on presented the same volume, color, and general character as that of the opposite side; the only difference was that the convolutions of the epididy- mis in the former were distended with fluid, containing a mul- titude of spermatozoa. The excision of a portion of the vas deferens had completely cut off the communication with the penis. These experiments proved that isolation of the testicle in the lower animals does not produce atrophy of this organ, which remains in an apparently healthy condition, and continues to secrete semen. The nineteen persons who had had double epididymitis were met with at the Hopital du Midi, and in the private practice of Dr. Gos- selin. The time which had elapsed since the formation of the indu- SYMPTOMS. 125 ration, at the time of the observation, varied from a few weeks to ten years. The symptoms which they presented were in some re- spects singular and remarkable. In all of them there was a mass of induration in the lower portion of the epididymis of each testicle. In none of them was there any apparent change in the volume of the scrotal organs, and no pain was felt at any time, not even after sexual intercourse. None of them had observed any change in their sexual desires or powers. They were all as capable of coitus as the most healthy individuals. Their erections and ejaculations were complete. Their semen was normal in quantity, in consist- ency, in odor, and color; it presented the chemical reactions de- scribed by Berzelius, as characteristic of sperm. Only when examined by the microscope, was it found to differ at all from healthy semen, inasmuch as it was entirely destitute of spermatozoa. In the recent cases, most of which were still affected with urethritis, pus and blood-globules were found mixed with the semen; in the older cases, these were absent. The entire absence of spermatozoa in all of them was confirmed by repeated examinations by Drs. Gosselin, Robin, Yerneuil, and other eminent Parisian microscopists. In two of these cases, treatment, continued in the one case for three months, and in the other for nine, resulted in the disappearance of the induration in one of the testicles, and coincidently with this resolution spermatozoa again appeared in the semen, as shown by microscopical examination. These cases are of the highest interest, looking at them both in the light of physiology, and of pathology and therapeutics. They show, in the first place, that the quantity of fluid ejaculated is as abundant and presents the same general appearances when the canal of the vas deferens is obliterated as when it is free; also, that in case of obliteration, the secretion of sperm in the testis is not sufficient to distend the vessels to any great extent, or to occasion pain. Probably there is some absorption of the secreted sperm, but if as much of this fluid were secreted by the testicles as is commonly supposed, the effect upon the testicular vessels and upon the feelings of the patient would be more manifest. From these facts Dr. Gosselin concludes, that the normal function of the tes- ticle is to furnish the fecundating element of the sperm, viz., the spermatozoa; and that the other components of the spermatic fluid, to which it owes its color, odor, and chemical reactions, and which 126 SWELLED TESTICLE. constitute the medium in which the spermatozoa live, are derived for the most part from the vesiculse seminales. But the conclusions from these facts which chiefly interest us at the present time, are those bearing on the pathology and treatment of epididymitis. These conclusions, as stated by Dr. Gosselin, are the following:— 1. The induration is generally situated in the globus minor of the epididymis, though it may, strictly speaking, be seated in any part of this organ. Since the epididymis below the globus major is composed of but a single vessel, the obliteration of this vessel is sufficient to prevent the passage of the sperm. 2. The presence of the induration excites no pain, provided that the inflammation which produced it has entirely subsided. 3. It does not occasion any change, appreciable by the patient, in the exercise of the genital functions. 4. If the spermatic vessel be obliterated on both sides, the patient is necessarily impotent; if on one only, fecundation is possible, provided that the other testicle is sound. 5. The success of treatment in several of the cases reported affords assurance that the power of fecundation may sometimes be restored by appropriate remedies. M. Godard states that he has confirmed Gosselin's observations by microscopical examination of the semen of more than thirty persons affected with double chronic epididymitis; and in every instance spermatozoa were wanting.1 If gonorrhoeal epididymitis attack a testicle which has been arrested in its descent from the abdomen to the scrotum, the nature of the case may readily be mistaken. If the testis have not left the abdominal cavity, it may simulate peritonitis or iliac abscess; if it be arrested in the spermatic canal, it may counterfeit strangulated hernia or bubo; and the liability to error is especially great, when, as often occurs, the tunica vaginalis is still connected with the abdominal cavity, and true peritonitis is set up by extension of the inflammation, attended by its usual alarming symptoms. Numerous cases in illustration of these remarks may be found in the work of M. Godard before referred to. A still rarer abnormal position of the testicle is in the perineum; ' Etudes aur la Monorchidie et la Cryptorchidie chez l'Homme; extrait des Me- moires de la Soc. de Biologie, annee 1856, Paris, 1857, p. 105. SYMPTOMS. 127 an anomaly first observed by John Hunter, who met with two cases. " Many years ago, a little boy, one of whose testicles had thus deviated from its proper course, was brought to the London Hospital. The gland was lodged in the perineum at the root of the scrotum."1 Ricord and Yidal2 (de Cassis) have each observed two cases; Mr. Ledwich3 met with one in a dissecting-room subject, and Godard4 gives the history of another, with a plate of the abnor- mity. These nine cases are all with which I am acquainted. A perineal testicle affected with gonorrhoeal epididymitis may simulate a perineal abscess or inflammation of Cowper's glands, as in the two instances observed by Ricord.' " In one, there was a perineal tumor, which was exquisitely painful, fluctuating and about the size of a pigeon's egg. It was at first taken for an abscess, and Ricord was about to open it, when examination of the scrotum led to the discovery that one testicle was absent." There is another consideration connected with abnormal position of the testicle, which is worthy of mention. In most cases of this anomaly, the gland is useless for the purposes of procreation. According to Goubaux and Follin,6 it undergoes fibrous or fatty degeneration. This is denied by Godard, who, however, has equally shown that the gland, as a general rule, is impotent, by microscopical examination of the contained sperm after death. In eight cases out of nine, spermatozoa were wanting. Now, if the anomaly be con- fined to one side, and the opposite testicle be in a healthy condition, fecundation is still possible; but if the descended testicle be attacked by epididymitis, obliteration of its vas deferens will deprive the patient of all procreative power, as in the cases of double epididy- mitis observed by Gosselin. Godard gives the history of a man with one undescended testis, who had a child by a mistress, but who, after an attack of swelled testicle on the opposite side, was twice married without progeny, and his semen, twenty-one years afterwards, was found destitute of spermatozoa. 1 Curling, op. cit., p. 46. 1 Traite de Pathologie Externe, t. 5, p. 432. 3 Dublin Quart. Journ. of Med. Sci., Feb., 1855. ♦ Op. cit., page 65, and Plate III. 6 Godard, op. cit., p. 96. * Follin, Etudes Anatomiques et Pathologiques sur les Anomalies de Position et les Atrophies du Testicule ; Arch, de Med., Juillet, 1851, p. 262. . Goubaux et Follin, De la Cryptorchidie chez l'Homme et les Principa'ux Animaux Douiestiques; Mem. de la Soc. de Biolog., 1855, p. 317. 128 SWELLED TESTICLE. Pathological Anatomy.—Since epididymitis, when uncom- plicated, is never fatal, opportunities for post-mortem examination are rare, and only occur in case some intercurrent disease produce the death of the patient. The most complete report of such examination with which I am acquainted, is to be found in the Gazette des Hopitaux, for Dec. 21, 1854. Case. The patient entered Yelpeau's wards at la Charite with swelled testicle, of eight days' duration ; the epididymis was situated in front of the testicle, and was swollen and hard; the cord was also involved, while the body of the testicle appeared to be sound, aud there was no effusion in the tunica vaginalis. Eighteen days after his admission, and twenty-six after the commence- ment of his attack, this patient died of cholera. The post-mortem was made by M. Gosselin, with the following result:— 1. The tunica vaginalis contained no fluid and was free from injection of its vessels. 2. The body of the testicle was healthy. 3. The globus major and the body of the epididymis were also healthy; but the globus minor was swollen and formed a hard, uniform mass, the size of a haricot bean. On cutting open this mass, it was found to be destitute of bloodvessels, of a uniform yellow color, resembling tubercle, and of firm consistency. The sections of the convoluted spermatic duct upon the cut surface showed that this vessel had attained three or four times its natural size, and, instead of being hollow, that it was filled with uniform yellow matter ; there was none of this matter between the convoluted vessels: it was entirely within, and in the substance of the walls. M. Robin examined this matter under the microscope and found pus-globules, mixed with fat-globules and the granular globules of inflammation. He also confirmed the statement that this matter was limited to the interior of the vessels. 4. The vas deferens, which had recovered its normal size, was filled with yellowish matter, containing no spermatozoa and composed of pus- globules, cylindrical epithelial cells, and granular corpuscles. Its walls exhibited a perfectly normal appearance. 5. The vesicula seminalis on the affected side was healthy. It con- tained a small amount of fluid, with pus-globules and epithelial cells, but no spermatozoa. Spermatozoa were found in the vesicula seminalis on the opposite side. M. Gaussail (Arch. Gen. de Med., 1831, torn, xxvii. p. 188) has also reported two cases of post-mortem examination of swelled testicle, in which, however, the examination was made wi,th less care than in the case just quoted. pathological anatomy. 129 Case. In the first case, the patient died of acute arachnitis after suf- fering from swelling of the right testicle for ten days, and of the left for five days. The vesicula? seminales were found enlarged and indu- rated, and their internal surfaces, especially the portion contiguous to the ejaculatory ducts, much injected. The cavity of each was filled with matter of a yellowish white color and slightly granulated. The vasa efferentia were thickened throughout, their cavities contracted and filled with matter similar to that in the vesicula?, and their internal surfaces injected. The epididymis on each side was enlarged and hard ; its external sur- face of a reddish hue, which did not extend to the surface of the testicle. They both contained matter analogous to that found in the vesiculae. The testicles preserved their normal size and exhibited no lesion except marked injection of the small vessels entering into the substance of the left testicle. There was a small amount of reddish serosity in the tunica vaginalis. Traces of inflammatory action were found in the bulbous and prostatic portions of the urethra. Case. In the second case, the patient died of typhoid fever thirteen days after the commencement of an attack of swelled testicle on the right side. The vesicula? seminales were distended with a large quantity of sper- matic fluid, which was thicker than natural, but did not present the yellow color noticed in the preceding case. The left vas deferens (on the opposite side to the affected testicle) was engorged from the urethra to the poste- rior opening of the inguinal canal; the right was thickened throughout, while its cavity was diminished; its internal surface was red and the in- jected vessels very apparent. The right epididymis was double its usual size and very hard. On first examination the testicle appeared to be much larger than normal; but on opening the tunica vaginalis, a quantity of thick, muddy, and slightly bloody fluid flowed out, leaving the testicle nearly of its natural size. The tunica albuginea appeared to be thickened and a network of numerous small vessels was spread over its outer sur- face. The substance of the body of the testicle was not perceptibly changed, except that it was a little more consistent and of a deeper color than natural. Mr. Curling (op. cit., p. 209) says that he has twice had the opportunity of making a post-mortem examination of swelled testicle, but gives no account of the appearances presented. Mr. Brodie1 examined the body of a gentleman who had had gonor- 1 Clinical Lecture on Diseases of the Testis; London Medical Gazette, vol. xiii. p. 219, 1834. 9 130 SWELLED TESTICLE. rhceal epididymitis twenty years before, and found the testicle smaller than natural and " one-third of the tubuli testis converted into a white substance, having the consistence, but not the fibrous structure, of ligament." The first case which I have quoted as occurring in the service of M. Yelpeau, is, I believe, the only one on record, in which the examination has been made with all the light which modern science affords, and I would especially call attention to the fact that the fibrinous deposit was found to be situated within the vessel of the epididymis and not between the convolutions. This fact is in opposition to the statement of Mr. Curling; but it can hardly be called in question in the case here reported, and it strongly favors the opinion of M. Gosselin that the communication between the testis and the penis is almost invariably obstructed during an acute attack of epididymitis, and also during the continuance of the in- duration which is often left behind. I would not be understood as asserting, however, that the exudation is always confined to the interior of the vessel; it may also involve the areolar tissue con- necting the convolutions, but its deposit in the former situation appears to be the more persistent, and the more important so far as the procreative powers of the patient are concerned. The pathological changes produced by epididymitis can only be studied to advantage in recent cases. In the masses of induration which have existed for months or years, the anatomical elements are so confounded that it is impossible to distinguish them. Teeatment.—The treatment of gonorrhoeal epididymitis should be decidedly antiphlogistic. It is indeed true that under temporizing measures, the inflammation will subside in time, but an effusion of plastic lymph, endangering the procreative powers of the patient, will be more likely to occur, than when the case is treated actively at the outset. Rest in the horizontal posture, even if the feelings of the patient do not demand it, should be strictly insisted on. As the patient lies in bed upon his back, the scrotal organs should be supported by a number of folded towels, placed between the thighs, or by a folded handkerchief arranged around them like a slmg, with its ends attached to a bandage round the waist. I usually order an emetico-cathartic, as in the following prescription:— TEEATMENT. 131 I£. Antimonii tartarizati gr. iv. Magnesiae sulphatis ^iss. Aquae camphorse |vj. M. I direct the patient to take a tablespoonful of this mixture every twenty minutes or half hour, until free vomiting has been excited, and then repeat the same quantity every few hours, or sufficiently often to keep him slightly nauseated and to produce a number of evacua- tions from the bowels during the day. If the case be at all severe, the application of leeches should not be omitted. It is better to apply them over the cord, directly below the external abdominal ring, rather than upon the scrotum. They thus deplete the part even more directly than in the latter situation, and any irritation from their bites is avoided. Their number should vary from four to ten, according to the severity of the case. They rarely fail to reduce the swelling and greatly relieve the pain; in some cases, however, they require to be repeated in twenty-four or forty-eight hours, or after the lapse of a few days, in case the symptoms, after once subsiding, again become aggravated. In the absence of leeches, blood may be drawn from several of the scrotal veins. The patient should stand up, and the parts be bathed with hot water until the veins are well distended, when they may be opened with a lancet. When a sufficient quantity of tflood has been drawn, the patient should again lie down and the flow of blood will usually cease in a short time; or, if excessive, it may be arrested by compression with serres fines, ordinary forceps, or by one of the haemostatics. Both cold and hot local applications have been recommended in this disease. Judging from my own experience, the former, when applied at the outset, will often succeed in arresting the progress of the inflammation; but when the disease is fairly established, the latter are more grateful to the patient and more effectual in hasten- ing resolution. If called sufficiently early, I usually order half an ounce of muriate of ammonia to be dissolved in a pint of water, and direct the patient to keep a single thickness of cloth wet with this lotion applied to the scrotum. Simple cold water may be used in place of the solution of muriate of ammonia, although I consider the latter preferable. The bedclothes should be kept elevated, so that evaporation may be free and the temperature of the part re- duced. In the course of a few hours, ice may gradually be added to the solution, with comfort and benefit to the patient, and his 132 SWELLED TESTICLE. sensations may be taken as an index of the degree of cold required. At night, the frequent wetting of the cloths would prevent rest, and it is better, therefore, to remove them. Extract of belladonna, moistened with a little water, and smeared over the scrotum, may now take the place of the lotion, and will ease the pain and favor sleep. The internal administration of an opiate may also be re- quired. If cold applications are not well supported, or if, in spite of our efforts, the pain and swelling increase, poultices of bread and hot water, or linseed meal, should be substituted for the cold lotion; or in robust subjects, poultices of tobacco leaves may be employed for the purpose of obtaining the nauseating and sedative effect of this narcotic. If at any time in the course of the treatment we have reason to suppose there is a collection of fluid in the tunica vaginalis, it is best to evacuate it. Yelpeau directs, in performing this operation, that the tumor should be rendered tense by grasping it posteriorly as in the operation for hydrocele, and that the lancet, plunged into the cavity of the tunica vaginalis, should be retained in the wound, and gently twisted on its axis, in order to preserve the parallelism of the incisions in the skin and mucous membranes, until all the fluid escapes. I have not found this latter precaution necessary. When a broad lancet is used the wound is sufficiently patent, and the parallelism of the incisions is preserved by retaining the hold on the scrotum posteriorly; indeed the fluid escapes more freely with the instrument withdrawn. I have found the results of the above method of treatment very satisfactory. Resolution generally commences within 24 or 36 hours, and the patient is rarely confined to his room longer than five days, or a week. When the swelling has been somewhat reduced and the pain dis- sipated, and the parts will bear gentle handling, resolution may be hastened by the application of strips of adhesive plaster so as to ex- ercise compression upon the testis. This method of treatment was first suggested by Dr. Fricke, of Hamburg, and is known by his name.1 It is not to be used until the acute symptoms have sub- sided, nor while the spermatic cord is much engorged, nor if there 1 Dr. Fricke's paper was published in the Zeitschrift fur die gesammte Medicin. B. j. h. 1. Hamburg, 1836. A translation of it appeared in the British and Foreign Medical Review, vol. ii. 1836, p. 253. TEEATMENT. 133 is reason to fear the formation of an abscess in the testicle or sub- scrotal cellular tissue. The objections which have been urged against this method have been founded upon its indiscriminate use. The feelings of the patient after the straps are applied will indicate whether they should be continued or not. If applied at the proper stage of the disease, they will afford a sensation of support and relief; should they increase the pain, they are doing harm and ought to be at once removed. A mixture of two parts of adhesive plaster with one part of extract of belladonna spread upon thin leather, is more elegant, and, in many respects, better than adhesive plaster alone. It is softer, more elastic, less likely to chafe the skin about the cord, is removed with greater facility and ease to the patient, owing to its adhering less firmly to the skin and hairs, and, moreover, the belladonna acts powerfully as a sedative. Before applying the plaster, the hair should be carefully removed from the scrotum with a razor or scissors. The plaster is to be cut into strips about three-quarters of an inch in width. The tes- ticle is now to be pressed' down to the lower portion of the sac and held there by the thumb and forefinger of the left hand, while a strip is placed firmly round the affected side of the scrotum just below the abdominal ring. Successive strips are added, each overlapping the preceding for one-third its width, and care being taken that they all fit smoothly, until all but the bottom of the testicle is enveloped; the latter should then be covered with strips applied longitudinally, like the bottom of a wicker basket, and finally, the whole is to be secured by a long narrow strip carried circularly several times around the whole. In the course of from twelve to twenty four hours, the plaster will be found to be loosened by the decrease of the swelling, when it should be removed and fresh strips applied. The compression should be continued until the testis has nearly returned to its normal dimensions, and in the meanwhile the parts still be supported by a bandage. The application of collodion to the scrotum as a means of com- pression, suggested by M. Bonnafont, was a subject of discussion before the Academy of Medicine in Paris, in 1854, and a trial was made of it by Ricord and others, who reported against it. In those cases in which, after the subsidence of the acute symp- toms, the testicle remains in a condition of chronic engorgement, it is not best to persevere in an antiphlogistic course of treatment. 134 SWELLED TESTICLE. The diet should be nourishing, but not stimulant. Any effusion into the tunica vaginalis should be evacuated and the scrotal organs carefully strapped. The bowels should be kept free, and marked benefit will be derived from small doses of mercurials, as, for in- stance, a few grains of blue mass administered every night at bedtime. Opinions as to the propriety of treating the urethritis during an attack of swelled testicle have been widely different. Those who believe in the metastatic origin of epididymitis, have not only refused to take measures to cure the urethral discharge while the testicle was still inflamed, but have even advised that the urethra should be irritated by bougies or otherwise, so as to recall the disease to its original seat. Such practice is founded on a false assumption, and is both useless and dangerous. The continuance of the urethritis can only aggravate the epididymitis, or tend to produce a relapse if it has already subsided. The cure of the ure- thral discharge can alone afford security for the future. This, however, is not to be attempted by irritant injections. I am in the habit of employing the injection of glycerin, extract of opium, and sulphate of zinc, which I have recommended in the acute stage of gonorrhoea, never, however, adding a sufficient quantity of the sulphate to excite more than a momentary prickling sensation in the canal. The following formula is generally applicable:— $. Extracti opii 9j. Glycerin §j. Zinci sulphatis gr. vj-xij. Aquae gvj. M. The necessity of confining the patient to his bed for a period may be regarded as a very fortunate one, so far as the cure of his gonorrhoea is concerned, and he will, very probably, soon return to his business, cured both of his clap and swelled testicle. Copaiba and cubebs have no curative action upon epididymitis, and I think it best to abstain from using them when this complication super- venes. There are two other modes of treating gonorrhoeal epididymitis which require a passing notice. The first is that proposed by M. Yelpeau, and consists in puncturing the tunica vaginalis and evacu- ating the contained fluid, no matter how small its quantity. This procedure has already been recommended above, when the fluid has attained an appreciable amount. The peculiarity of M. Yelpeau's practice lies in the frequency with which he employs it, even where TREATMENT. 135 a few drops only escape from the incisions. He claims for this method that it gives immediate relief to the pain, that it shortens the duration of the disease, and takes the place of leeches and other troublesome and expensive remedies. The frequency with which this procedure is resorted to appears to be confined to M. Yelpeau. Other surgeons deem it advisable only under the circumstances already indicated. The dread of the knife which patients laboring under this disease naturally have, is a strong objection to its fre- quent employment. As a general rule, it is safe, for in one case only, so far as I am aware, has it been attended with any unpleasant result. This was in a patient under the care of M. Montanier,1 in whom excessive hemorrhage followed a simple incision into the tunica vaginalis, which was very difficult to control, and which even endangered life. Probably some scrotal artery of considerable size was wounded in the operation. The late M. Yidal (de Cassis) revived an operation which is said to have originated with a French surgeon by the name of Petit, who published a work on venereal in 1812. This operation is simply an extension into the substance of the testicle of the incisions recommended by Yelpeau. Yidal states that he first employed these incisions in swelled testicle when the body of the testicle was involved, to which form of the disease he gives the name of paren- chymatous orchitis. His design was, by dividing the tunica albu- ginea, to relieve the constriction exercised by this fibrous tunic upon its inflamed contents. Finding, as he says, that the operation was unattended by any unpleasant result, and that it relieved the pain and hastened resolution, he extended it to the more frequent cases in which the epididymis is alone attacked, and found the effect equally favorable. In his work on venereal, this author states that he has performed this operation with impunity in four hundred cases, and claims for it preference to all other modes of treatment. His directions as to the manner of performing it, are to incise the tunica albuginea with a bistoury or lancet passed through the scro- tum and tunica vaginalis to the extent of six-tenths of an inch (un centimltre et demi), and to penetrate the parenchyma of the testicle to the depth of less than three-tenths of an inch (de moins de moitie). Only one puncture of this kind is to be made. In spite of M. Yidal's testimony in its favor, we can hardly believe this operation entirely devoid of danger, especially since the recent report of four 1 See the Gaz. des Hopitaux, 1858, p. 106. 136 SWELLED TESTICLE. cases observed by a single surgeon, M. Demarquay, in which the substance of the testicle gradually oozed from the incision in fila- ments, and in three of which the testicle was totally lost.1 If re- sorted to at all, it should probably be reserved for those cases in which it was first used, viz., where the body of the testicle is exten- sively implicated. Numerous other topical remedies have been recommended in gonorrhoeal epididymitis, but many of them are not worthy of mention. Inunctions of mercurial ointment upon the scrotum may relieve the pain, but are liable to cause salivation. They may be used with caution in those cases in which the acute symptoms have subsided, leaving chronic engorgement of the epididymis. The application of chloroform has been advised, but before affording ease it usually increases the pain and renders it almost insupportable. The active treatment by leeches and purgatives, above recom- mended during the acute stage of epididymitis, includes the best prophylactic measures that we can adopt to prevent any induration being left behind in the epididymis. If such be detected, however, the earlier it is attacked the better, for the chances of success are certainly superior, while the plastic material is not yet fully organ- ized. If the indurated epididymis is still abnormally sensitive to pressure, the application of a few leeches over the cord, repeated several times at intervals of a few days, will be found of service. A small quantity of mercurial ointment should be rubbed into the scrotum morning and night; the genital organs should be well sup- ported by a suspensory bandage, and the bowels be kept free. Much is to be expected also from the internal administration of iodide of potassium, which is so powerful an agent in resolving inflammatory products generally. It is impossible to say how old an induration of the epididymis can be treated with hopes of suc- cess. M. Gosselin's cases show that they may disappear after exist- ing for several months, and it is not improbable that a cure may be effected after a much longer period. Where the epididymis on both sides is affected, the attempt should certainly be made, especially if the patient is young and intends to marry. It is a serious question whether the surgeon should inform him of the impotency which his disease entails, since the effect of this informa- tion upon his mind might possibly be most disastrous. 1 British and For. Medico-Chirurg. Rev., Am. ed., Apr. 1859, from the Bulletin de Therapeutique, tome lv. p. 549. INFLAMMATION OF THE PROSTATE. 137 CHAPTER VII. INFLAMMATION OF THE PROSTATE. ACUTE PROSTATITIS. Acute prostatitis may be due to violence from sounds, catheters, or lithotrity instruments; to the application of caustic to the deeper portions of the urethra; to stricture, the irritation of a stone in the bladder, immoderate coitus, or excessive purgation; but by far the most frequent cause is urethral gonorrhoea. Gonorrhoeal prostatitis owes its origin to the extension of the inflammation from the urethral walls to the substance of the pros- tate gland; it occurs, therefore, at a time when the disease has invaded the deeper portions of the canal, and is consequently rare during the first two weeks of a gonorrhoea; resembling in this respect its more frequent congener, gonorrhoeal epididymitis. The accessory causes of the last mentioned disease, viz., highly irritant injections, forcible distension of the urethra in using a syringe, excessive exercise, alcoholic stimulants, exposure to cold and wet, and venery, may also contribute to the production of prostatitis. There is less ground for believing that this affection is occasioned by the use of copaiba and cubebs, unless in very immoderate doses. The earliest symptoms of an attack of prostatitis are an increased frequency in the desire to micturate, and a sensation of weight or a dull pain in the perineum. As the disease progresses, the calls to pass water become more and more frequent, while the stream is very small, is only forced out by prolonged straining, and is attended by a severe scalding sensation at the neck of the bladder; some- times only a few drops appear, or there is complete retention of urine. The bowels are generally constipated, though the patient is often led by a feeling of distension in the rectum to make fruit- 138 INFLAMMATION OF THE PROSTATE. less efforts at stool; and should defecation take place, the act excites severe pain. The system at large sympathizes with the local trou- ble, and general febrile excitement ensues. Exploration of the prostate by the finger in the rectum reveals abnormal sensibility and tumefaction of this organ proportioned to the severity of the disease; and a sound introduced into the urethra, upon reaching the prostatic region, meets with an obstruction and excites a degree of suffering that is with difficulty endured by the patient. Acute prostatitis may terminate in resolution, in suppuration, and, in rare instances, in gangrene. Several cases are recorded in which the inflammation has extended to the peritoneum, and in which death has ensued from peritonitis. Of the above modes of termination, suppuration, next to resolu- tion, is the most frequent. The formation of matter is not always announced by well-marked symptoms, but may be strongly sus- pected if, after the disease has been increasing in intensity for eight or ten days, the patient is seized with repeated chills followed by fever and general depression. It is possible, however, for an abscess to form without affording the least reason to suspect it. A case recently occurred at St. George's Hospital under the care of Dr. Pitman, in which prostatitis supervened upon an attack of gonor- rhoea, and terminated in suppuration and the death of the patient, with entire absence of rigors and the ordinary symptoms of ab- scess of the prostate. At the post-mortem examination, an exten- sive abscess, which had not been suspected during life, was found between the bladder and rectum.1 An abscess may be situated between the rectum and the gland, in the substance of the latter, or upon its urethral aspect. In the first two instances, a soft fluctuating tumor can be felt in the region of the prostate by the finger introduced into the rectum, especially if the gland be immovably fixed by a sound in the urethra. An abscess in the neighborhood of the urethra is more difficult of de- tection, except from its encroachment upon the canal, and its in- terference with the exit of urine and the introduction of a catheter. A prostatic abscess most frequently breaks upon the side of the urethra during the efforts of the patient to expel the urine or feces, or it is often perforated by the point of an instrument introduced for the purpose of exploration or catheterization; sometimes it opens 1 London Lancet, Am. ed., Jan. 1861, p. 69. ACUTE PROSTATITIS. 139 into the rectum, bladder, or cellular tissue of the pelvis; or it may communicate with both bladder and rectum and give rise to a uri- nary fistula. In other instances the fluid contents are absorbed, and the abscess becomes surrounded by a kind of cyst which is filled with a semi-solid substance resembling a deposit of tubercle. Treatment.—The appearance, during an attack of gonorrhoea, of a frequent desire to pass the urine, and pain in the perineum, indicating that the inflammation has involved the neighborhood of the neck of the bladder, should lead the surgeon at once to abandon the use of astringent injections, copaiba and cubebs; and, neglecting the urethral discharge for a time, to direct his whole attention to the more serious affection which has supervened. The patient should now observe the most perfect rest and quietude. If the symptoms be at all severe, from six to a dozen leeches should be applied to the perineum, and be followed by a hot bath at the tem- perature of 100°, which may be repeated with benefit several times in the twenty-four hours. Some authors recommend the application of leeches by means of an anal speculum to the anterior wall of the rectum, where contiguous to the inflamed gland. In the intervals of the baths the perineum should be covered with hot fomentations or poultices. Internally we may resort to those remedies, as the salts of potash and soda, which exert a beneficial effect upon inflammation of the neck of the bladder and its neighborhood, and which render the urine more dilute and mild in its character. The formula containing mucilage, bicarbonate of potash, and hyoscyamus, already given in the chapter upon urethral gonorrhoea in the male, is well adapted for the treatment of the disease we are now considering. The diet should be abstemious, consisting of gruel, mucilaginous drinks, milk, and farinaceous substances, at least in the early stages of the dis- ease ; at a more advanced period, and after suppuration has taken place, our utmost efforts may be required to sustain the strength of the patient by a nourishing diet and even tonics. Sleep should be secured by the exhibition of a Dover's powder at night. Mr. Adams speaks highly of warm enemata, consisting of four or five ounces of simple water or gruel, administered at bed- time, which are said to afford comfort to the patient, and to act as a fomentation to the inflamed gland.1 1 Anatomy and Diseases of the Prostate, p. 41. 140 INFLAMMATION OF THE PROSTATE. Complete retention of urine will require evacuation of the bladder by means of a catheter. When an abscess has formed and fluctua- tion can be distinctly felt by the finger in the rectum, a puncture may be made through the intestinal wall; or when the collection of matter is most prominent towards the urethra, it may sometimes be opened by a conical sound introduced as far as the prostatic portion of the canal, while a finger within the rectum presses the tumor against the point of the instrument. This attempt, however, is by no means free from danger, and should never be made, unless the symptoms are urgent and the existence of matter in the neighbor- hood of the urethra highly probable. CHRONIC PROSTATITIS. The preceding affection is that form of prostatitis which most frequently accompanies and originates in urethral gonorrhoea. Chronic prostatitis, on the contrary, is more commonly due to onanism, excessive venereal indulgence, or sedentary habits; and, although not unfrequently occurring in persons who have suffered from gonorrhoea, is in most cases less directly traceable to this affection. For a long period chronic prostatitis was confounded with irrita- tion and inflammation of the neck of the bladder, and was not recognized as a distinct disease until the publication of the admirable descriptions of it by Mr. Adams,1 Mr. Ledwich,2 and more recently by our distinguished countryman, Dr. Gross, of Philadelphia.3 Chronic prostatitis is most common in young men, and especially among those who lead a sedentary life, or who are the victims of masturbation. It is also met with in persons who have abused their sexual powers either in promiscuous intercourse or early married life. One of the most frequent and prominent symptoms of this affec- tion is a discharge of clear and transparent, or sometimes turbid, 1 Anatomy and Diseases of the Prostate Gland. London, 1853. 2 Dublin Quarterly Journal, Aug. 1857, p. 30. » North Am. Med.-Chir. Rev., July, 1860. Dr. Gross describes this as a hitherto unknown affection under the name of " prostatorrhcea," but his account of it cor- responds in almost every particular with that given by Mr. Adams under the head of "prostatitis from onanism." The increased secretion of prostatic fluid is a mere symptom of irritation or inflammation of the gland, and it is therefore desir- able that the term prostatitis should be retained. CHRONIC PROSTATITIS. 141 mucus from the meatus, which is found by the microscope to consist of: 1. "Morphous crystals of uric acid, or ammoniaco-magnesian phosphates; 2. Mucus-corpuscles; 3. Blood-disks; and4. Epithelium cells,"1 either with or without a few pus-corpuscles. The discharge may be almost constant in its appearance and sufficient in quantity to stain the linen, or, more frequently, it is forced from the urethra by the pressure of the hardened feces during straining at stool, and is not perceptible at any other time. Most patients suppose that it consists of semen, from which it may be distinguished under the microscope by the absence of spermatozoa. Yery many of the cases of spermatorrhoea so-called are doubtless instances of this affection. In most cases, the frequency of micturition is more or less in- creased; the stream of urine is ejected without force; the last drops dribble away, or are only expelled with considerable effort; and a scalding sensation is felt in the urethra during and after the act. Pain and uneasy sensations are experienced in the perineum, thighs and lumbo-sacral region; there is often great irritation about the anus attended by haemorrhoids or eczema; the bowels are con- stipated, and defecation difficult and painful; the passage of an in- strument into the bladder excites severe pain as it passes through the prostatic region; on examination per anum, the gland is found to be tumefied, sensitive on pressure, and sometimes indurated; the patient is irritable and low spirited; is incapable of mental or phy- sical exertion; suffers from weakness, headache, and dyspepsia; watches his symptoms with the greatest anxiety; imagines that he is losing his memory, that he is impotent or affected with syphilis, and, in short, becomes a desperate hypochondriac. Independently of its action upon the nervous system, chronic prostatitis is not a serious, although a very obstinate disease. It never terminates in suppuration and abscess, nor in the chronic hypertrophy so common in old men. Mr. Ledwich has had an opportunity, in two instances, of becom- ing acquainted with the pathology of this affection; "one case oc- curred at the age of 18, the second at 30; both were well-marked examples of the disease, and succumbed to phthisis, but this latter had no connection with the urethral affection. The prostato-vesical plexus was full, and many of its branches varicose; the capsule of the prostate adhered intimately to its surface, and, on slicing the Ledwich, op. cit. 142 INFLAMMATION OF THE PROSTATE. gland, it seemed soft, with large, open, venous branches on the sec- tion, from which blood exuded, whilst the whole gland exhibited an augmented volume; the mucous membrane of its urethral aspect was red, soft, thickened, and villous, whilst the ducts could be dis- tinguished with the unassisted eye; the uvula and trigonum vesicae were red and turgid, but the remainder of the bladder was healthy. I examined with some anxiety for the presence of tubercular deposit in the gland, but, although this morbid condition was often antici- pated, no evidence of any such structural lesion could be detected. The seminal ducts did not present any alteration as to size, their excretory orifices being discovered with the greatest difficulty, the vesicula? seminales being full and swollen, but without any other abnormal appearance; scrofulous tubercles existed in the epididy- mis, yet the testicles, although soft and small, were otherwise healthy." Treatment.—In most cases of chronic prostatitis, the patient is laboring under a combination of mental as well as physical symp- toms, and the treatment must be directed to the mind equally with the body. It is not sufficient in these cases to dash off a hurried prescription and dismiss the patient after five minutes conversation. The victim of mental more than physical suffering has for weeks or even months been brooding over his complaint during all his waking moments, not absolutely necessary to his daily occupation, exagge- rating each trifling symptom, entertaining the most gloomy fore- bodings of the future, and perhaps contemplating suicide. First of all, he needs a friend who can lead him, however reluctantly, to un- burden his mind of its sorrow. This load removed, he at once feels lighter and more hopeful. The surgeon's first object, there- fore, should be to gain his confidence by friendly yet manly conver- sation, lending a ready ear to the familiar story of the hypochondriac, encouraging him to feel that he has found a sympathizing friend as well as physician, and gradually and skilfully leading him from the depths of despondency to more rational views of his position and prospects in life. One great source of anxiety to the patient is probably the idea that the transparent viscid discharge which appears during strain- ing at stool, or is mingled with the last drops of urine, consists of semen. The surgeon is generally safe in assuring him of the con- trary, without special examination, since diurnal spermatorrhoea CHRONIC PROSTATITIS. 143 without some degree of spasmodic action is exceedingly rare; but any doubt upon the subject may be removed by placing a drop of the fluid under the microscope which will probably confirm his assurance by showing the absence of spermatozoa. In many cases, however, chronic prostatitis is really complicated with seminal emissions, taking place at night, with greater or less frequency. In such instances, the most substantial meal in the twenty-four hours should be taken about noon, the supper should be light, and food and drink entirely avoided in the evening; the bedchamber should be well ventilated, a hair mattress preferred to a feather bed, and much covering avoided; and the patient should be directed to sleep upon his side instead of upon the back, and to rise as soon as he wakes, seminal emissions occurring most fre- quently during the semi-consciousness of the early morning nap. Tobacco in every form should be prohibited, since it not only in- creases the general irritability of the nervous system, but appears to have a direct influence upon the genital organs in diminishing their tone and thus favoring seminal emissions. Above all, the mind of the patient should be distracted from his complaint by con- stant occupation, and the general health be promoted by a plain but nourishing diet, and by daily out-door exercise, not carried to fatigue. Spermatorrhoea is not unfrequently associated with, and in a great measure dependent upon, the presence of varicocele, phy- mosis, or an excessively elongated prepuce, the removal of which, by an operation, is essential for the relief of the nocturnal emis- sions. It is natural to suppose that any local source of irritation will keep up the excitability of the genital organs, and this sup- position is abundantly confirmed in practice. I have met with a number of instances in which the relief afforded to spermatorrhoea by circumcision or an operation for varicocele was most decided and unquestionable. There is a fact which is generally unknown to the subjects of spermatorrhoea, and a knowledge of which affords great relief from mental anxiety and thereby assists recovery. It is this, that noc- turnal seminal emissions occasionally occur to nearly all unmarried men, especially between the ages of fifteen and twenty-five, or even later, and are not inconsistent with robust health. Indeed, their repetition as often as once or twice a week, provided the patient is aware of no debility or other ill effect in consequence, need cause no apprehension. After the age of twenty-five, the excitability of 144 INFLAMMATION OF THE PROSTATE. the genital organs gradually diminishes, and involuntary seminal emissions decrease in frequency or cease altogether. The charlatan finds it for his interest, by every means in his power, to heighten the fears of the subjects of spermatorrhoea; the true surgeon equally endeavors to allay them, and, without ex- ceeding the bounds of truth, may give positive assurances of recovery to every patient in early life (say under the age of 25) and of a naturally good constitution, upon the following conditions: 1. That any habits of self abuse which may have been indulged in be totally abandoned; 2. That he cease to think only of himself and his com- plaint, and find some healthy occupation for his mind and body. At the same time he should be informed that he is not to expect immediate and complete relief; that his emissions will still for a time recur, although at gradually increasing intervals; but that, if he will only persevere, his ultimate recovery is certain. If he can be brought to think lightly of the emissions at the time of their oc- currence, trusting in the surgeon's assurance that they are a merely temporary evil, a cure is well nigh accomplished. The numerous popular works which have appeared upon mastur- bation and seminal emissions, most of them written by quacks with the basest of motives, have done an immense deal of mischief by inducing that state of mind in the reader best calculated to keep up his disease. The purest and most unexceptionable work of this class that I have ever seen, was written by a noble physician and philanthropist recently at the head of one of our Insane Asylums; but only one edition was allowed to appear, because the author be- came convinced that the most guarded treatise upon this subject was not free from danger. I am happy to quote this high authority in confirmation of the statement above made, that seminal emissions occurring in youth very rarely produce disastrous results, provided the habit upon which they most frequently depend is entirely aban- doned. The frequent co-existence of seminal emissions with chronic prostatitis and the similarity of the patient's mental condition, re- quiring, in the two diseases, the same treatment directed to the mind, will excuse the apparent digression in the above remarks. In addition to the general hygienic means above recommended, most cases of chronic prostatitis require the administration of iron, of which the tincture of the chloride, in the dose of twenty drops after each meal, is undoubtedly the best preparation. I have also ob- CHRONIC PROSTATITIS. 145 tained favorable results from a solution of strychnine in dilute phos- phoric acid:— R. Strychniae gr. j. Acidi phosphorici diluti |iij. M. A teaspoonful three times a day. The large proportion (about two-thirds) of muscular fibre enter- ing into the composition of the prostate, explains why affections of this body are but slightly amenable to those remedies, as iodine, the action of which is so favorable upon organs strictly glandular. Chronic inflammation of the prostate is perpetuated by the con- stipated state of the bowels and consequent straining at stool which usually attends it, and which should, therefore, be obviated by lax- atives or enemata; but aloes, which is a constituent of most of our pharmaceutical preparations for this purpose, should be avoided, on account of its well-known tendency to produce congestion of the haemorrhoidal vessels. Saline cathartics may be administered in small doses in the morning on rising; but I much prefer enemata of cold water, taken immediately before the usual time of going to stool, which are followed by a loose evacuation unattended by strain- ing, and which prevent the discharge of prostatic fluid. In cases complicated with gleet, and in the absence of acute inflammation, benefit may be derived from weak astringent urethral injections. As a general rule local applications may be dispensed with, and are so far objectionable as they tend to direct the thoughts of the patient to the seat of his disease. Yet when decided tenderness of the prostate is found on examination per anum, the repeated appli- cation of leeches or blisters to the perineum will prove beneficial. The late Dr. J. C. Warren, of Boston, highly recommended in these cases the use of the cold douche to the perineum. It is only in extreme cases, which have resisted milder methods of treatment, that cauterization of the prostatic portion of the urethra, repeated at intervals of a week or ten days, should be resorted to. Moderate sexual indulgence is found to relieve the morbid irritability of the genital organs, and matrimony, when practicable, should be recom- mended to those who are single. 10 146 INFLAMMATION OF THE BLADDER. CHAPTER VIII. INFLAMMATION OF THE BLADDER. Cystitis is* a less frequent complication of gonorrhoea than pros- tatitis, but occasionally occurs as a consequence of the extension of the inflammation along the continuous mucous surface common to the urethra and bladder. It has also been attributed in rare instances to the gonorrhoeal discharge finding its way, or being forced into the bladder and there lighting up inflammation similar to that affect- ing the urethral walls. A case of this kind is reported in the Arch. Gen. de Medecine* in which cystitis suddenly supervened after using a simple emollient injection. All those causes which aggravate the urethritis may concur in exciting cystitis, among which the abuse of injections should be included. In this disease the highly sensitive condition of the inflamed blad- der prevents the retention of more than a few drops of urine, and the calls to urinate are very frequent and urgent. There is also pain in the hypogastric region radiating towards the perineum, and in the direction of the kidneys along the course of the ureters; together with tenderness upon pressure above the pubes. The urine is high colored, sometimes tinged with blood, and mixed with stringy mucus or pus. In some instances complete retention takes place from a loss of contractility in the vesical walls, and the distended bladder can be felt rising above the symphysis pubis and rendering the abdomen more prominent than natural. When the bas-fond of this organ is chiefly involved, there is frequent desire to go to stool and rectal tenesmus; while in some instances fhe valvular outlets of the ureters are closed by the tumefaction of the vesical walls, giving rise to distension and dilatation of the ureters, and severe pain along their course and in the region of the kidneys. General febrile excitement is present at the commencement, but if the disease 1 Tome xiii. p. 454, 1829. TREATMENT. 147 proceed to a fatal termination, great prostration soon sets in, marked by a small quick pulse, dry tongue, clammy perspiration, hiccough, sleeplessness, and delirium. In many cases of gonorrhoeal cystitis the inflammation is confined to the neck of the bladder, when the retention of urine is more obstinate, the difficulty in passing a catheter greater, and the symp- toms generally more acute than if the whole viscus be involved. According to Lallemand, inflammation confined to the neck of the bladder may be recognized by the peculiar phenomena attending catheterization. " In proportion as the instrument advances through the curved portion of the urethra, the pain of its introduction increases, and, when it reaches the vesical neck, becomes intolerable. The neck of the bladder closes as the catheter approaches and is pushed on before it, so that the instrument may appear to have entered the bladder; but, if left to itself, is partially forced out of the canal by the restoration of the neck to its natural position. Under these circumstances nothing would be gained by u^ing force, which, moreover, is capable of doing much harm. The catheter should be left in place until the spasmodic contraction has passed off; when the vesical neck opens of itself and appears to draw the point of the instrument into the bladder by a kind of suction pro- cess accompanied by a slight to-and-fro movement. The pain at, this time is especially severe; it appears to the patient as if the catheter were touching a raw surface; and considerable difficulty is experienced in withdrawing the instrument, owing to the contraction of the vesical neck around it." Acute cystitis most frequently terminates in resolution; though sometimes, in the chronic form of the disease, in abscess situated in the substance of the vesical walls, or between the bladder and rec- tum; in hypertrophy, ulceration, rupture, or even gangrene. If rupture take place, the escape of the urine into the pelvic cellular tissue or peritoneal cavity, soon leads to a fatal termination. Treatment.—The treatment of acute cystitis consists in the application of cups or leeches to the perineum and hypogastric region, prolonged immersion in warm hip-baths, hot fomentations and poultices to the hypogastrium, warm opiated enemata, and the internal administration of mucilaginous drinks in small quantities, with the addition of the nitrate or bicarbonate of potassa and hen- 148 INFLAMMATION OF THE BLADDER. bane. Catheterization is required for the relief of retention of urine, but should not be performed with unnecessary frequency, for fear of increasing the inflammation; and a permanent instrument is objectionable for the same reason. At the same time, the urine is rendered acrid and irritating by the admixture of mucus and pus, and should not be left to accumulate in large quantities. GONORRHOEA IN WOMEN. 149 CHAPTER IX. GONORRHOEA IN WOMEN. The mucous membrane of the genital organs is far more exten- sive in the female than in the male. Besides lining the urinary canal and the vulva—parts corresponding to the urethra and balano- preputial fold in man—it is continued over the walls of the vagina, where its surface is increased by numerous folds, and, reflected over the os tincse, extends into the cavities of the cervix and body of the uterus. Any portion of this extensive surface may be attacked by catarrhal inflammation, which, according to its seat, is called gonor- rhoea of the vulva, urethra, vagina, or uterus. Some of these parts are more frequently affected than others. Thus, gonorrhoea of the vagina is more common than that of the urethra or vulva, and gonorrhoea of the uterus is the least frequent of all. It is rare for all the different portions of the female genital organs to be attacked together, though two or more are, in many instances, combined as the seat of gonorrhoeal inflammation. The manner of union appears to be chiefly determined by the anatomical relation of the parts. Thus, when the vulva is affected, the urethra and lower portion of the vagina are likely to be involved; while, on the other hand, the upper part of the vagina and uterus are not unfrequently implicated together. Causes.—Gonorrhoea is a much less common disease in women than in men. This may be accounted for by several reasons. The mucous membrane of the vagina is less sensitive than that of the male urethra; it receives no little protection from the sebaceous and mucous secretions which constantly cover it; the size of the passage is such that it can be readily cleansed; and the urethra, in conse- quence of its being but very slightly concerned in the sexual act, and of the situation of its meatus, is less exposed to contagion. But another reason, and one perhaps of still greater weight, is to be found 150 GONORRHOEA IN WOMEN. in the absence in men of those chronic discharges, the presence of which in women is so fruitful a cause of urethritis in the opposite sex. When speaking of the causes of gonorrhoea in the male, I endeavored to show that it is frequently due to the irritation pro- duced by a leucorrhceal discharge, by the menstrual flow, or by the normal secretions of the female genital organs. Women, in sexual intercourse, are not exposed to these exciting causes of gonorrhoea. In a condition of health, there is no secretion about the maje genital organs capable of exciting inflammation in the female; while during the acute stage of gonorrhoea the pain excited by turgescence of the penis is generally sufficient to deter from coitus, and even in cases of gleet, the amount of the discharge is so small, the urethra so frequently cleansed by the passage of urine, and the vagina so well protected by sebaceous matter, that intercourse may often take place without much exposure to the woman. Owing to these circumstances, women more frequently communicate than receive gonorrhoea. It would seem to be a fair deduction from the foregoing, that, taking a given number of gonorrhoeal cases in the two sexes, more are due to infection in women than in men; and such I think is unquestionably the fact. But while assigning to direct contagion the first place in the etiology of the gonorrhoea of women, other in- fluences must not be overlooked. These, however, are less appreci- able in the female than in the male. The history of women seeking advice for gonorrhoea can rarely be ascertained with certainty, or their disease traced with accuracy to its source. It is notorious that a woman often receives the embraces of several men within a short space of time, and there are many reasons for her concealing important facts which a man would readily confide to his physician. It is, therefore, only under peculiar circumstances that we can satisfactorily ascertain the origin of gonorrhoea in women; still, op- portunities for such investigation do sometimes occur, and, in several which I have met with, it was evident that the disease was due to other causes than contagion. Thus, I have known intercourse with a healthy man to excite acute and extensive inflammation of the genital organs in women suffering from leucorrhoea and congestion of the cervix, especially if the stimulus of liquor was added to that of coitus. In such cases, chronic may readily be transformed into acute inflammation, in the same way as a gleet in man may be changed into a clap. In some instances, I have had reason to believe that the frequent repetition of the sexual act has produced CAUSES. 151 gonorrhoea in women free from any previous disease, and it is a well established fact that a purulent discharge sometimes follows the first exercise of marital rights, although there may have been no laceration of the female genital organs. In general, the causes of gonorrhoea in women, independently of contagion, may be enume- rated as follows: Immoderate sexual intercourse, violence, mastur- bation, the presence of vegetations, syphilitic or other eruptions, errors of diet, ascarides in the rectum, and the external influences of cold, moisture, etc. Many women have, during pregnancy, a muco-purulent discharge, which usually makes its appearance after the fourth or fifth month, though sometimes before, and chiefly affects the upper portion of the vagina. An examination of the vaginal mucous membrane reveals the existence of numerous granulations, similar to those observed also in some cases of vaginitis from contagion. Cazeaux states that this discharge may produce disorder of the digestive functions, as shown by the coexistence of gastralgia, which is more or less severe according to the intensity of the vaginitis.1 The discharge usually disappears spontaneously after the termination of gestation. Yaginitis may be attendant upon scarlet fever, or it may follow this and other exanthemata as a sequela.8 Yery young girls may be attacked with inflammation of the genital organs, producing a copious purulent discharge from the vulva, and sometimes from the vagina also, the cause of which has often been misapprehended. It has been supposed that the disease was contracted from men who had been seen to caress or fondle them, and innocent persons have been arrested and tried on this charge. No one in such cases has done more for the honor of our profession and for the cause of humanity than Mr. Wilde, of Dublin, who has repeatedly come forward when the accused party was about to be convicted for an offence which he never committed, has shown the o-roundlessness of the charge and proved his innocence. In most cases, the discharges in question are no more venereal in their nature than the otorrhcea which is so common in children. Their predis- posing cause is hereditary cachexia, or, as it is commonly called, a strumous diathesis. The exciting cause may be deficient cleanli- ness, derangement of the digestive functions, the irritation of teeth- 1 Traitfi de 1'Art des Accouchements, 4e Edition, p. 317. 1 Cormack, London Journal of Medicine, Sept., 1850, p. 872; and Barnes, Medi- cal Gazette, July 1-', 1850, p. 65. 152 GONORRHOEA IN WOMEN. ing, and the presence of ascarides in the rectum, or within the vulva, where they may have found their way from the gut. Such dis- charges are contagious when applied to the ocular conjunctiva, and not less so, in all probability, if brought in contact with the genital organs of a second person; thereby proving that the contagiousness of gonorrhoeal matter depends upon the seat of the disease, and not upon the presence of a specific poison necessarily transmitted from one individual to another. Symptoms.—The initiatory symptoms of gonorrhoea in women are often obscured, in the rare instances afforded for their examina- tion, by the previous existence of a leucorrhceal discharge. They do not differ from the early symptoms of inflammation of other mucous membranes, and consist in the gradual development of swelling, redness and tenderness, and an increase of, and change in, the secretion of the part. The discharge varies in consistency and color as in gonorrhoea in the male. It is at first transparent and mucous, then muco-purulent, and finally, when the disease has attained its height, thoroughly purulent. When secreted by the vagina it is acid, fluent, creamy, and readily removed from the sur- face; when derived from the cavity of the cervix,1 without being mixed with the acid matter of the vagina, it is alkaline, nearly transparent, tenacious like the white of egg, and very adhesive. Examined under the microscope, the vaginal secretion is found to consist of pus-corpuscles, mucus, an abundance of epithelial scales and flakes of epithelium in masses; while the viscid plug drawn from the cervix, which, as shown by Dr. Tyler Smith, is glandular in its structure, exhibits mucus-corpuscles, oil-globules and purulent matter. The consistency and yellowish color of the vaginal secre- tion are dependent upon the quantity of organized elements it con- tains. The thicker it is, the more opaque, and the more resemblance it bears to cream or pus, the greater the quantity of pavement epi- thelium and pus-globules, as shown by the microscope.2 M. Donne" has also called attention to the presence of a small infusorial animalcule which he at first supposed to be pathogno- monic of gonorrhoeal vaginitis. He has since renounced this opinion, 1 The most convenient method of collecting the cervical secretion for the pur- pose of examination, unmixed with the vaginal mucus, is by means of Lalle- inand's porte caustique, uncharged. * Pathology and Treatment of Leucorrhoea, Phil, ed., 1855, p. 122. GONORRHOEA OF THE VULVA. 153 but still asserts that the Trichomonas is not seen in healthy vaginal mucus, but only when there is a large admixture of pus-globules. Farther researches by Kolliker and Scanzoni1 would show that it is never present in the secretion of the cervix, so that it cannot be a mere cell of ciliary epithelium, and these authors state that there can be no doubt of its independent animal nature. It was first found by them in pregnant women, and, after their attention was called to it, in more than half the women whom they examined. Hence it cannot be considered as characteristic of gonorrhoea. Still, it is never met with in perfectly healthy mucus, destitute of pus- globules. It appears to depend upon certain changes in the vaginal secretion, and is not developed to any extent except in mucus which is clearly abnormal.2 Traces of a discharge from the genital organs are to be sought for chiefly upon the posterior portion of a woman's linen, and not upon the anterior. The absence of any external evidence of disease does not, however, prove her sound; since the upper portion of the vagina may be inflamed and the secretion be retained within the vulva. The symptoms of gonorrhoea in women vary according to the part affected, and it is convenient to make a corresponding divi- sion in their description, recollecting, at the same time, that the different forms may be more or less combined in a given case. Gonorrhoea of the vulva is less common than that of the vagina, and, in many cases, is secondary to the latter, being produced by contact with the discharge flowing from above. It is, however, often primary, and is that form which is commonly met with as the result of violence, or the presence of vegetations and syphilitic or other eruptions, as chancres, mucous patches, etc. The gonorrhoea of young girls, already referred to, is also, in most cases, vulvar. The patient's attention is early attracted to the part by a sensation of heat a*nd pruritus. On examination, the mucous membrane is found to be reddened, tumefied, and more moist than natural. As the disease advances the discharge increases in quantity and becomes muco-purulent, or purulent, and very offensive. The labia and nymphae are swollen to such a degree that it is almost impossible to expose the orifice of the vagina. If the nymphae be naturally 1 Das Secret d. Schleimhaut d. Vagina und des Cervix Uteri. Scanzo>i's Bei- trage, Bd. ii. p. 128. Wurzburg, 1855. 2 Traite1 Pratique des Maladies des Organes Sexuels de la Femme, par F. W. de Scanzoni ; traduit de PAllemand, Paris, 1^58, p. 452. 154 GONORRHOEA IN WOMEN. large, they may swell to such an extent as to protrude beyond the labia and become constricted; a condition which may be compared to paraphymosis. The mucous membrane may be deprived of its epithelium in patches, identical in character with the superficial excoriations of balanitis. The inflamed parts are exceedingly sen- sitive to the slightest touch or pressure, and motion is very painful. The last drops of urine fall upon the excoriated surface and give rise to severe scalding. The discharge collects in the hair on the mons veneris and upon the external surface of the labia, and flows upon the integument of the perineum, and upon the upper portions of the thighs. Wherever it remains for any length of time it irri- tates and inflames the skin, which soon assumes an erythematous or even excoriated condition, and itself secretes an acrid humor. If the discharge comes in contact with the anus, as is very likely to occur when the patient lies upon the back, it may produce irritation of the rectum, attended by frequent desire to go to stool, pain on the passage of the feces, and sometimes slight diarrhoea.1 The sexual desires are often heightened, and amount at times to nymphomania, but coitus is attended with severe pain, if it even be possible. No other form of gonorrhoea in women equals this in the suffering which it occasions. This is partly owing to circum- stances already mentioned, and partly also to the great sensibility possessed by the vulva in common with other outlets of mucous canals. The general system sometimes sympathizes with the local disease, and the patient is found to be hot and feverish. All cases of vulvar gonorrhoea are not, however, so severe as that just de- scribed. Instances occur in which there is but little redness, tume- faction, or sensibility, and merely an increase of the secretion of the part; and the symptoms may vary all the way from this mild cha- racter to the intensity of the above description. The anatomy and pathology of the glandular apparatus of the female genital organs have been admirably given by M. Huguier,3 and no account of vulvitis would be complete without including a description of the changes which take place in these bodies. The vulva is abundantly supplied with sebaceous and muciparous folli- cles, which are lined by a prolongation of the mucous membrane. Travelling along this continuous surface the inflammation readily 1 BadmSs, Pr6cis sur les Maladies Veneriennes, t. ii. p. 163. 8 Meraoires de l'Academie de Med., 1850, p. 529. GONORRHOEA OF THE VULVA. 155 gains access to the interior of the follicles, which soon pour out a thick purulent secretion from their mouths. The entrance to the vagina is also provided with two larger and more deeply situated secretory organs, which, although noticed by several anatomists subsequent to the seventeenth century, were comparatively unknown up to quite a recent date. These glands were first discovered by Duverney in the cow, and afterwards by Bartholin in woman, but, having been sought for in vain by Haller, they were entirely forgotten, until attention was again called to tiiem, in 1840, by Tiedemann,1 of Heidelberg, and by M. Huguier, of Paris, in 1850. They are now known by the name of Duverney's, Bartholin's, Cowper's, or the vulvo-vaginal glands. They are situ- ated, one on either side of the entrance to the vagina, in the trian- gular space, bounded by the ascending ramus of the ischium, the vaginal orifice, and the transversalis perinaei muscle, and are covered by the superficial perineal fascia, and some fibres of the constrictor vaginae. Their size varies in different subjects, and they appear to be largest in women addicted to sexual intercourse. When most developed their diameter usually measures about six-tenths of an inch. They are conglomerate glands, consisting of congeries of small tubes, surrounded by a common envelope, and during the act of coitus, pour out a copious secretion of albuminous fluid, by means of a duct six or seven lines in length, opening just in front of the hymen, or near the lateral and posterior carunculae myrti- formes, which often conceal its orifice. The inflammatory process may invade this duct, and the gland beyond it, in the same manner that it does the superficial follicles; and when suppuration has taken place, if the matter do not find free exit through the natural outlet of the gland, an abscess is formed either within the dilated duct, or in the substance of the gland itself; the former being generally the case when gonorrhoea is the exciting cause. Now, abscesses in the neighborhood of the vulva are quite com- mon in cases of vulvitis, and though some of them are situated in the submucous cellular tissue, yet most of them are of the character above described, and are seated in the vulvo-vaginal gland or duct. A frequent and peculiar feature which marks them, is the facility with which, having once emptied themselves, they again fill up, on 1 Von den Duverneyschen Driisen; Heidelberg, 1840. 156 GONORRHOEA IN WOMEN. the occurrence of any slight cause, as a return of the menstrual period, indulgence in sexual intercourse, exacerbation of the vulvar inflammation, etc. This circumstance has led some authors to the erroneous conclusion that these abscesses are surrounded by a true cystic wall, whereas their envelope continues to be, as at first, either the dilated duct or gland, which, to a certain extent, performs the office of a cyst. These glandular abscesses, however, may generally be recognized without much difficulty. The patient complains of a "swelling" in the vicinity of the vulva, which, on examination, is found to occupy the lower third of the labium, and borders upon the posterior commissure. The affected side is more prominent than its opposite, and the labium is pear-shaped, with its broader extremity directed backwards and inwards towards the median line; the integument on its external aspect preserves its normal color, and is free and movable, while the internal surface of mucous membrane is red and adherent to the tumor. The part is exceed- ingly sensitive to the touch, and the patient can neither walk, stand, nor sit, without difficulty, owing to the pain excited by the slightest pressure. The contents of the tumor are occasionally discharged through the normal duct of the gland, but, unless art intervene, the abscess usually bursts in the neighborhood of the glandular orifice, and very rarely on the external or integumental surface of the labium. M. Huguier contradicts the statement made by Yidal and other authors, that a recto-vaginal fistula is liable to form. This never occurs, according, to the first named surgeon, if the rectum be in a sound condition. The frequent recurrence of abscesses of the vulvo-vaginal gland, or duct, is a source of great annoyance to women of the town, when suffering from chronic inflammation of the vulva. Dr. Salmon1 has called attention to certain cases of gonorrhoea, in which the vulvo-vaginal gland and duct are alone affected; the remainder of the genito-urinary organs retaining their normal con- dition. According to this surgeon, this affection is quite common, and especially so among young prostitutes, in whom it would seem to be due to the irritation of coitus upon parts as yet tender. The patient experiences no pain or inconvenience, and an examination, such as is ordinarily made, might lead to the conclusion that the 1 Med. Times and Gaz., Dec. 23, 1854, p. 646, quoted from L'Union Medicale.— Braithwaite's Retrospect, Part 31, p. 208. VAGINITIS. 157 genital organs were sound; but if the labium, on one or both sides, be firmly pressed against the ramus of the ischium, the gland, which is not perceptible to the touch in a state of health, may be felt as a moderately firm tumor, and its muco-puriform contents are seen to escape from the orifice of the duct. Dr. Salmon is of the opinion that vulvo-vaginal gonorrhoea will explain many cases in which a clap is contracted from a woman apparently healthy. Farther researches, however, are requisite to establish beyond a doubt the statement, that it is a common occurrence for gonorrhoea to affect primarily and exclusively the parts in question; although, after the subsidence of an attack of vaginitis or vulvitis, the inflammation may undoubtedly lurk for an indefinite period in the vulvo-vaginal gland and duct. Vaginitis is more common than any other form of gonorrhoea in women. The whole extent, or only a portion of this passage may be inflamed. The lower part is more or less implicated in most cases of vulvitis, while frequently the upper part is alone involved, and the woman might be supposed free from disease, if not examined with the speculum; especially as, from the comparative insensibility of the upper portion of the vagina, her sensations are an unreliable index of its condition. Ricord states that the posterior wall of the vagina is more frequently affected in leucorrhoea, and the anterior wall in gonorrhoea. The modern application of the speculum to the study of venereal diseases (for which we are indebted to Ricord) has rendered an affec- tion, which was before obscure and of difficult diagnosis, at once clear and easily recognizable; and the zeal, of late years, brought to the pathological investigation of the female genital organs, has induced many observers to describe the lesions of vaginitis with great minuteness and detail. It is not to be regretted that these lesions have been subjected to so severe a scrutiny, although they have for this reason acquired an unmerited degree of importance, since it has been shown that they are characterized by no features sufficiently peculiar to indicate their venereal origin, and that they are, in nearly all respects, identical with the more familiar morbid appearances of other mucous membranes, as the conjunctiva oculi, the lining membrane of the mouth, ear, etc. The speculum should not be employed during the acute stage of vaginitis, as it is likely to excite severe pain and irritate the in- flamed tissues. The presence of the catamenia is also a contra- 158 GONORRHOEA IN WOMEN. indication to its use. The ordinary cylindrical instrument, made of glass and coated with a layer of India rubber, is of easy intro- duction, and is generally sufficient for the examination of the vagina in suspected cases of gonorrhoea, but when it is desired to make local applications, or when thorough exposure of all the recesses of this passage is requisite in order to discover if any concealed chan- cre be present, a valvular speculum should be preferred. In order to remove the discharge which may obstruct the field of vision, the surgeon should provide himself with several swabs, which may be conveniently made by winding cotton wadding around the end of a thin splinter of wood. The patient may lie in the "obstetric position" upon her left side, or, as I prefer, upon her back, with the knees drawn up; and delicacy requires, even when treating a woman of the town, that she should be covered with a sheet. When the vaginitis is intense and seen at an early period, a portion or the whole of the vaginal walls may be found red, hot, and dry, and entirely destitute of moisture. Ricord states that in several instances he has seen this condition finally terminate in resolution without the slightest discharge appearing at any time. Similar cases of dry or erysipelatous gonorrhoea have been reported as occurring in men, although the impossibility of examining the internal surface of the urethra throughout its whole extent has left them open to criticism. Generally, however, this dry condition of the vagina, if present at the outset, is succeeded in the course of twenty-four hours by the appearance of a discharge, which, at first transparent, afterwards undergoes changes similar to those which occur in gonorrhoea in the male; and when the disease has attained its height, the vaginal walls are bathed with offensive purulent matter of a creamy or greenish color, or sometimes streaked with blood. Before proceeding with the examination, the field of the speculum must be cleared from the discharge by the assistance of the swabs of cotton-wadding, when the mucous membrane will be exposed. This surface is found to be red and tumefied. The red- ness varies in intensity and also in extent. It is sometimes uniform and at others arranged in spots or striae. Frequently patches are seen from which the epithelium has become detached, forming superficial abrasions similar to those met wi,th in balanitis, or Re- sembling blistered surfaces. Another condition which is at times met with has received the name of granular vaginitis. It consists in a development of the vaginal papillae, which project above the VAGINITIS. 159 surrounding surface, and are readily recognized by their darker red color. These granulations are most frequently observed in the upper part of the vagina, where they may exist in large numbers covering the whole surface, or they may be merely scattered here and there. They have been erroneously regarded by Dr. Deville as peculiar to the vaginitis of pregnant women.1 They are analogous to the granulations which are so common upon the palpebral con- junctiva. Ricord says that, in one case of vaginal gonorrhoea, he observed an eruption presenting every appearance of herpes phlycte- nodes situated upon the deeper portion of the vagina, and Ashwell speaks of " herpetic pustules," which by bursting form ulcers. In addition to the above symptoms, vaginitis is characterized by increased heat and sensibility. The former may be verified by introducing a finger within the vagina, when the parts will be felt to be much hotter than natural. The degree of sensibility varies, and is greatest when the vulva is also involved. In such cases, it is generally quite impossible to introduce a speculum owing to the pain which it excites ; but when the disease is confined to the vagina this instrument may often be employed without causing much suf- fering. During the course of vaginitis, there is often a frequent desire to pass the urine, and dull pain is felt in the hypogastric region, owing to sympathy excited on the part of the bladder. Gonorrhoea of the vagina rarely continues any length of time without extending to the mucous membrane covering the cervix, which may exhibit lesions identical with those now described, but more especially patches of superficial abrasions. Gonorrhoea of the uterus is commonly confined to the cavity of the cervix. It is sometimes secondary in this situation, being occasioned by the extension of the disease from the vagina, while at other times it is primary, and if the patient be examined at a sufficiently early period, the parts may be found in a perfectly healthy condition until the uterus is exposed when the lips of the os are seen to be tumefied and red, the cervix congested and enlarged, and its cavity filled with tenacious and transparent muco-purulent matter. This secretion owes its transparency to the alkali which it contains. It becomes curdled and opaque when mixed with the vaginal acid, and hence cannot always be recognized after it has descended into the vagina or is discharged from the vulva. The fact that gonor- 1 Archives Generates de Med., 4e sene, vol. v. p. 305. 160 GONORRHOEA IN WOMEN. rhoea confined to the cervix uteri may readily be overlooked, may explain some of the cases in which a clap is derived from an appa- rently healthy woman. The acute stage of vaginitis rarely continues longer than a week or ten days, and may be of much shorter duration. As the acute symptoms subside, the pain and difficulty of motion are diminished. The discharge becomes less copious and purulent, and the redness and tumefaction of the tissues gradually disappear. After this partial advance towards recovery, however, the disease often lingers for an indefinite period, and is extremely difficult to eradicate. The vaginal walls may seem to have recovered their normal condition, having lost the morbid appearances which characterized the acute stage, but there is still a small amount of discharge from their surface or from the cervical cavity, which is capable of producing gonorrhoea in the male. Gonorrhoea of the urethra usually coexists with that of the vulva, or vagina, and sometimes with that of the uterus alone. Cases, however, are reported in which this was the only part of the genital organs affected. Gibert met with three such instances j1 Ricord with two,2 and Cullerier with one;3 and in several of them, it was noticed that the stains of the discharge upon the woman's linen were small and circular, instead of being large and irregular as in cases of vul- var and vaginal gonorrhoea. The shortness of the urethra in women and the oblique position of the canal, which favors the spontaneous flow of matter, render the diagnosis of urethritis less easy than in the male. The discharge in cases of vulvitis, also, being seen, as might easily happen, in the vicinity of the meatus, may be erroneously supposed to come from that orifice. Again, the passage of urine causes all traces of ure- thritis to disappear for a time. An examination, in order to be conclusive, should be made at least an hour or two after an evacua- tion of the bladder, and any discharge around the meatus should first be removed. The finger may then be passed into the vagina, and pressure be made against the pubic arch, in the course of the canal, from behind forwards; when, if urethritis be present, one or more drops of purulent matter will appear at the meatus, the lips 1 Gibert's first case was published in the Revue M6dicale, t. i. 1834. He has also given two other cases in his Manuel sur les Maladies Syphilitiques, p. 284. '-' Memoires de l'Academie Royale de Med., t. 2e. p. 159. Paris, 1833. 3 Dictionnaire de Med. et de Chir. prat., t. 4e, p. 253. GONORRHOEA OF THE URETHRA —COMPLICATIONS. 161 of which will be found swollen and inflamed; and the introduction of a sound into the canal is attended with considerable pain. Scald- ing during micturition may easily be a deceptive symptom, since it may be produced to a still greater degree by the contact of the urine with the excoriated mucous membrane of the vulva, when the latter is involved. If no vulvitis be present, it is a symptom of value. Gonorrhoea of the urethra, occurring in women otherwise healthy, does not show the same tendency to run into a gleet as in men. It almost always disappears before the accompanying vaginitis or vul- vitis, and is therefore to be regarded as of secondary importance.1 In broken-down constitutions, however, and in women who have borne many children, or who are suffering from congestion of the abdominal viscera, it may assume a chronic form, and prove exceed- ingly obstinate. A thickening takes place throughout the whole canal, which can be traced as a firm cord behind the pubis, and may be seen standing out in relief at the upper part of the entrance of the vulva, when the nymphae are separated. This condition is attended with uncomfortable sensations in the part, and a frequent desire to pass water, aggravated by motion, by coitus and the return of the menstrual period, and relieved by rest and the recumbent posture.8 The value of urethritis as indicating contagion has been noticed by many authors. In the majority of cases in which it is present, patients acknowledge that they have been exposed to impure inter- course. On the other hand, urethritis is absent in many cases in which the disease undoubtedly originated in contagion, and the fact is well established that it may depend upon uterine displace- ments and other causes independent of coitus; hence it cannot be said to furnish more than presumptive proof that a woman has been unchaste. Complications.—Bubo is a less frequent complication of gonor- rhoea in women than in men, and Ricord states that it very rarely occurs unless the urethra is affected.3 Durand Fardel reports the case of a woman who had a rape committed upon her by several men, and in whom a bubo formed and terminated in suppuration.4 An 1 DrRAND Fardel, M6moire sur la Blennorrhagie chez la Femme, et ses Diverses Complications. Journal des Connaissances Medico-Chirurg., Juillet, Aout, et Sep- tembre, ls4(>. 2 West, Lectures on the Diseases of Women, 2d ed. p. 618. 3 Notes to Hunter, 2d ed. p. 106. * Op. cit. 11 162 GONORRHOEA IN WOMEN. examination showed that she had acute inflammation of the vulva and vagina, and that there was no laceration or ulceration of the mucous membrane, yet the violent origin of the disease would excite suspicion as to the bubo being due entirely to the gonorrhoea. No mention is made of the condition of the urethra. Vegetations, mucous patches or tubercles, and chancres, are fre- quently found to coexist with gonorrhoea of different portions of the female genital organs, and especially with vulvitis.' Their presence is a constant source of irritation, and their removal is essential to a cure of the primary disease. Yegetations should be destroyed by the knife or caustics; mucous patches are a symptom of constitutional syphilis and require general as well as local treat- ment ; and chancres are to be treated according to rules to be laid down hereafter. As a general rule, gonorrhoea in women is confined to the exter- nal organs of generation, or does not extend above the cavity of the cervix, but cases are sometimes met with in which the internal sur- face of the body of the uterus is involved, or in which there is true metritis. In exceptional instances, also, the inflammation may ex- tend to the Fallopian tubes, and even through the continuity of tissue, to the peritoneum. At the post-mortem examination of a case of this character, M. Mercier1 found one of the Fallopian tubes obliterated by a deposit of lymph upon its fimbriated extremity and the peritoneal surface inflamed to a considerable extent around it. West mentions two successive attacks of vaginitis, at an interval of eighteen months in the same patient, which were followed by such severe peritonitis as to call on each occasion for the abstraction of blood.2 Inflammation of the ovaries as a complication has also been seen by several authors, and has been compared to the swelled testicle which occurs in the male. The symptoms are well described in a case related by Ricord. The patient, aged thirty-two, an inmate of the Hopital du Midi, was suffering from acute gonorrhoea of the uterus and external genital organs, when a swelling suddenly ap- peared in the left iliac fossa. The part was very sensitive to the touch and its temperature increased. There was considerable febrile excitement and nausea. The patient lay on her back, inclined a ' MSmoire sur la Peritonite considered comme Cause de Ste>ilit6 chezles Femmes ; Gaz. M&L, 1838, p. 577; also Gaz. des Hop , 1846, p. 432. i Op. cit., p. 627. DIAGNOSIS. 163 little to the left, with the thighs flexed. The discharge from the urethra and vagina had almost entirely disappeared. Pressure upon the neck of the uterus, with the finger introduced within the vagina, was not painful; but when the womb was pressed toward the right side, pain and a sense of tension were felt in the left broad ligament. Pressure toward the left side, tried for the sake of com- parison, caused scarcely any inconvenience. The passage of the feces and urine, and all motion of the abdominal walls were painful. Under the use of antiphlogistic remedies, these symptoms gradually diminished and disappeared in about twelve days, and at the same time the discharge increased in quantity. The patient, however, was shortly afterwards seized with a second attack on the opposite side, with the same symptoms and the same suspension of the dis- charge.1 My friend Dr. Geo. T. Elliot, Jr., of this city, informs me that he has met with two cases of pelvic cellulitis, originating in gonor- rhoea. So far as I am aware, this dangerous affection has never before been noticed as a complication of gonorrhoea in women. The statement of so accurate an observer as Dr. Elliot is entitled to great weight, but it is to be regretted that notes of the cases, essential to render them conclusive as evidence of the fact stated, were not taken. Diagnosis.—Before the application of the speculum to the study of venereal diseases, the diagnosis of gonorrhoea in women was often difficult and sometimes impossible; and the discharges of vaginitis and of various syphilitic lesions within the vulva were confounded together. To a surgeon of the present day, acquainted with modern methods of investigation, such mistakes are not likely to occur. With the recognition of the disease, however, our power, so far as diagnosis is concerned, ceases. It is impossible to go farther and determine its origin. Many authors have attempted to give diag- nostic signs as between gonorrhoea originating in contagion and that produced by other causes, but they have all most signally failed to produce any which are at all satisfactory, simply for the reason that none such exist. " The microscope fails to furnish us with a means of distinguishing between gonorrhoeal and simple vaginitis, and no symptom or combination of symptoms is absolutely conclusive on 1 Notes to Hunter, p. 107. 164 gonorrhoea in women. this point."1 Acute inflammation and the presence of urethritis may render impure intercourse probable, but cannot be regarded as decisive; and what is wanting in the physical diagnosis must be sought for in the history of the case. Treatment.—The treatment of the different forms of gonorrhoea in women varies but little in the acute stage of the disease. It is chiefly during the chronic stage that any variation is required to meet special indications, presented by inflammation of particular portions of the mucous membrane. Moreover, nature does not always, nor indeed in most instances, follow the classification which we have found it convenient to adopt; several of the genito-urinary organs are generally involved together—more commonly the vagina and vulva—and the treatment of this most numerous class of cases will first claim our attention. The chief remedies adapted to the acute stage are rest, cathartics, hot baths, lotions, and a general antiphlogistic regimen. It is of the first importance that the patient should abstain from exercise of all kinds, and, if possible, be confined to her bed; indeed, in most cases her own sensations demand this, without the order of the surgeon. Meats and stimulants should be forbidden, and the diet restricted to weak tea, toast, a decoction of flaxseed, rice or barley-water, gruel, etc., unless the symptoms are subacute from the first, or the patient debilitated. In selecting a cathartic at the outset of the disease, preference should be given to a mercurial, for the purpose of un- loading the abdominal and pelvic vessels, and the bowels should afterwards be freely opened every day, by small doses of Epsom salts, citrate of magnesia or other salines. Aloes, and the numerous preparations which contain it, should* be avoided, on account of its tendency to produce congestion of the haemorrhoidal vessels. Leeches.—The local abstraction of blood is not generally neces- sary, except in decidedly acute cases, when from six to ten leeches may be applied in the neighborhood of the vulva. There is one serious objection to their use, however. We can never be certain— except after an examination with a speculum, which the sensibility of the parts in this stage does not permit—that there is not a chancroid concealed within the vulva, the secretion of which may inoculate the leech-bites, and give rise to troublesome sores. Hence 1 West, op. cit., p. 628. TREATMENT. 165 if leeches be employed, they should be applied to the upper part of the groins or hypogastric region, where the discharge is not likely to reach, and their bites should be protected by an application of collodion or by cauterization with nitrate of silver.1 Baths and Lotions.—A hot bath, repeated once or twice a day during the acute stage, is very grateful to the feelings of the patient, and beneficial in equalizing the circulation and relieving the local inflammation; and immersion of the whole body is to be preferred to hip-baths. Meanwhile, the external genital organs should be frequently bathed with some emollient lotion, and a piece of lint soaked in the same be inserted between the labia, in order to separate the inflamed sur- faces and absorb the discharge. The following is an excellent for- mula for this purpose:— R. Decocti papaveris 3 pts. Liquoris plumbi subacetat. dilut. 1 pt. M. Sedatives, of which Dover's powder is perhaps the best, should be administered at night to induce sleep, and also at intervals during the day, if the pain is severe, or the patient nervous and irritable. The above measures are the only ones admissible during the acute stage of the disease, especially if the vulva is involved; in which case the insertion of an enema tube is too painful to admit of injec- tions. When, however, the inflammation is chiefly confined to the vagina, the lotion just mentioned may be injected into this canal every few hours, and in many cases of a subacute type, injections may be used from the very commencement. As soon as the sensi- bility of the parts will permit, it is also desirable to introduce a speculum, and ascertain if any chancre be present. The kind of syringe used, and the mode of injecting, are matters of no little importance. The small metallic or glass instruments in common use are entirely inadequate for the removal of the discharge. The astringent ingredients of the first portion of fluid injected are spent in coagulating the purulent matter collected in the vagina. To wash away the coagula thus formed, and exert a medicinal effect upon the mucous membrane, the quantity of the injection should not be less than a pint. A pump syringe, or better still, one of Davidson's or Mattson's syringes, made of India rubber and pro- ' Ricord, Leqons Cliniques, Gaz. des Hopitaux, 1846, p. 157. 166 GONORRHOEA IN WOMEN. vided with metallic valves, will enable the patient to inject any desired quantity with one introduction of the tube. While using the injection, the patient should lie on her back, with the pelvis elevated; if she merely stoop down, the fluid escapes as fast as it is injected, and fails to reach the deeper portions of the canal. By means of a bed-pan the wetting of the floor and clothes may be avoided. As a general rule, injections of greater strength may be used for women than for men, and for the sake of cheapness and convenience, they are commonly made more simple in their composition. The patient may be supplied with the solid ingredients, and allowed to mix them as required, and in order to avoid the expense of having them put up by the druggist in divided portions ready for use, it is desirable, among the poor, to supply them in bulk. A little instruction from the surgeon will enable the patient to measure them out with sufficient accuracy. A heaping teaspoonful, or, in other words, as much as can possibly be taken up by a teaspoon, of the more common ingredients of injections, is nearly as follows:— Alum gij. Sulphate of zinc gij. Acetate of zinc 3iss- Subacetate of lead 3iij- Tannin gss. From one to two drachms of either of these salts to the pint of water, is the average strength employed, but the ratio should always be proportioned to the effect produced, and the sensibility of the parts. Whenever severe or long-continued pain is induced, the strength of the solution should be at once diminished, and after- wards increased, as the tenderness becomes less. I would repeat what I have said with reference to injections for men, that young practitioners often lose time, to the neglect of more important mat- ters, in frequently changing from one form to another; cases, how- ever, occur, in which one injection appears to lose its effect, and another may be substituted with advantage, but no change should be made, unless it is evident that the unsatisfactory result is not due to a faulty method of using the syringe, or to constitutional causes, or again, unless the solution, however diluted, excites severe pain and uneasiness. When the subsidence of the more acute symptoms first permits the introduction of an enema tube, a drachm of alum may be dis- TREATMENT. 167 solved in a pint of flaxseed tea, and injected warm, but the temper- ature should be gradually lowered, and the injection ultimately used cold. Injections of cold water alone, during the chronic stage of vaginitis, are of great value. They not only cleanse the parts, but exert a tonic influence upon the vagina and neighboring organs. Their effect, however, is increased by the addition of alum, or the other salts above mentioned. They should be employed from two to three times a day, but must be omitted, for obvious reasons, dur- ing the menstrual periods. A combination of tannin and alum, as recommended by Dr. Tyler Smith1 is also an excellent form of injection, and one which I have prescribed with much success. The proportions are 3ss-j of tannin, and 3ij of alum to the pint of water. Tannate of alumina is formed by chemical decomposition. It should be recollected, however, that tannin, and the salts which contain it, stain the linen almost as indelibly as nitrate of silver, which is a serious objec- tion with many women to its use. I have also employed injections of the sulphate and acetate of zinc, and subacetate of lead, with satisfactory results. Labarraque's solution of chlorinated soda, diluted with from eight to twelve parts of water, may be injected, when the discharge is very offensive. A solution of chloride of zinc, of the strength of from one to three grains to the ounce of water, is a favorite injection with some surgeons. My opinion of this preparation of zinc has been expressed in the chapter upon urethral gonorrhoea in the male.2 The following formula, intended as a substitute for the aromatic wine of the French Pharmacopoeia, is one.pf the best injections for general use:— R. Claret wine, Compound spirits of lavender, aa 3 V. Tincture of opium Jss. Water §iijss. Tannin 3J—|j. M. I usually direct the patient to add two tablespoonfuls of this mixture to a tumblerful of water, and to gradually increase the strength. I rarely prescribe a solution of nitrate of silver for the patient's 1 Pathology and Treatment of Leucorrhoea, p. 183. 2 See p. 69. 168 GONORRHOEA IN WOMEN. own employment, but frequently myself apply it to the vaginal walls, by first introducing a glass speculum as far as the cervix uteri, and then pouring a few drachms through the instrument. If the speculum be slowly withdrawn, the fluid will come in contact with the whole extent of the vagina. I regard this method as one of special value, for if the patient lie on her back with the pelvis well elevated, and if the speculum be as large as the parts will admit, the force of gravity carries the solution into every recess of the dilated vagina, and insures its thorough application to this canal, and also, in a measure, to the cavity of the cervix. The parts should be thoroughly cleansed with copious injections of simple water, before the speculum is introduced. In this manner, a solu- tion of nitrate of silver, containing 9j-iij to the ounce, may be ap- plied by the surgeon every third or fourth day, and the patient at the same time use some mild astringent injection twice a day. An application of the solid nitrate of silver crayon, a favorite method of treatment among French surgeons, is requisite in some cases which do not improve under a solution of the same salt. The deepest folds of the vagina should be exposed by means of a bivalve speculum, and the caustic applied to the mucous membrane cover- ing the cervix, and to that of the vaginal walls, as they are brought into view by the gradual withdrawal of the instrument. The com- pound tincture of iodine, pencilled over the surface, with a camel's- hair brush attached to a long handle, is sometimes preferable to the lunar caustic. The contact of purulent matter with the mucous membrane of the genital organs is doubtless a constant source of irritation, and is probably sufficient to account for some of the superficial abrasions and other lesions, revealed by a specular examination. The col- lection and retention of pus upon the external integument will soon excoriate the surface, and, with still greater reason, may it be sup- posed to act thus upon the more delicate mucous membrane. The abrasions, once formed, increase the quantity of the discharge by their own secretion, and thus the two react upon each other, and prolong the disease. This evil is easily remedied in balanitis and vulvitis by interposing between the inflamed surfaces some porous material, capable of absorbing the discharge as fast as it is secreted, and wet, if desired, with an astringent lotion, which will exert a constant medicinal effect upon the mucous membrane. The same result may be attained in vaginitis, and has even been attempted in TREATMENT. 169 gonorrhoea of the cervix.1 For this purpose, a folded piece of lint is sometimes used, but a plumasseau of charpie or carded cotton is preferable, since it retains its elasticity to a greater degree, and is a better absorbent. To facilitate its withdrawal, a small string may be previously attached to it. The size of this tampon must be pro- portioned to the dimensions of the vagina in each case, and will vary in diameter from half an inch to two inches. In some in- stances, it is medicated; in others, not. In the former case, the medicinal substance may be an absorbent or astringent powder, as prepared chalk, subnitrate of bismuth, calamine, tannin, powdered alum, etc.; or, it may consist of any of the lotions which have been recommended for the purposes of injections either in the male or female. Calamine and powdered alum are the best dry prepara- tions, and a solution of tannin in glycerin (3j-ij ad 3j) an excellent fluid astringent. The plug may be inserted by the surgeon through a speculum, or the patient may be taught to introduce it with her finger, or by means of a stylet. It should be withdrawn at the end of twelve hours, the vagina washed out with a copious injection, and a fresh plug introduced, or the latter may be deferred till the following day. Scanzoni employs a plug of cotton wool, sprinkled with alum powder, either pure or mixed with one or two parts of- sugar. Pure alum is liable, on the second or third application, to excite a very disagreeable sensation of heat and constriction in the vagina, render- ing it necessary to suspend the treatment for a week or two; hence it is not to be used undiluted, unless the parts are quite insensible; and on this account, therefore, it will be best to try, in the majority of cases, a mixture of alum and sugar. The plug, thus prepared, should not be used oftener than every second or third day, nor be allowed to remain in longer than twelve hours, and warm water should be injected immediately on its withdrawal. If these pre- cautions be neglected, acute inflammation of a troublesome character may be excited, and the discharge augmented instead of diminished.2 Demarquay recommends a plug moistened with a solution of one part of tannin in four parts of glycerin. His directions are: first to subdue the inflammatory symptoms of the acute stage by appro- 1 Hourmann, Du Tamponnement, comme Methode de Traitement des Ecoule- ments Utero-vaginaux. Journal des Connaissances Medico-Chirurg., Mars, 1841, p. 89. * Op. cit., p. 456. 170 GONORRHOEA IN WOMEN. priate regimen, baths and frequent emollient injections; next as soon as a speculum can be introduced, to inject simple water in large quantities, so as to remove all secretion from the vaginal walls, which are afterwards to be dried by means of swabs; and, finally, to introduce plugs of charpie saturated with the mixture of tannin and glycerin. On the following day, the patient should take a bath, the plugs be removed, the injections repeated, and fresh plugs introduced. M. Demarquay states that he has never found it necessary to renew these applications more than four or five' times. After discontinuing them, astringent injections, consisting of an in- fusion of walnut leaves, in which one drachm of alum to the quart has been dissolved, should be used two or three times a day for a week or ten days.1 The active principle of the infusion of walnut leaves, recommended by M. Demarquay, is tannin, and a convenient substitute may be found in a solution of alum and this vegetable acid in simple water, according to the formula previously given. Thiry exposes the vaginal walls with a speculum; cauterizes the surface, if much inflamed, with solid nitrate of silver; then sprinkles over it finely powdered charcoal or cinchona, and introduces a tam- pon of cotton wool, which he allows to remain from three to five hours.2 Simpson, of Edinburgh, has proposed an efficacious mode of keeping an astringent in constant contact with the vaginal walls, by means of pessaries, prepared according to the following formu- las:— R. Acidi tannici 9'j- Cerse albse J} v. Axungiae 3vj. Misce, et divide in Pessos quatuor. R. Aluminis jjj. Pulveris catechu jj. Cerse navae 3J. Axungiae J^vss. Misce, et divide in Pessos quatuor.3 Hip-baths, taken every morning on rising or in the early part of the day, are valuable adjuvants in the treatment of chronic vaginitis. The temperature of the bath should be determined in part by the season of the year, and in part by the strength and habits of the 1 Bulletin de Therapeutique, tome i. p. 541. 2 Journal de Med. de Bruxelles, Fev. 1854. 3 Edinburgh Monthly Journal, June, 1848, and Obstetric Works, p. 98. TREATMENT. 171 patient. It is well to commence with lukewarm water, and gradu- ally lower the temperature as the system becomes accustomed to them; but they should never be so cold nor continued so long, that the patient feels chilly for some time after their employment, and reaction should be promoted by friction with a coarse towel, flesh- brush or hair-mitten. These baths may be rendered still more effectual by the addition of a handful of coarse salt to each bucket of water used. Astringents, as alum, in the proportion of half a pound to each bath, are also recommended by some authors. The hygienic management of the case should always receive special attention in chronic vaginitis. As the inflammatory symptoms of the acute stage subside, the patient may be allowed a more generous diet and greater freedom of motion, but she should still avoid violent or prolonged exercise, and especially all sexual excitement. Walk- ing and even standing for any length of time should be but moder- ately practised at this stage of the affection. No absolute rules can be laid down for diet, which should be adapted to each individual case. In general, the food should be plain and simple, and yet sufficiently nourishing, and the meals should be taken at regular hours. Highly seasoned dishes, pastry, salt meats, cheese and strong tea and coffee, should be forbidden; and bread, eggs, fresh meat once a day, vegetables, and simple puddings, recommended. Regu- larity of the bowels should be secured, if necessary, by small doses of saline cathartics, taken on rising in the morning; and, in brief, all such measures should be adopted, as are calculated to bring the general health to the best possible condition. The latter rule implies that the system should neither be stimulated above, nor depressed below, the happy mean; yet, at the same time, there are but few cases of chronic vaginitis which do not require some support, and in which either mineral acids, preparations of iron, vegetable tonics, quinine, or even stimulants, are not, at some period, indicated. There is really no inconsistency in pulling down with one hand, and, at the same time, building up with the other; in applying leeches, for instance, to the cervix, and unloading the pelvic vessels by cathartics, while tonics are given to elevate the general tone of the system. Such a course must often be pursued, especially with corpulent women of sedentary habits, whose condition, in spite of their apparent excess of health, is in reality below par. I would refer the reader to the chapter on gleet, for much that has reference to the hygienic management of chronic vaginitis, which is in fact 172 GONORRHOEA IN WOMEN. * the analogue of gleet in man. In both of these affections, constitu- tional and local treatment must proceed hand in hand, if any perma- nently good result is to be attained. The formulae for various tonics, already given when treating of this disease in the male sex, are equally applicable to the female. The only one which I would add at present is the following old, but excellent combination of a tonic, cathartic, and astringent. Its cheapness recommends it especially for the poorer class of patients, while for those in better circumstances a more palatable substitute may be found in Seidlitz powders or citrate of magnesia, taken on rising from bed, and in the French dragees of iron administered just before or after meals. R. Magnesiae sulphatis §iss. Ferri sulphatis 9ij. Acidi sulphurici gtt. x. Infusionis gentianae comp. Oj. M. A tablespoonful two or three times a day. In gonorrhoea of the vulva lotions may be applied with great facil- ity, and the parts separated by the interposition of lint or charpie. Cauterization with the solid nitrate of silver or a solution of this salt is often beneficial. Resolution of a commencing abscess of the vulvo-vaginal gland or duct may sometimes be obtained by rest, cathartics, and antiphlogistic regimen, assisted, in some cases, by the application of leeches to some adjacent part. If suppuration takes place, the abscess should be opened without delay. Ricord and Yidal advise making the incision upon the external surface of the labium, to avoid the admission of the urine and discharges, which would irritate the cavity of the abscess and prevent its healing. An incision in this situation, however, fails to prevent a spontaneous opening on the mucous surface, where the abscess naturally tends to point.1 By making a small incision on the internal and inferior aspect of the tumor, and directing the knife somewhat upwards so that the cut shall be valvular, and also by allowing the abscess to evacuate itself by the contraction of its walls without the exercise of pressure, the entrance of foreign matter may generally be pre- vented. In case the abscess repeatedly recurs, its exact seat should be carefully ascertained. If it occupy the duct, it should be laid open by a free incision, and the cavity filled up with lint. If it be 1 Hcgcier, op. cit., p. 843. TREATMENT. 173 seated in the gland, this must be dissected out. I have tried, in several instances, to cure these abscesses by the introduction of a seton, but have always failed. Whenever, after an attack of vulvitis, there still remains a puru- lent discharge from the vulvo-vaginal duct, and also in the cases described by Dr. Salmon in which this part is primarily affected, a solution of nitrate of silver may be injected by means of Anel's syringe. In gonorrhoea of the uterus, the cervical cavity should first be thor- oughly cleansed of its muco-purulent secretion by means of swabs of cotton wool introduced through the speculum, and its internal surface then cauterized with a stick of nitrate of silver, which should be passed as high up as possible. To avoid breaking the nitrate within the uterus—an accident attended by no very serious conse- quences, however—crayons of this salt may be obtained, diluted with nitrate of potash or chloride of silver, which adds greatly to its firmness without materially diminishing its remedial power. This application should be repeated every third or fourth day, and the astringent injections, which are continued in the intervals, should be made to reach as high as the cervix. In obstinate cases, the saturated tincture of iodine, crayons of potassa cum calce, or the acid nitrate of mercury may be applied to the cervical cavity in a similar manner; but when the stronger caustics are used, care should be taken to guard the upper portion of the vagina from injury. Intra-uterine injections have been recommended in the treatment of gonorrhoea of the cervix, especially by Yidal de Cassis;1 but in several instances severe and even fatal peritonitis has been produced, probably in consequence of the fluid reaching the abdominal cavity through the Fallopian tubes. This has been shown to be possible by experiments upon the dead body, performed by Bretonneau, Hourmann, d'Astros, and others. It appears from some of their observations, that the injected fluid may even gain entrance to the venous system.2 This practice is therefore generally abandoned at the present day. Whenever, in gonorrhoea of the vagina or uterus, the cervix is found enlarged and congested, from four to six leeches may be 1 Essai sur le Traitement de quelques Mai. de l'Uterus, Injections Intra-vaginales et Intra-uterines. Paris, 1840, in-8. 2 IIouKMA*..N, Note sur le Danger des Injections faites dans l'Uterus. Journal des Connaissances Med.-Chirurg., July, 1840, p. 22. 174 GONORRHOEA IN WOMEN. applied. They are especially applicable at the outset of the treat- ment, and may require to be repeated once or twice at intervals of a week; but the patient should not be debilitated by their frequent use. The surgeon should apply them himself, taking care to plug the cervix beforehand, that they may not fasten upon the sensitive membrane of its internal surface. If the flow of blood is excessive it may be arrested by cold injections of a solution of alum. The acute stage of urethritis is of so short duration as to demand but little special treatment. In most cases, the measures adopted for the concomitant inflammation of the vulva, vagina, or uterus, aided, perhaps, by the administration of alkalies, neutral salts, or sedatives, are sufficient to effect a decided amelioration, and often the entire disappearance of the disease. When this result fails to be attained, I do not hesitate to resort to injections, as in urethral gonorrhoea in men; but as they cannot be used by the patient, it is necessary for the surgeon to administer them himself. Their active principle may be one of the salts of lead or zinc, or tannin; or from one to two drachms of a solution of nitrate of silver, containing ten or twenty grains to the ounce, may be thrown in. If, in this case, we carefully guard against having the bladder entirely empty, no evil result need be feared. Copaiba and cubebs may also be employed in this affection, ad- ministered in the manner directed for men.1 Ricord's experiments have shown that their effect in gonorrhoea of any portion of the genital organs not traversed by the urine is so slight, that they are not to be recommended in vaginitis or vulvitis. Indeed, they can readily be dispensed with in all forms of gonorrhoea in women. 1 See p. 74. GONORRHEAL OPHTHALMIA. 175 CHAPTER X. GONORRHEAL OPHTHALMIA. Gonorrheal ophthalmia has been supposed to originate in three ways—from inoculation, from metastasis, and from sympathy, each of which has from time to time been received by certain authors as its exclusive mode of origin. The occurrence of gonorrhoeal ophthalmia from inoculation or contagion, cannot, at the present day, be called in question. Nu- merous cases reported by Mackenzie, by Lawrence, and by nearly every modern writer on diseases of the eye, leave no room to doubt that the discharge of gonorrhoea applied to the ocular conjunctiva, may set up a severe and destructive form of inflammation, similar to if not identical with purulent conjunctivitis. But, besides these reports of cases in which the inoculation has been the result of accident, farther proof is to be found in the treatment of pannus— employed of late years chiefly by French and German surgeons— in which the eyes have been intentionally inoculated with the pus of gonorrhoea. Discharges from the genital organs have been transferred to eyes affected with pannus, with the express design of exciting acute inflammation, which, it was hoped, might cure the chronic disease; and, however questionable may have been the results of this practice, so far as the accomplishment of the latter purpose is concerned, there has been, at all events, no difficulty in producing acute inflammation by such inoculation. With these facts before us, therefore, no farther doubt of gonorrhoeal ophthalmia from contagion is admissible; indeed, direct inoculation is now regarded by all surgeons, with but few exceptions, as the only mode in which originates that destructive form of purulent con- junctivitis which sometimes attends gonorrhoea. The idea of a metastatic origin of gonorrhoeal ophthalmia was first advanced by Saint Yves, who was acquainted with no other 176 gonorrhoeal ophthalmia. mode, as appears from his chapter, " Of the Yenereal Ophthalmy,"1 which is so short, quaint, and interesting, that I shall quote it in extenso: "This tenth species of ophthalmy has almost the same signs with the precedent ('the most dangerous ophthalmy, called chemosis'), with this difference that the conjunctiva, which is swelled, appears hard and fleshy. It begins thus: a great quantity of whitish matter with a yellowish cast, oozes constantly through the eye. This disease, which proceeds from a venereal cause, is very rare; yet I have seen several attacked with it. In most of them, this disease appeared two days after the beginning of a viru- lent gonorrhoea; the matter, not running off by its usual passages was removed to the eye, through which there flowed a like matter, which stained the linen in the same manner as when it passed through the usual channels." Gonorrhoeal ophthalmia from metastasis, as here stated, implies a translation of the disease from the genital organs to the eye; and, to prove its existence, it would be necessary to produce unques- tionable instances in which the urethral discharge has suddenly subsided or disappeared prior to the inflammation of the ocular tunics. But few cases, however, at all likely to fulfil these con- ditions, have been adduced, and even these few have been of such doubtful character, that the idea of a metastatic origin of gonor- rhoeal ophthalmia is at the present day almost entirely abandoned. Still, numerous instances are on record of disease of the eye accompanying gonorrhoea, in which the circumstances of the case preclude the admission of direct inoculation, and in which the symptoms and course of the ophthalmia are decidedly different from those of gonorrhoeal ophthalmia from contagion. While dis- carding the term metastatic as applied to these cases, many surgeons have given them the name of sympathetic; rather as a convenient expression, however, than as really explaining their mode of origin. In the next chapter I shall endeavor to show that all those cases which have been termed metastatic and sympathetic gonorrhoeal ophthalmia, are merely a manifestation of gonorrhoeal rheumatism, which, like ordinary rheumatism, may attack several of the ocular tissues. At present, I shall consider gonorrhoeal ophthalmia origi- nating in contagion, and allied to purulent conjunctivitis. » A New Treatise of the Diseases of the Eyes, by M. De St. Yves, Surgeon Oculist of the Company of Paris, translated from the original French by J. Stockton, M. D., London, 1741, p.168. FREQUENCY —CAUSES. 177 Frequency.—Next in order to swelled testicle, gonorrhoeal ophthalmia is the most common complication of gonorrhoea; and yet, considering the great frequency of the latter disease, which everywhere abounds, it is comparatively a rare affection. The following table exhibits the number of cases of gonorrhoeal oph- thalmia received at the N. Y. Eye Infirmary during a period of fifteen consecutive years, and the proportion which these cases bear to the whole number of patients. Whole Ntmber Cases of Gonorrheal Year. of Patients. Ophthalmia. 1845.......1366 2 1846.......1245 3 1847.......1485 2 1848.......1815 5 1849.......1902 3 1850.......2082 3 1851.......2472 6 1852.......2732 7 1853.......2719 5 1854.......2635 6 1855.......2652 5 1856.......2634 4 1857.......3216 3 1858.......3908 2 1859....... 4171 3 Total 37,034 59 It thus appears that, compared with the whole number of dis- eases of the eye treated at this institution, cases of gonorrhoeal ophthalmia are only as 1 to 628. We have no statistics by which to determine the proportion of this disease to the whole number of cases of gonorrhoea; yet I think the experience of every physician would lead him to infer that it is not much greater than to diseases of the eye, since gonorrhoea must be nearly as frequent as all ocular affections combined. Causes.—The contagious matter which has produced acute in- flammation of the conjunctiva in a given case, may have been derived from the genital organs or from the opposite eye—already affected with gonorrhoeal ophthalmia—of the same, or from those of another person. An opinion, originating with Mr. Yetch,1 pre- vailed at one time, that the pus of gonorrhoea was innocuous when 1 A Practical Treatise on the Diseases of the Eye. London, 1820. 12 178 GONORRHOEAL OPHTHALMIA. applied to the eye of the individual secreting it. This surgeon drew this conclusion from several unsuccessful attempts which he made to inoculate the urethrse of persons suffering from gonorrhoeal ophthalmia with their conjunctival discharge, in the hope of "divert- ing the disease from the eye to the urethra." At the same time he succeeded in producing urethritis in another patient by applying to his meatus matter taken from the eye of another. The results of these experiments, however, have been proved to be worthless, and the fact is now well established, that the source from which the matter is derived does not influence its power of contagion. In many of the reported cases of this disease, the ophthalmia was produced by patients washing their eyes with their own urine, with which gonorrhoeal pus was mixed, or by otherwise applying the discharges from their own persons. The personal habits of those affected with gonorrhoea, and the degree of intimacy existing between members of the same house- hold, will, in a great measure, determine the frequency of infection. Among the poor and squalid, where cleanliness is neglected and the same vessels and towels are used in common, gonorrhoeal oph- thalmia may readily be communicated from one individual to another, until it has attacked all the members of the same family. Ricord states that he has never seen gonorrhoeal ophthalmia pro- duced by discharges from any portion of the genital organs except the urethra; and that he has never known it to be caused by the pus of balanitis or vaginitis. There is reason to believe, however, that a simply vaginal discharge is capable of exciting the disease under consideration. It is a well established fact that " ophthalmia neonatorum" is fre- quently caused by inoculation of the infant's eyes with leucorrhceal discharges from the mother. I have repeatedly seen severe puru- lent conjunctivitis in very young girls, who were affected with that form of vaginitis which sometimes attacks children, independently of contagion, and which has been so ably treated of by Mr. Wilde, of Dublin. Analogous cases are reported in treatises on diseases of the eye, and Dr. Jiingken mentions one instance, in which the ophthalmia, originating in this manner, spread to seven members of a family.1 I know of no authentic case of gonorrhoeal ophthalmia occasioned 1 Annales d'Oculistique, 8e se>ie, t. ler, p. 355. causes. 179 by the pus of balanitis. Matter from a venereal or ordinary abscess must also be regarded as generally innocuous. Yet it is,- perhaps, impossible to determine with accuracy the limits within which puru- lent matter is capable of exciting severe inflammation of the con- junctiva. The predisposition of the person exposed will doubtless have no small influence upon the effect produced. Still, so far as at present known, these limits are confined to the urethra and vagina. The inoculations which have been employed in the treatment of pannus, will throw some light upon the conditions under which con- tagion may be supposed to take place. The puriform matter used in these inoculations has been derived either from the genital organs, or from an eye affected with gonorrhoeal ophthalmia, or ophthalmia neonatorum. When such matter is kept from contact with the air, it is found to retain its contagious property for about sixty hours. If exposed to the air, and allowed to dry, it soon becomes innocu- ous. In the experiments of M. Piringer, of Gratz, a piece of linen was moistened with gonorrhoeal matter, and allowed to dry; the cloth was then rubbed upon the eyes of several persons, and no inoculation ensued. The dried matter scraped from the cloth, and applied directly upon the conjunctiva, took effect within about thirty-six hours after it was first obtained. Matter, once dried and immediately moistened again, either by the addition of water or by contact with the secretions of the eye, was found to be contagious. Fresh matter was contagious, even when diluted with one hundred parts of water. M. Yan Roosbroeck experimented with the pus of a common abscess, and found that it was innocuous when applied to the eye. This surgeon was also led to the conclusion that the discharge from an eye affected with purulent ophthalmia, diluted with water, retains its power of contagion until decomposition has begun to take place, as shown by its evolving the odor of putrefaction. When the inoculation is successful, no disagreeable sensation is at first excited by the application of the matter; and no effect is perceived until after the lapse of from six to thirty hours, when the eye begins to feel hot, and there is an increase in the ocu- lar secretions, which are at first entirely mucous, but soon become muco-purulent. Gonorrhoeal ophthalmia is much more common in men than in women. Ricord ascribes this difference to the greater frequency of urethritis in the male, this being the only form of gonorrhoea, capa- 180 GONORRHOEAL OPHTHALMIA. ble, as he supposes, of occasioning gonorrhoeal ophthalmia. I have already dissented from this opinion of Ricord, and I believe that so far as any explanation can be given of the difference in the relative frequency of its occurrence in the two sexes, it must be based upon their different habits. Symptoms.—Gonorrhoeal ophthalmia may occur at any stage of an attack of gonorrhoea, although it is said to be more frequent during the decline. The urethral or vaginal discharge is doubtless most contagious when most purulent, which is during the acute stage, but the short duration of this stage affords less opportunity for it to be applied to the eye than the longer stage of decline. At first, the disease usually attacks one eye alone. It may remain con- fined to this eye, but not unfrequently, after the lapse of a few days, the opposite eye becomes implicated. The symptoms of gonorrhoeal ophthalmia are, in the main, iden- tical with those of purulent conjunctivitis. The former disease, however, is more rapid in its development, and even more destruc- tive to sight than the latter. The earliest indications of an attack of this disease are an itching sensation just within or on the margins of the lids, a feeling as if some foreign body were in the eye, and an increase in the ocular secretions. The latter retain at the outset their normal transparency, although they appear unusually viscid; the ciliae become adherent and glued together, and a collection of dried mucus may be seen at the inner canthus. As the disease progresses, the vessels under- lying the conjunctiva become distended with blood. They may at first be distinguished from each other as in simple conjunctivitis, but they are soon lost in a uniform red appearance of the globe, extending as far as the cornea; which retains its normal transpa- rency. The conjunctiva is also found to be somewhat elevated above the sclerotica by an effusion of serum, and its surface is roughened by the development of its papillae. Meanwhile, the discharge has become purulent, and is secreted abundantly from the inflamed surfaces. An attack of gonorrhoeal ophthalmia is so rapid in its progress, that the early symptoms just now described may have passed away before the first visit of the surgeon, who is often called to see his patient only after the full development of the disease. He probably finds him sitting up, his head bent forwards, his chin resting on his symptoms. 181 breast, and his handkerchief applied to the cheek to absorb the discharge, which irritates the surface upon which it flows. The eyelids are swollen, especially the upper, which slightly overlaps the lower, and is of a reddish or even dusky hue. The patient states that he is unable to open the eye. His inability to do so is caused less by an intolerance of light, than by the mechanical obstruction which the swelling of the lids occasions, and by the pain which is excited by any friction of the inflamed surfaces upon each other. The surgeon now moistens the edges of the lids with a rag dipped in warm water in order to facilitate their separation, and proceeds with his examination. In his attempt to open the eye, he is careful not to make pressure upon the globe, in order to avoid giving unnecessary pain, and also, lest the cornea, if already ulcerated, may be ruptured, and the contents of the globe escape. With one finger placed just below the eye, he slides the integument down- wards over the malar bone, and thus everts the lower lid; the upper lid being elevated by a similar manoeuvre with another finger of the same hand applied below the edge of the orbit; or, again, he may expose the globe by seizing the lashes of the upper lid with the thumb and finger and drawing the lid forwards and upwards. All this may be accomplished with the left hand, the right being left free to wipe away the discharge, or to make applications to the eye. As soon as the lids are separated, a quantity of thick, yellow pus wells up between them and partially obstructs the view; the swollen palpebral conjunctiva, compressed by the spasmodic action of the orbicularis muscle, may also project in folds. The collection of matter is now removed with a soft, moist sponge or rag, and the surface of the ocular conjunctiva exposed. This membrane is found to be of a uniform red color, with its vessels undistinguishable from each other, and elevated above the sclerotica by an effusion of serum and fibrin in the cellular tissue beneath it. This swelling of the conjunctiva is seen to terminate at the margin of a central depression occupying the position of the cornea, and filled with a collection of the less fluid constituents of the puriform discharge, which may at first sight be mistaken for the debris of a disorganized cornea. On removing this matter, however, the latter structure may still be found clear and transparent, at the bottom of the depression, where it is overlapped by the swollen conjunctiva. In less fortunate cases, it may have become hazy from the infiltration 182 GONORRHOEAL OPHTHALMIA. of pus between its layers, or ulceration may have already com- menced. If an ulcer is not evident on first inspection, it may often be discovered at the margin of the cornea by gently pushing to one side the overlapping fold of conjunctiva. Meanwhile, the secretion of pus is constantly going on and requires repeated removal. It is astonishing to observe how large a quantity of this fluid can be secreted by so limited a surface. The secretion has been estimated at more than three ounces per day. The amount of pain, occasioned by this disease, varies in different cases. During the development and acme of the inflammation, it is generally severe. It is described by the patient as a sensation of burning heat and tension in the eyeball, radiating to the brow and temple. The system at large sympathizes with the local disease. For a time there may be general febrile excitement, but symptoms of depression soon appear; the pulse becomes rapid and irritable, the skin cold and clammy, and the patient anxious and nervous. This depression of the vital powers is not invariably met with, but is the most frequent condition of the patient, after the disease has continued for a few days; and it may occur even at an earlier period, when the health has been previously impaired by any cause. Notwithstanding the severity of the symptoms, resolution is still possible. Under proper care and treatment, the inflammatory action may abate, and the tissues recover their normal condition, leaving the eye as sound as before the attack. So fortunate a result, how- ever, is more to be hoped for than confidently anticipated. The chances of success are greater when the case is seen at an early period, before the effusion beneath the conjunctiva has been ren- dered firm by a deposit of fibrin, or before ulceration of the cornea has commenced. The latter is the chief danger to be feared. Ulcer- ation usually commences at the margin of the cornea, and may extend around its circumference, or advance towards its centre. It is in some cases superficial; in others, it penetrates through the whole thickness of the cornea, and prolapse of the iris ensues, or more or less of the contents of the globe escapes. Sometimes a portion or the whole of the corneal membrane becomes disorgan- ized, and comes away en masse. The eye has been known to be destroyed in this manner within twenty-four hours after the first symptoms of the disease were observed, and this catastrophe is said to have occurred in a single night, in a case at the New York Hos- pital. The escape of the aqueous humor, and other contents of the DIAGNOSIS- TREATMENT. 183 globe, is usually followed by an amelioration of the pain, and the patient often entertains the hope that he is improving, while the surgeon knows that his sight is irretrievably lost. The amount of permanent injury inflicted upon the eye will de- pend upon the extent and situation of the ulceration. When the latter has been superficial, and situated near the margin of the cor- nea, the resulting opacity will not interfere with vision, and even when the leucoma is central, an operation for artificial pupil is still practicable, if any portion of the cornea remain clear. Perforation of the anterior chamber and prolapse of the iris, when partial, may also be remedied by art; but when the whole, or the larger portion of the cornea has sloughed away, and the prolapsed iris has become covered with a dense layer of fibrin, forming an extensive staphy- loma, the case is hopeless. Diagnosis.—Independently of the history of the case, we have no means of distinguishing gonorrhoeal ophthalmia from severe purulent conjunctivitis. It has been asserted that the former com- mences in inflammation of the ocular conjunctiva, while the latter first affects the lining membrane of the lids. Even if this were true, it would afford but little assistance in the diagnosis, since we are rarely enabled to watch the early symptoms. Dr. Hairion,1 Professor of Ophthalmology at the University of Louvain, supposed he had discovered a diagnostic sign of gonor- rhoeal ophthalmia in the presence of a bubo in front of the ear; but as no one else ever saw such buboes in this disease, the statement must be regarded as a sad instance of obliquity of vision produced by preconceived notions as to the nature of the disease. Treatment.—In undertaking the treatment of a case of gonor- rhoeal ophthalmia, it is of the first importance that the patient be intrusted to the care of an intelligent, careful, and faithful nurse, whose whole time and attention can be devoted to carrying out the surgeon's directions. This disease is so rapid in its progress, that neglect for a few hours only may prove fatal to vision; if the eye be saved, a large share of the credit will be due to the faithfulness of the attendant. It hardly need be said that the light touch and gentle hand of a devoted woman should be secured, if possible. 1 Annales d'Oculistique, t. xv. p. 159. 184 GONORRHOEAL OPHTHALMIA. The directions of the surgeon should vary according to the stage of the disease. If the inflammation has commenced within a few hours only, and has not as yet attained its height, from four to six leeches may be applied near the external canthus of the affected eye, or a number of them be made to attach themselves to the mucous membrane of the corresponding nostril. If leeches are not at hand, cups to the temples will suffice. Such local depletion may generally be repeated with benefit, for a day or two, once or twice in the twenty-four hours, especially if the patient be of full habit. If, however, the disease progresses unchecked, and especially if there be any symptoms of general depression of the system, even this slight abstraction of blood should be avoided. It is adapted only to the early stage of the inflammation, and, at a later period, is use- less, if not positively injurious. A free purge should be administered, as, for example, five grains of calomel followed by half an ounce of castor oil, a full dose of Epsom salts, or three " compound cathartic pills." With regard to the diet of the patient, much will depend upon his general con- dition. As a general rule at this early stage, it should be light, consisting of gruel, broths, etc.; at the same time it is important to recollect the tendency in this disease to depression of the vital powers, and to be governed by the indications of each individual case. Lastly, but by no means of least importance, the directions which will presently be given for the frequent cleansing of the eye, should be insisted on, and a collyrium of nitrate of silver, ten grains to the ounce, should be dropped between the lids every two hours, or every hour in threatening cases. The treatment above recommended is intended for the early stage of gonorrhoeal ophthalmia, before much chemosis, swelling of the lids, or other severe symptoms have set in. In most cases, however, as already stated, the surgeon does not see his patient till the disease has attained its height, when some modification of the above treatment is required. Leeches and cups can now rarely be used to advantage. At the best, they will be impotent to stay the progress of the inflammation. Cathartics should be given as in the first stage,1 and one or two free 1 When the disease has already made considerable progress before the surgeon is called, an active cathartic, as croton oil, should be selected. TREATMENT. 185 evacuations from the bowels secured each day. Here again the general condition of the patient will in a measure determine the diet to be recommended; but in the great majority of cases nourish- ment should be administered as freely as the appetite will admit, and may consist of bread, milk, beef-tea, steaks, mutton, eggs, etc. When the patient is unable to eat, and especially if his skin is found to be cool and his pulse irritable, or again, if ulceration of the cornea has already commenced, we must resort to stimulants and tonics. These are almost always required in this stage of the disease in hospital practice, where patients are generally more or less cachectic, and even in private practice the subjects of gonorrhoeal ophthalmia are often run down by an irregular course of life. Nothing will so much contribute to hasten destructive ulceration of the cornea as a low state of the vital powers. The least indication of this con- dition should be met by quinine, ale, porter, wine, or milk-punch, freely administered. The room occupied by the patient should, if possible, be spacious, dry, and well ventilated. The eyes may be protected from a glare of light by the position of the patient, or by a pasteboard shade, or by curtains; but the room should not be entirely darkened, as the complete exclusion of light favors congestion of the eye. With still stronger reason, should the eyes be uncovered and kept free from poultices, alum-curds, tea-leaves, raw oysters, or similar appli- cations, which are often recommended by some officious acquaint- ance. No surer way of destroying the sight could be devised than by using these articles. When chemosis has already taken place, no time should be lost in dividing the conjunctiva and the subjacent cellular tissue by means of radiated incisions, in the manner recommended by the late Mr. Tyrrell. This surgeon believed that ulceration of the cor- nea in this disease was caused by the constriction of the conjunctival vessels, exercised by the chemosis; that thus the vascular supply was cut off from the cornea, and that free incisions would afford relief by removing the strangulation. Division of the chemosed con- junctiva had been recommended and practised before his time, but the incisions had been made at random, while Mr. Tyrrell advised that they should radiate from the cornea, in order that they might at the same time be free, and yet avoid wounding the larger vessels. It is doubtful whether the hypothesis on which Mr. Tyrrell founded this practice is correct, and less favorable results on the whole have 186 GONORRHOEAL OPHTHALMIA. been obtained by others than appear to have resulted from it in his hands; yet there can be no question of the advantage of these incisions in many cases, however we may explain their mode of action. The greatest benefit may be expected from them when the effusion beneath the conjunctiva consists chiefly of serum; at a later period when the chemosis has become firm from a deposit of fibrin, they are less advantageous. The method of making these incisions, as recommended by Mr. Tyrrell, is as follows: The patient is to be seated in a low chair, supporting his head against the chest of the surgeon, who stands behind him; the upper lid is elevated by the forefinger of one hand as in the operation of extraction, while an assistant depresses the lower lid; the incisions are to involve the conjunctiva and subjacent cellular tissue; they should extend from the margin of the cornea towards the circumference of the globe like the radii of a circle, at the same time avoiding the position of the recti muscles, lest the larger conjunctival vessels be wounded; the surgeon, holding a cataract knife in his disengaged hand, enters its point, with its back turned towards the cornea, at the junction of the cornea and sclero- tica, and cuts from within outwards, making two incisions in each of the four spaces between the insertions of the recti muscles; imme- diately after the operation, the flow of blood and serum is favored by the application of hot water for ten or fifteen minutes. If chemosis has already taken place, the surgeon should make these radiated incisions on his first visit, and, at the same time, freely scarify the palpebral conjunctiva. Within half an hour after the blood has ceased to flow, the whole inflamed surface should be freed from pus and brushed over with a camel's hair pencil dipped in a solution of nitrate of silver containing forty to sixty grains to the ounce, taking care to remove the residue of the solution by a free application of tepid water afterwards. The incisions and scarifica- tions are to be repeated every twenty-four hours, so long as the chemosis continues severe. At this visit, also, the attendant, who is to take charge of the case, should be instructed as to her duties, and the importance of her faithfully performing them. She should be made to look on while the surgeon goes through the process of opening and cleansing the eye, and be taught to follow his example. A syringe is sometimes recommended for the purpose of removing the pus. There are, however, two objections to the employment of this instrument: in TREATMENT. 187 the first place, unless used with gentleness, the force of the stream irritates the inflamed and sensitive conjunctiva; and, again, the in- jected fluid, mixed with contagious matter, may be reflected back, and strike the eye of the attendant or fall upon the opposite eye of the patient. Several cases are recorded in which this accident has occurred. For these reasons a soft rag is to be preferred, and this, again, is better than a sponge, because it is more cleanly and may be frequently changed. By squeezing the fluid from the rag upon the adherent portions of the discharge, or by gently touching them with a free fold of the cloth projecting beyond the fingers, they can readily be detached. Simple tepid water may be used for these ablutions, but I prefer a solution of alum, of the strength of a drachm to the pint. The nurse should be directed to repeat them every hour or every half hour, according to the severity of the case, and the patient may be furnished with a cupful of the solution to bathe the external surface of the eye and wash away the discharge, still more frequently. Cleanliness may be still farther promoted by cutting off the cilise, so as to prevent their becoming incrusted with matter; and by smearing the edges of the lids with simple cerate. The strong solution of nitrate of silver, already mentioned, may be reapplied by the surgeon twice a day when he makes his visits, but, meanwhile, a weaker solution of the same salt, containing ten grains to the ounce, should be dropped into the eye, after it is thoroughly cleansed, every two or three hours. The patient must not be deprived of sleep by too frequent repetition of these measures during the night, but he- should be provided with a watcher, who will cleanse the eye and apply the solution of nitrate of silver every few hours. If necessary, sleep must be promoted by the adminis- tration of an opiate. The time has gone by, when mercurials were thought requisite in this disease, on account of its supposed syphilitic origin. The only circumstance which can justify their employment is the pre- sence of a firm, fleshy chemosis, which, owing to its consistency, cannot be relieved by Tyrrell's incisions. In such cases, mercurials may perhaps hasten the absorption of the fibrinous deposit; but they should be used with great caution, especially when ulceration of the cornea has already commenced, and should never be pushed to salivation. An excellent formula, combining the "gray powder" with quinine, is the following:— 188 GONORRHOEAL OPHTHALMIA. ty. Hydrarg. cum creta gr. ij. Quiniae sulphatis gr. j-iv. Misce et ft. pulv. One to be taken morning and night. When only one eye is affected, the greatest care should be taken to avoid inoculation of the other by allowing the discharge to come in contact with it. On the slightest indication of inflammation in the latter, the weaker solution of nitrate of silver should be applied to it, as frequently as to the eye first affected. When there is excessive oedema of the lids, it may interfere with opening the eye and cause pressure upon the globe; in which case relief may be given by puncturing the skin in several places with a lancet. Division of the external canthus, in order to facilitate the exposure of the inflamed conjunctiva, has been recommended by Mr. France1 and others, but it is not generally required. As the symptoms improve, the stronger solution of nitrate of silver may be omitted, and the weaker applied less frequently. When the chief danger is passed, the collyrium may often be changed with benefit, and one of the following substituted:— R. Zinci sulphatis gr. ij. Glycerin 5ij- Vini opii 3j. Aquae 3v. M. R. Acidi gallici gr. x. Glycerin 3iij- Vini opii ^ij. Aquae camphorae q. s. ad §iv. M. A pleasant method of employing these collyria is by means of an eye-cup. I have met with cases in which a solution of nitrate of silver appeared to irritate the eye, and in which the above collyria were found preferable even in the acute stage of the disease. The occurrence of an ulcer upon the cornea is of serious moment, and the friends of the patient should be informed of the danger to vision. The progress of the ulcer may sometimes be arrested by gently touching its surface with a stick of nitrate of silver, the point of which has been rounded off and somewhat sharpened by rubbing it upon a wet rag; or a saturated solution of the same salt may be Guy's Hospital Reports, third series, vol. iii. TREATMENT. 189 applied with a fine camel's hair pencil. The whitening of the sur- face which follows the application will indicate whether the whole of the ulcer has been touched. At the same time the pupil should be dilated by dropping a solution of atropine upon the globe once a day, or by smearing extract of belladonna, moistened with glyce- rin, around the orbit. The former is much more cleanly. The usual strength of the solution employed is two grains to the ounce; the atropine should first be dissolved in a drop or two of vinegar. The object of thus dilating the pupil is to diminish the prolapse of the iris if the ulcer should penetrate through the cornea, and, if pos- sible, to prevent the pupil's becoming involved in the resulting synechia. The chances of accomplishing this are not very great, for a pupil dilated by mydriatics contracts as soon as the aqueous humor escapes, as is seen during the operation of extraction for cataract; still, as the evacuation of the contents of the anterior chamber in perforating ulcer of the cornea is often sudden, some hope may be entertained of limiting the prolapse. I would again remind the reader of the importance of avoiding antiphlogistic remedies, and of the necessity of supporting the strength, when the cornea, a tissue of low vitality, is attacked by the ulcerative process. Cupping, leeching, low diet, and mercurialization will be sure to hasten destruction of the eye, which can only be saved, if saved at all, by generous living, stimulants, and tonics. A granular condition of the palpebral conjunctiva is frequently left after an attack of gonorrhoeal ophthalmia, and may keep up a slight discharge and irritation of the eye for a considerable time. The best means for its removal consists in the application of a crys- tal of sulphate of copper to the everted lids every second or third day; and the general system should, at the same time, be supported by fresh air, good diet, and tonics. When a staphyloma is formed, its friction against the lids is often a source of irritation to the affected eye, and, through sympathy, to its fellow. If it is small, there may be hope of its contracting and being less prominent, as the fibrin covering it becomes more firmly organized; and it may be pencilled over daily with a strong solution of nitrate of silver with a view of favoring this result. When, however, it has already attained considerable size, and covers so large a portion of the cornea that there is no chance of the eye serving as an organ of vision in future, it is useless to make any farther attempts to save the eye, especially as its inflamed condition 190 GONORRHOEAL OPHTHALMIA. endangers the integrity of its fellow, and the intraocular pressure will probably still farther increase the size of the staphyloma, until it bursts of itself or is relieved by art. Two operations are avail- able under these circumstances: one, the ordinary excision of the staphylomatous projection and sinking of the eye; the other, extir- pation of the globe by the modern or Bonnet's method. The former is to be preferred, as a general rule, in cases of sta- phylomata following gonorrhoeal ophthalmia, because the staphyloma is usually limited to the cornea, and the deeper tissues of the eye are commonly, though not always, sound. Moreover, the mobility of an artificial eye is greater when worn upon a sunken globe, than when the latter is removed; and, again, patients, through ignorance of the simple modern operation for extirpation, are very averse to its performance. At the same time, it should be recollected that a sunken eye, especially when irritated by wearing a glass substitute, may at any future period become inflamed and endanger the integ- rity of its fellow through sympathy. After the removal of a sta- phyloma, therefore, patients should always be warned of this dan- ger, and cautioned to seek advice at once, if ever the stump should become mflamed, or the sight of the fellow eye should begin to fail.' The operation for removing a staphyloma is too well known to require description here. There is only one point to which I desire to call attention. After the operation, the lids should be closed by strips of isinglass plaster and remain so until the wound has entirely healed; otherwise the friction of the lids and the exposure of the hyaloid membrane to the air, will be likely to set up inflammation in the deeper tissues of the eye and cause much suffering. Extirpation of the globe should be preferred, when internal or general ophthalmia has supervened; when the staphyloma includes not only the cornea but a portion of the sclerotica; or when hemor- rhage has taken place from the bottom of the eye, either on the perforation of the anterior chamber, on the bursting of the sta- phyloma, or during an operation for its removal. The blood, in these cases, comes chiefly from the choroidal vessels; its flow may ' Calcareous deposit is very liable to take place in sunken globes which have become the seat of chronic inflammation, and in such cases it is impossible to relieve the irritation except by extirpation. I have this day removed the stump ( of an eye, destroyed by granular conjunctivitis, in a boy aged 16, in which I found a plate of calcareous matter the size of a three cent piece. * TREATMENT. 191 be arrested, but the clot can only be eliminated by the slow and tedious process of suppuration, and it is better to remove the eye at once. The modern operation for extirpation of the globe is exceedingly simple. The ball of the eye is alone removed, while the remaining contents of the orbit are left. The instruments required are a pair of toothed forceps, blunt-pointed straight scissors, and a strabismus hook. The eye should be kept open with a wire speculum. The conjunctiva and underlying fascia are divided close around the margin of the cornea, and the tendons of the four recti muscles hooked up and severed as in an operation for strabismus. The scissors are then passed in behind the globe and the optic nerve cut at its point of entrance, when the ball may readily be removed, after dividing the oblique muscles and any remaining points of attach- ment. There is no danger of subsequent hemorrhage. The lids may be allowed to close, and the clot which forms within them is the best hemostatic for such cases. If the operation has been well performed, without extending the incisions beyond the ocular fascia, the wound will heal with great rapidity. I have frequently been able to insert an artificial eye on the third or fourth day after the operation.1 The remedies recommended in the preceding pages for gonorrhoeal ophthalmia may be recapitulated, in the order of their importance, as follows: cleanliness, frequent application of an astringent solu- tion, nourishment, and, in most cases, stimulants and tonics, radiated incisions of the chemosed conjunctiva, cathartics, and local depletion. This plan of treatment differs widely from the copious and repeated venesections, the low diet, and the free administration of mercurials and tartar emetic, prescribed by nearly all writers on this affection until within a very few years. If the practice which I have advised were new, it might be requisite to say something farther in its de- fence ; but its claims have already been established by most of the eminent authorities of what may be called the modern school of ophthalmic surgery. When supported by the writings and practice 1 It would be out of place in this work to enter more fully into the details of this and other operations which may be required after gonorrhoeal ophthalmia. For farther particulars with reference to extirpation of the globe, the reader is referred to an essay by Mr. Critchett, in the London Lancet (Am. ed.), Jan. 1856; also to papers by Dr. C. R. Agnew and by the present writer, in the N. Y. Journal of Med., Jan. and May, 1859. • 192 GONORRHOEAL OPHTHALMIA. of such men as Prof. Graves,1 Critchett,2 Bowman, Wilde, Dixon,3 France,4 Hancock,5 and others, both in this country and abroad, it is unnecessary to say anything farther in its favor. I will only add that my own experience, drawn from the largest infirmary for dis- eases of the eye in this country, perfectly coincides with that of the authors above mentioned.0 In the words of Mr. Dixon: "The student ought constantly to bear in mind that, although the disease termed purulent ophthalmia has received its name from that symptom which readily attracts notice, namely, the profuse conjunctival discharge, the real source of danger lies in the cornea; and that, even if it were possible so to drain the patient of blood as materially to lessen or even wholly arrest the discharge, we might still fail to save the eye. It is not the flow of pus or mucus, however abundant, that should make us anxious, but the uncertainty as to whether the vitality of the cornea be sufficient to resist the changes which threaten its transparency. These changes are twofold—rapid ulceration and sloughing. Now, has any sound surgeon ever recommended excessive general bleed- ing and salivation as a means of averting these morbid changes from any other part of the body except the eye? And if not, why are all the principles which guide our treatment of other organs to be thrown aside as soon as it attacks the organ of vision?" 1 London Medical Gaz., vol. i., 1838-9, p. 361. a Lectures on Diseases of the Eye, London Lancet (Am. ed.), Aug. 1854. 3 Guide to the Practical Study of Diseases of the Eye, London, 1859. 4 Op. cit. « London Lancet, Nov. 1859. 6 Dr. O'Halloran appears to have been one of the first to discard the old depletive treatment of purulent ophthalmia. In his " Practical Remarks on Acute and Chronic Ophthalmia, and on Remittent Fever" (London, 1824), he says : " I am of opinion that if any inquiry be instituted amongst the army surgeons, it will be found that those who used the greatest depletion were the least successful practi- tioners, and that sloughing, ulcers, &c, more fr quently succeeded the evacuating plan than when the patient was partly left to nature." GONORRHOEAL RHEUMATISM. 193 CHAPTER XI. GONORRHOEAL RHEUMATISM. Gonorrhoeal rheumatism was first recognized by Swediaur, who described it under the name of " Arthrocele, Gonocele, or Blennor- rhagic Swelling of the Knee."1 Since Swediaur's time, this disease has received particular attention from various writers on venereal and diseases of the joints, among whom Sir Benjamin Brodie,2 Sir Astley Cooper,3 Ricord,4 Bonnet, of Lyon,5 Foucart,8 Brandes,7 and Rollet,8 are especially worthy of mention. During this period, however, gonorrhoeal rheumatism has by no means been allowed to retain its place in the nosological system undisturbed, and there have been many who have attempted to explain it away, on various hypotheses. Its claims to be considered a distinct complication of gonorrhoea will appear in the course of this chapter. To an observer who had never heard of the connection between gonorrhoea and rheumatism, it might indeed appear a mere coinci- dence, if a patient suffering from gonorrhoea should suddenly be seized with inflammation of the joints; but should this same pa- tient, after entirely recovering from both affections, and after seve- ral years of perfect health, again contract gonorrhoea, and again be seized with articular rheumatism, the occurrence would be suffi- ciently remarkable to excite a suspicion in the mind of the most 1 A Complete Treatise on the Symptoms, etc., of Syphilis, by F. Swediaur, M. D. Translated from the fourth French edition, by Thomas T. Hewson. Philada., 1815, p. 108. 2 Brodie's Select Surgical Works: Diseases of the Joints. Philada., 1847. 3 Lectures on the Principles and Practice of Surgery. London, 1835, p. 482. 4 Notes to Hunter, 2d ed. Philada., 1859, p. 275. 6 Traits des Maladies Articulaires. Paris, 1853, t. i. p. 376. 8 Quelques Considerations pour servir a l'Histoire de PArthrite Blennorrhagique; in 8vo. pp. 45. Bordeaux, 1846. 7 Archives GenSrales de Medecine, Sept. 1854. ' Annnaire de la Syphilis ; annee 1858, Lyon. 13 194 GONORRHOEAL RHEUMATISM. careless observer that there was some connection between the two. Let this second attack be followed by a third, fourth, and fifth, and the suspicion would be converted into a very strong probability. Suppose that numerous other patients were met with in whom these two affections thus repeatedly coexisted, an attack of gonorrhoea in each of them being followed by one of rheumatism, with such certainty that the latter might be predicted immediately on the ap- pearance of the former, and a manifest relation between the two diseases could no longer be doubted. Now, this repetition of these two diseases in the same person is not merely hypothetical—it is a reality; and it is observed in subjects entirely free from any rheu- matic diathesis, who have inflammation of the joints at no other time than when they have gonorrhoea. Among the many cases which might be cited, none perhaps will better illustrate this point than the following, which I quote from the lectures of Sir Astley Cooper:— " I will give you," says this distinguished surgeon, " the history of the first case I ever met with; it made a strong impression on my mind. An American gentleman came to me with a gonorrhoea, and after he had told me his story, I smiled, and said: do so and so (particularizing the treatment), and that he would soon be better; but the gentleman stopped me, and said, ' Not so fast, sir; a gonor- rhoea with me is not to be made so light of—it is no trifle; for, in a short time you will find me with inflammation of the eyes, and in a few days, I shall have rheumatism in the joints; I do not say this from the experience of one gonorrhoea only, but from that of two, and on each occasion I was affected in the same manner.' I begged him to be careful to prevent any gonorrhoeal matter coming in con- tact with the eyes, which he said he would. Three days after this I called on him, and he said, ' Now you may observe what I told you a day or two ago is true.' He had a green shade on, and had ophthalmia in each eye; I desired him to keep in a dark room, to take active aperients, and apply leeches to the temples. In three days more he sent for me, rather earlier than usual, for a pain in one of his knees; it was stiff and inflamed; I ordered some appli- cations, and soon after the other knee became inflamed in a similar manner. The ophthalmia was with great difficulty cured, and the rheumatism continued many weeks afterwards." Similar cases are related by nearly every author who has written on this affection, and, further on, many are given in a table of the CAUSES. 195 diseases of the eye which accompany gonorrhoeal rheumatism. M. Rollet relates in detail five such instances occurring in his own practice, and this repetition took place in eight of thirty-four cases reported by Brandes, of Copenhagen, and in three of eight cases observed by M. Diday. According to Rollet's researches, this repe- tition has been noted in nearly one quarter of the total number of cases of gonorrhoeal rheumatism which have been published. The frequency of cases like these can leave no doubt in the mind that a close relation exists between these two affections, and additional evidence is found in the fact that the rheumatism attend- ant upon gonorrhoea presents certain peculiarities, which, in general, are sufficient to distinguish it from the ordinary forms of rheuma- tism. Causes.—In comparison with the great frequency of gonorrhoea, gonorrhoeal rheumatism is exceedingly rare. Very little is known of the causes which occasion it in the few, while the many affected with gonorrhoea escape. Its occurrence might naturally be attrib- uted to a rheumatic diathesis, especially as the fact is well estab- lished that persons subject to rheumatism are particularly prone to contract gonorrhoea; and it is distinctly asserted by several writers that a constitutional tendency to rheumatism is a predis- posing cause of inflammation of the joints during an attack of gonorrhoea. There is reason to believe, however, that the plausi- bility of this opinion, founded on d priori reasoning, has given it greater weight than it deserves. Those who have expressed it, have failed to produce any evidence in its support; and if we examine the published cases of this disease, we frequently find it noted that the patient never suffered from rheumatism except when he had gonorrhoea. M. Rollet has made this point a special subject of inquiry, and states that in the great majority of cases of gonor- rhoeal rheumatism which have come under his observation, there was no rheumatic diathesis either in the patients or in their parents. He also states that he has had under treatment many patients with gonorrhoea, who were predisposed to rheumatism, and yet in them, urethritis has not been attended by any inflammation of the joints; and this fact derives additional weight from the frequency with which gonorrhoeal rheumatism, after having once occurred, is re- excited by a subsequent clap. These statements of M. Rollet go far to show that a rheumatic diathesis has no part in the production 196 GONORRHOEAL RHEUMATISM. of gonorrhoeal rheumatism; it is desirable, however, that this point should be subjected to further observation.1 The exciting cause of gonorrhoeal rheumatism cannot be found in the use of copaiba and cubebs, as has been sometimes asserted, or in exposure to cold and sudden changes of temperature. In- flammation of the joints has frequently been known to occur in patients who have taken neither of these drugs, and who have been confined to the wards of a hospital during the whole course of their attack of gonorrhoea. On the other hand, how frequently are copaiba and cubebs administered for gonorrhoea, and how often must the subjects of clap be exposed to cold and moisture, and yet how rare is gonorrhoeal rheumatism! The phenomena of gonorrhoeal rheumatism are also inconsistent with the idea of a metastasis from the urethra to the joints, since in most cases there is an exacerbation of the urethral discharge preceding the articular inflammation. This is especially noticeable in chronic cases of gleet, in which gonorrhoeal rheumatism super- venes. The influence of sex in the production of gonorrhoeal rheuma- tism cannot be questioned. All the undoubted cases of this disease that have been published relate to men, and it must be extremely rare, if it exists at all, in women.2 Ricord, Vidal, and 1 M. Rollet weakens his position by asserting an antagonism between a rheu- matic diathesis and gonorrhoea, in virtue of which, he believes that a clap some- times cures a patient of a tendency to rheumatism, from which he has previously suffered for years! He says that he has observed one such case, and quotes another in detail which occurred in the practice of M. Diday; but surely it is more reasonable to suppose that the disappearance of the rheumatism in these two cases was a mere coincidence. 1 Foucart says : " I have not been able to find a single case of gonorrhceal rheu- matism in the female, either in special treatises on this subject or in the medical journals." Brandes says: " The cases of gonorrhceal rheumatism reported by a few authors are far from conclusive. My own attention has been fixed on this point for six years, during which time I have not been able to find a single case at the only hospital in Copenhagen where venereal diseases in women are treated." Two very questionable cases are reported as occurring in the service of M. Rayer in 1846, the only account of which is as follows : " One woman was affected with inflammation of the elbow joint during the course of an attack of vaginitis. Another had nearly all the joints of the extremities slightly and successively inflamed, after several attacks of vaginal discharge." (Rollet.) Another questionable case is related by MM. Blatin and Nivet (Traite des Mala- dies des Femmes). SEAT. 197 a few other writers admit that it is occasionally met with in women, but have not reported any cases. It will be seen from the above remarks how imperfect is our knowledge of the etiology of this disease, and it would be useless to enter into any farther speculations upon the subject.1 Seat.—None of the joints are exempt from an attack of gonor- rhceal rheumatism, but this disease affects the knee far more frequently than any other joint. The following table exhibits the order of frequency with which the various joints were affected in 81 cases observed by MM. Foucart, Brandes, and Rollet:— Articulation of the knee ankle hips . fingers and toes . shoulder wrist . elbow sternum and clavicle tarsal bones sacrum and ilium lower jaw . tibia and fibula . 64 30 15 15 10 10 8 3 2 2 1 1 161 Thus in 81 cases 161 joints were affected, and the knee was involved in 64. Besides the joints, gonorrhoeal rheumatism fre- quently affects the ocular tunics; also the bursae connected with the muscular tendons, especially the tendo-Achillis; and some- times the sheaths of the muscles, as in muscular rheumatism. Again, Ricord states that he has met with several patients who suffered from severe pain in the plantar region, apparently seated in the fasciae. The knee-joint, therefore, is the favorite seat of gonorrhceal rheumatism, though all the joints of the body are liable to its attacks. This disease, however, is less prone to change its seat from one joint to another than ordinary articular rheumatism. 1 Rollet is inclined to believe that an explanation of the origin of gonorrhoeal rheumatism is to be sought for in the seat of gonorrhoea. He says : " There is no difficulty in admitting that when gonorrhoea extends to certain tissues or portions of the urethra, as yet undetermined, it may, in subjects constitutionally predis- posed to this disease, excite inflammation of the joints." 198 GONORRHCEAL RHEUMATISM. This fact is evident from an examination of the above table, which shows that there were but 161 joints affected in 81 cases; an aver- age of about two joints to each case. I know of no similar table exhibiting the number of articulations affected in a given number of cases of ordinary rheumatism, but the proportion is undoubtedly much greater. Again, in 10 of the 19 cases in the above table, furnished by M. Foucart, only one joint was affected; of the 34 cases of M. Brandes's, the rheumatism was mono-articular in 5, and also in 10 of the 28 cases collected by M. Rollet. These facts, therefore, would give us a ratio of about one-third, in which gonorrhoeal rheumatism attacks but a single joint, but more extended statistics are required before this proportion is received as accurate. Even when gonorrhceal rheumatism does not remain confined to one joint, but extends to others, the articulation first affected does not recover its normal condition, as it often does in ordinary articu- lar rheumatism, but generally continues in a state of inflammation after the disease is lighted up in other joints. In this respect, gonorrhoeal rheumatism again differs from acute rheumatism, but approximates to the character of rheumatic gout. There can be no question, I think, that gonorrhceal rheumatism sometimes attacks the heart, but it is equally certain that this complication is much less frequently met with than in ordinary acute articular rheumatism.1 Ricord states that in several clearly marked cases of gonorrhoeal rheumatism, he has observed symptoms of endocarditis, and also of effusion within the pericardium, and it is to be regretted that he has not given these cases in detail. The rarity of any mention of heart disease, however, in the reported cases of gonorrhoeal rheumatism, proves the correctness of the above assertion that this disease is usually free from such complication. The only undoubted case that I am acquainted with is one reported by Mr. Brandes:— A man, 50 years of age, had had five attacks of gonorrhoea within ten years; each attack being attended with disease of the joints. In a sixth attack he was seized with violent pain and swelling of several joints, especially the knee. A few days after, inflammation of the eye and pericardium ensued. The friction sound was well marked; and the pulsations of the heart were irregular. There was 1 "I am induced to think that, under ordinary circumstances, some heart affection arises in about half of all cases of acute rheumatism." (Fuller on Rheumatism.) SYMPTOMS. . 199 dulness on percussion over a considerable space, with palpitation and pain in the precordial region. These symptoms improved under venesection and mercurials. Meanwhile the iris became inflamed in the right eye, and a week after this eye recovered, the left was attacked. The patient finally recovered, but suffered from weakness of the lower extremities for a long time, so that he was obliged to walk with crutches for several months. I have also received a verbal report of a similar case occurring in the practice of one of the most reliable surgeons of this city, but the details, drawn only from memory, are not sufficiently full to entitle them to publication. Ricord is the only authority, so far as I am aware, who has seen any affection of the nervous centres in gonorrhoeal rheumatism. This surgeon states that he has met with symptoms of compression of the spinal marrow and of the brain, such as paraplegia and hemiplegia, which appeared to be produced by increased effusion within the serous membranes of the brain and spine, and which followed the same course as the affection of the joints. No affection of the lungs or pleura has ever been observed in gonorrhoeal rheumatism. Gonorrhoeal rheumatism is essentially an hydrarthrosis, and in many instances the inflammation is confined to the synovial mem- brane of the joint during the whole course of the affection. The predilection of this disease for serous membranes is shown by its attacking the bursae connected with the tendons, especially about the wrist and ankle. Rollet states that he has seen one case in which the seat of the disease appeared to be a bursa accidentally developed over the acromion process. Symptoms.—In describing the symptoms of gonorrhoeal rheu- matism, it is desirable to take those of ordinary articular rheumatism as a standard of comparison. Proceeding in this manner, we find that gonorrhoeal rheumatism is generally ushered in with less febrile disturbance than its more frequent congener. In some cases there is an entire absence of premonitory symptoms, and the patient's attention is not attracted to the joints until effusion has taken place and motion has thereby been rendered painful and difficult. In other instances, a slight chill and wandering pains have been ex- perienced, before the morbid action has become settled in any one joint; and those cases are exceptional in which the inflammatory 200 GONORRHCEAL RHEUMATISM. symptoms at the outset are comparable in violence to those of acute rheumatism. When the articular disease is fairly established, the pain is in- creased and is often severe; but here, also, we find the symptoms less acute, as a general rule, than in ordinary rheumatism. Even in those cases in which the local pain is great, there is much less general febrile excitement; and an examination of the blood drawn in five cases by M. Rollet and in one by M. Foucart, failed to show that buffed and cupped condition of the clot which is so frequently met with in acute rheumatism. The integument covering the affected joint generally retains its normal color, though it sometimes puts on the blush of inflamma- tion. When the knee-joint is the seat of the disease, as is fre- quently the case, the symptoms of a serous effusion within the capsule are readily detected. The patella is elevated above the femur and is freely movable; the joint has the form of a cube, the usual depression on either side of the patella being replaced by swellings, and fluctuation can be detected without difficulty. It is evident that the inflammatory process is confined to the synovial membrane, and that the fibrous and osseous tissues are unaffected. The collection of serum necessarily impairs the mobility of the joint, and pain is excited by pressure or by any attempt at motion. If the disease do not yield readily to treatment, other tissues about the joint become involved, and we may then find redness of the skin, together with fulness of the vessels and a corresponding increase of the pain and general febrile disturbance, assimilating the case to one of acute rheumatism. Those cases of gonorrhoeal rheumatism which commence with the most decided inflammatory symptoms are generally the most amenable to treatment; those, on the contrary, in which the febrile action is but slight, and in which there is but little more than a passive effusion into the synovial sac, are more obstinate. Recovery, in any case of this disease, can rarely be expected in less than a month or six weeks, and is often delayed for several months or even years, especially when the patient is debilitated and when the affection of the urethra is allowed to run on, or does not yield to treatment. It is unnecessary to describe the symptoms of the cardiac affec- tion which sometimes complicates a case of gonorrhoeal rheumatism, since these do not differ from those of endocarditis and pericarditis SYMPTOMS. 201 attendant upon ordinary acute rheumatism. The inflammation of the eye which frequently precedes or accompanies—or sometimes alternates with the disease of the joints, and which is evidently de- pendent upon the same condition of the general system, will presently receive special mention. Most cases of gonorrhoeal rheumatism terminate sooner or later in complete resolution, although they may render the patient a cripple for a long period. Suppuration within the bursa very rarely occurs. MM. Velpeau, Foucart, Bonnet, Brandes and Rollet state that it never takes place; it is admitted by Ricord, who says, how- ever, that it is always due to some accessory cause of inflammation; and Vidal mentions one case occurring under his charge in which it was necessary to open the joint and evacuate the purulent collec- tion. Anchylosis, especially of the smaller joints, is a more frequent termination of gonorrhoeal rheumatism, and in scrofulous subjects, this disease has not unfrequently been followed by that strumous affection of the joints known as "white swelling;" here, as in other well-known instances, a constitutional cachexia selects the weakest part of the body as the seat of its manifestation. Dr. Holscher1 reports a case in which death is said to have oc- curred from gonorrhceal rheumatism. An abscess formed in the affected joint, and purulent infection ensued. The period at which rheumatism makes its appearance in the course of a gonorrhoea appears to be more variable than that of epididymitis. Some cases are met with in which the affection of the joints occurs during the acute stage, or first week or two of the duration of the clap; and yet in the majority of cases we find that the rheumatism manifests itself at a later period, when the urethral discharge has passed its climax. Generally, we find that the run- ning has been more copious for a few days preceding the outbreak of the rheumatism, and this is especially noticeable in long-standing cases of clap which have been accompanied by several repetitions of the articular affection, each of which has followed an exacerba- tion of the discharge. Cases in which the running suddenly di- minishes or entirely dries up before the rheumatism appears, must be regarded—in spite of the opposite opinion so frequently ex- pressed—as rare and exceptional, and not sufficient for the basis of a theory of metastasis. In deciding this point—to which much 1 Annales de Holscher, 1844. 202 GONORRHCEAL RHEUMATISM. importance has been attached—it should be recollected that if the rheumatism occurs several weeks after contagion, the discharge will probably have somewhat diminished, following the course which it usually pursues in cases entirely free from any complication. After the disease of the joints is established, the running sensibly de- creases in most cases, as a consequence of revulsive action. In other instances—estimated by Rollet at about one-third—it remains without much change. It rarely disappears entirely, except as the result of treatment. Gonorrhceal rheumatism, unlike acute rheumatism, but like rheu- matic gout, frequently attacks the eye.1 The ocular affection in these cases, is that form of "gonorrhoeal ophthalmia" which has been described by authors as " metastatic or sympathetic;" but the difference in the mode of origin, symptoms, prognosis, and treat- ment, between this form of ophthalmia and purulent conjunctivitis arising from contagion, is so great, that it would be desirable to dis- tinguish the two by different names, and to drop altogether the term gonorrhoeal ophthalmia, as applied to that ocular affection which accompanies gonorrhoeal rheumatism. But before proceeding to further discussion of this point, it will be interesting and instruc- tive to compare the views of different authors relative to these two diseases. Mr. Tyrrell2 denies the existence of gonorrhoeal ophthalmia allied to purulent conjunctivitis and arising in any other way than by contagion, but he admits a conjunctivo-sclerotitis, due, as he sup- poses to the metastasis of gonorrhoea. Mackenzie admits gonorrhceal conjunctivitis by contagion, by metastasis and by sympathy, and also a gonorrhoeal iritis. Mr. Lawrence3 admits three distinct forms of ophthalmic inflam- mation occurring in conjunction with, or depending on gonorrhoea, viz., 1st. Acute inflammation of the conjunctiva; 2d. Mild in- 1 " In true rheumatism, the eye seldom suffers ; so seldom, that I find no record of any affection of that organ in more than 4 out of the 379 cases of acute and subacute rheumatism admitted into St. George's Hospital, during the time I held the office of Medical Registrar. But in rheumatic gout, the eye is not unfrequently implicated. It was inflamed in 11 out of the 130 cases of rheumatic gout admit- ted during the same period: and it has suffered more or less severely in 5 out of 75 cases, which have fallen under my own care at the hospital." (Fuller.) ' Diseases of the Eye, vol. i. p. 387. 8 On the Venereal Diseases of the Eye, London, 1830. SYMPTOMS. 203 flammation of that membrane; and 3d. Inflammation of the scle- rotic coat, sometimes extending to the iris. In speaking of the last mentioned form, Mr. Lawrence says: " This affection of the eye is exactly the same as rheumatic inflam- mation of the sclerotic and iris, occurring independently of gonor- rhoea. Both this and the mild purulent inflammation of the con- junctiva are to be regarded as rheumatic affections of the organ excited by gonorrhoea; that is, they take place in individuals, in whom this constitutional disposition is shown by inflammation affecting either the synovial membranes, or the fibrous structures of the joints. Although the organs seem at first view very dissi- milar, there is an analogy of structure between the parts which suffer in the two instances; that is, between the synovial membranes and the conjunctiva, and between the ligaments and fibrous sheaths, and the sclerotica. Hence, we need not be surprised at finding that the eyes suffer under the influence of that unsound state of consti- tution which leads to these affections of the joints. The structure originally affected, the lining of the urethra, is also a mucous mem- brane, which sometimes becomes inflamed, and pours out a puri- form discharge, in gouty and rheumatic subjects from internal causes." Ricord admits two kinds of gonorrhoeal ophthalmia; one from contagion, the other metastatic or sympathetic; but although he states that the latter may present all the symptoms of the former, yet his description of it differs widely from uncomplicated purulent conjunctivitis. He says: "Not only the conjunctival, but also the sclerotic vessels are injected; the eye appears more tense and more brilliant than natural; the cornea often projects a little more than usual, and the iris is a little farther off; in some instances we may satisfy ourselves that the aqueous humor is increased. At times there are symptoms of iritis, as a change of color in the iris, con- traction of the pupil, which is rarely distorted, and more or less photophobia. The aqueous humor may be cloudy, lactescent, or flaky, owing to inflammation of the membrane of Descemet, and false membranes may be formed, which give rise to adhesions, or pseudo-cataracts; but pustules on the iris, or what have been called condylomata of the iris, are never seen as in syphilitic iritis. A process takes place in the eye analogous to what we meet with in the synovial membranes, in cases of gonorrhoeal arthritis, which, as I have already stated, sometimes accompanies this ophthalmia, or 204 GONORRHCEAL RHEUMATISM. alternates with it. Sympathetic gonorrhceal ophthalmia, other things being equal, is more irregular in its course, and more subject to relapses than the ophthalmia from contagion. It often changes its seat, which does not occur in the latter." It will be seen that this description covers the symptoms of inflammation of the deeper textures of the eye, especially the sclerotica and iris, rather than those of uncomplicated conjunctivitis; and, in spite of Ricord's sub- sequent statement that the symptoms of the sympathetic disease may be identical with those of gonorrhoeal ophthalmia from conta- gion, it is evident that he is describing a different affection. Finally, M. Rollet1 has taken the ground that sympathetic gonor- rhceal ophthalmia is almost always an inflammation of the mem- brane of Descemet, and that it is invariably a manifestation of gonorrhceal rheumatism. This surgeon calls attention to the fact so frequently noticed by others, that this form of ophthalmia is generally associated with gonorrhoeal rheumatism, but he is also inclined to believe that it may exist alone without any affection of the joints, and that as we often have one joint alone attacked by gonorrhceal rheumatism, so the eye may be the only part of the body in which the rheumatic tendency shows itself. With regard to the seat of this affection, M. Rollet does not deny that it may be in some other of the ocular tunics, but he maintains, that in the great majority of cases, it is in the iris. He goes farther, and asserts that it is the anterior layer of the iris which is attacked by the inflammatory process, which may extend to the posterior lamina of the cornea. According to this author, there- fore, this affection is an aquo-capsulitis, or, more properly speaking, a kerato-iritis, the symptoms of which are the following: injection of the conjunctival vessels and especially of the zone of sclerotic vessels around the cornea; occasional photophobia and increase in the flow of tears; a nebulous appearance of the cornea; an increase of the aqueous humor; dulness of the iris, and a deposit of plastic material in the anterior chamber (which Mackenzie states is un- equalled in degree in any other form of iritis), occasioning great obscuration of vision. Generally both eyes are attacked simulta- neously or consecutively. The disease may terminate in resolution, or atresia iridis. It differs from syphilitic iritis, in that the latter affects the substance of the iris, produces a greater change in its 1 Op. cit. SYMPTOMS. 205 color, often gives rise to tubercular excrescences, deforms the pupil to a greater extent, and is more likely to cause adhesions between the iris and anterior capsule of the lens. In the opinion of M. Rollet, the symptoms of gonorrhoeal iritis now described are so constant, and so different from the effects of common rheumatism upon the eye, that he regards this affection as one proof that gonorrhoeal rheumatism is a distinct species apart from rheumatism produced by other causes. It thus appears that several authors have recognized the fact that " sympathetic gonorrhoeal ophthalmia" is dependent upon the same condition of the general system as gonorrhoeal rheumatism. Moreover, in all the cases which I have been able to find recorded, these two diseases have coexisted within a short space of time; the affection of the eye, in all of them, has been either preceded, at- tended, or followed by rheumatism, and in some instances they have alternated with each other. Again, the tissues of the eye affected are the same as those usu- ally involved in rheumatic gout, with which gonorrhoeal rheuma- tism has so many other points of resemblance. These considerations are sufficient, I think, to establish the identity of the two diseases, and to authorize the conclusion that the affection of the eye is but one manifestation of gonorrhoeal rheumatism. It is no objection to this view that the ophthalmia sometimes precedes the affection of the joints, for the same is true of inflammation of the heart attendant upon acute rheumatism,1 and we may also admit, that in some cases, though I have not met with any such, the disease of the eye is the only evidence of a rheumatic tendency, the joints remaining entirely unaffected. The present classification of this form of ophthalmia, does away with many difficulties which have heretofore surrounded this sub- ject, and reconciles many discrepancies to be found in books. The "mild gonorrhceal conjunctivitis" of Lawrence, the "gonorrhoeal conjunctivo-sclerotitis" of Tyrrell, and the "gonorrhoeal iritis" of Mackenzie and others, are seen to be essentially the same disease, 1 " In summing up the principal facts deserving of notice in reference to rheu- matic inflammation of the heart, I should say that it is incidental to all the stages of acute rheumatism, occurring sometimes before the commencement of inflam- mation of the joints, and possibly, also, in some rare instances, without the concurrence from first to last, of any active articular symptoms." (Fuller on Rheu- matism, Am. ed., N. Y. 1854, p. 165.) 206 GONORRHCEAL RHEUMATISM. dependent upon a rheumatic tendency induced by gonorrhoea, and capable of manifesting itself in any of the external tunics of the eye. The difficulty of admitting a disease of the eye originating in gonorrhoea, otherwise than by contagion, is done away with; it is no longer necessary to call in question the cleanliness of patients, or to suspect constitutional syphilis in the entire absence of proof that such exists; and the obscure phenomena of metastatic and sympathetic gonorrhceal ophthalmia are found to be in accordance with the laws which govern ordinary rheumatic ophthalmia. In the following table of cases of gonorrhoeal rheumatic oph- thalmia, I have included all the more noted facts which from time to time have been published by some of the most eminent authori- ties in our profession. Most of them have been related by their authors as instances of "metastatic or sympathetic gonorrhceal conjunctivitis, iritis," etc. In many cases, the details are very imperfect, and it is very probable that in some the disease of the eye was merely catarrhal ophthalmia coexisting with gonorrhoea, but I have thought it best to make no attempt to sift them, the better to enable the reader to form his own conclusions on the facts at present in our possession. This table includes nearly all the cases which I have been able to find in a somewhat extended search through works on Venereal, and Diseases of the Eye. METASTATIC GONORRHCEAL OPHTHALMIA. 207 REPORTED CASES OF METASTATIC GONORRHCEAL OPHTHALMIA' SO-CALLED. Brodie's Se- lect Surgical Works; Dis- eases of the Joints; Phil., 1847, p. 35. Ibid., p. 36. Ibid., p. 37. 4 Ibid., p. 37. Ibid., p. 38. Patient 45 years of age. Four at- tacks. Case obscure- Nine. ly reported. Two. Patient with strictures of urethra. Patient setat 23. Lawrence on John Harley, the Yenereal Diseases of the Eye; London, 1830, p. 104. Ibid., p. 107. aged 38, had never had rheumatism before. Gentleman, 52 years of age. Ibid., p. Ill Mr G., »tat. 33, of good constitution; had never suf- fered from rheumatism Four. One. One. Seve- ral. Contracted gonorrhoea in the middle of June, 1817. Rheumatism of foot commenced June 23; ophthal- mia June 24; conjunctivae much inflamed with profuse discharge of pus. Complete recovery. 2d attack in Dec. 1817, similar to preceding, but leaving him crippled. 3d and 4th attacks in March, 1818 and 1822, in which the inflammation was situated in the " proper tunics" of the eye ^sclerotica, iris, and choroid). In four attacks, purulent ophthalmia; in two inflam- mation of the sclerotica and iris; inflammation of various joints and bursas mucosae. Gonorrhoea in 1809, with swelled testicle, purulent ophthalmia, and inflammation of synovial mem- branes. Similar attack in 1814, except no swell- ing of testicle. In all, the urethritis was the first symptom, and was followed by purulent ophthalmia and inflammation of synovial membranes. In two of the cases, the gonorrhoea was attributed to contagion, and in the two others to the use of bougies. Purulent discharge from the urethra; inflammation of knee-joint with effusion; slight inflammation of the conjunctiva, which subsided under the use of remedies directed to the rheumatism. One month after appearance of gonorrhoea was at- tacked with " acute external inflammation" of both eyes, resulting in extensive ulceration of corneae and impaired vision; within one week after commencement of ophthalmia, had rheuma- tism of several joints. Slight discharge from the urethra in 1822, which the patient did not attribute to infection, followed by inflammation of conjunctiva, chemosis, and puri- form discharge. The eye symptoms disappeared, when rheumatism of one knee and both hands set in; as the latter grew better, the eyes became in- flamed again. This attack lasted for two years. The patient was seen again in 1828. No recurrence of acute rheumatism, though the joints were still stiff from old attack. Had had at least six attacks of inflammation of the eyes since former visit, and the contraction of pupils and adhesions to capsule showed that the iris had been involved. No return of urethral discharge. Urethral discharge appeared July 9th, 1827; eyes became inflamed July 23d ; symptoms those of simple acute conjunctivitis, without chemosis or profuse purulent discharge. Severe pain in the hip and thigh came on July 24th. Patient im- proved and was supposed to be well, but had a short relapse of urethral discharge, ophthalmia, and pain in hip, after exposure, Aug. 9th. 208 GONORRHCEAL RHEUMATISM. 10 11 12 13 Ibid., p. 114. Mr. C, setat. 38; full liver and subject to rheumatism. Ibid., p. 115. Ibid., p. 118. Ibid., p. 120. Ibid., p. 123. Mr. C, aetat, 30, of spare habit and leading a se- dentary life. 14 Ibid., p. 124. Patient of spare habit and good con stitution; had always en- joyed good health; age 28. Patient 24 years of age, and good constitution. Patient aged 25. Mr. F., 29 years of age, One. One. Two. One. One. Gonorrhoea followed by inflammation, with effusion of knee and swelling of hands. Symptoms were improving and urethral discharge had ceased, when mild inflammation of the conjunctiva came on in both eyes; this subsided in a few days under the use of tepid lotions. Within a few years after marriage, had four attacks of discharge from the urethra, " without infec- tion." The last of the four attacks was attended with painful swelling of the foot and enlargement of the glands in the groin. Four years afterwards (June, 1827) had an acute attack of aquo-capsu- litis in left eye, with copious effusion of lymph in anterior chamber; under treatment these symp- toms entirely disappeared. Sept. 7th, contracted gonorrhoea from impure con- nection. Sept. 18th, mild conjunctivitis ensued in both eyes; and, Sept. 21st, rheumatism of foot and upper extremities, the discharge from the urethra still continuing. In Feb., 1828, he had severe inflammation of the external tunics and iris on both sides; some stiff- ness of joints still remained; no mention of the urethral discharge. An attack of gonorrhoea was getting better, when rheumatism of the joints of foot and of the knee appeared, followed in a short time by inflamma- tion of the sclerotica and iris in both eyes, which left permanent adhesions between the iris and anterior capsule. 1st attack. Patient contracted gonorrhoea, the symp- toms of which were very severe. In three weeks, both eyes became " red and inflamed, painful and acutely sensible to light; lachrymation and mu- cous discharge" (inflammation of the sclerotica and iris). No affection of joints mentioned. 2d attack, occurring 18 months after the preceding. As before, a severe attack of gonorrhoea followed in a fortnight by an attack of conjunctivitis, which disappeared in a few days. About a fortnight after, however, the gonorrhoea still continuing, the eyes again became inflamed; the inflammation being seated in the "deeper tunics." Soon after rheumatism appeared affecting all the joints of the body, but particularly the knee. Patient continued well for about two years, wben he had a severe attack of rheumatism without any affection of the eyes. Patient had had a slight gonorrhoeal discharge for some time, when inflammation of the internal tunics and iris of both eyes ensued, followed in a few days by inflammation of the knee-joint. The eyes recovered in a month, the urethritis and rheumatism still continued for a year afterwards. Five weeks after the commencement of an attack of gonorrhoea, had severe pains in the back, sides, and lower limbs; after these had continued a fort- night, he had injection of the sclerotic vessels, with profuse lachrymation and dimness of vision. METASTATIC GONORRHCEAL OPHTHALMIA. 209 15 Ibid., p. 127. Mr. L., 29 years of age. 16 Tyrrell, vol. Patient 46 i. p. 387. years of age. 17'lbid., p. 392. 18 Ibid., p. 394. 19 Ibid., p. 394 20 Ibid., p. 395. Patient 20 years of age, fair com- plexion and scrofulous diathesis. 21 Vetch, Prac- Patient 25 tical Treatise years of age on the Dis- eases of the Eye; London, 1820, p. 243. 22 Prof. Graves, London Med. Gaz., new series, vol. i. p. 440. 23 Had an attack of gonorrhoea nine years ago, unac- companied by any rheumatic affection. Four years ago, had gonorrhoea, followed by rheuma- tism, which affected particularly the feet. A third attack of gonorrhoea, ten months ago, fol- lowed in a week by rheumatism in the feet, which has continued till the present time; mean- while he has had an attack of sclero-iritis in each eye. Four. Gonorrhoea; inflammation of several joints with effu- ' sion ; inflammation of conjunctiva and sclerotica in both eyes, and in one extending to the iris and choroid. Order of sequence of these affections not given. Other three attacks similar. One. After the acute stage of an attack of gonorrhoea had subsided, inflammation of the synovial capsule of the knee and of the conjunctiva and sclerotica of both eyes. " Similar to the last case." One. Similar to the two previous cases, except that the inflammation extended to the iris and choroid of one eye. Six or Each attack was preceded by slight gonorrhoea; no seven, j inflammation of synovial membranes, but rheu- matic pains about shoulders, arms and neck prior to disease of eyes ; inflammation of conjunctiva and sclerotica, dull aching pain in globe and brow aggravated at night, dull condition of iris, irre- gular pupil, muscae. Two, In each attack the subsidence of the gonorrhoea was at five attended by rheumatism of the knee and joints of years' foot, followed by inflammation of the sclerotica inter- and iris ; irregular and contracted pupil, synechia, val. opacity of capsule of lens, and impaired vision. There was no chemosis or purulent discharge in either attack. Swelled testicle present in the first. P., aged 35 years. Sir Astley Cooper, Lec- tures on the Principles and Practice of Surgery; London, 1835, p. 482. Four. 'The gonorrhoea in each attack ran its course till the discharge and inflammation began to decline, when the eyes invariably became inflamed, presenting all the symptoms of simple acute conjunctivitis, and after a few days the sclerotica and other tissues became involved. Again, after the oph- thalmia had lasted a few days, one of his joints invariably became affected with acute inflamma- tion. Three An American gentleman applied to Sir Astley Cooper to be treated for gonorrhoea, and told him that in two former attacks he had had inflammation in the eyes, and rheumatism in the joints. Sir Astley cautioned him against allowing any matter from the urethra to come in contact with the eye. Three days after, the man had "ophthalmia" in both eyes, which was cured with great difficulty; and in three days more he had rheumatism in each knee. (It is evident that the disease of the eye in this case was not purulent conjunctivitis.) u 210 GONORRHCEAL RHEUMATISM. 24 Rollet, An- nuaire de la Syphilis; annee 1858, p. 19. 25 Ibid., p. 20. 26 Brandes, Arch. Gt'n. | de Med., ! Sept. 1854. 27 Same author. Patient aged. One. 24 years, an inmate of the Venereal Hospital at Lyon. Patient aged One. 30; never had rheumatism before. Two at an inter- val of three years. Patient had Five at stricture, and inter these several vals of attacks were one or probably not two due to fresh years contagion. Inflammation of eyes commenced eight days after gonorrhoea; redness of conjunctivae, lachrymation, cornea slightly opaque atresia and irregularity of pupils, circumorbital pains. Inflammation of knee-joint with effusion took place four days after the disease of eyes appeared. Disease of the eye appeared eight days after urethral discharge. Left eye only affected; injection of conjunctival vessels; pupil irregular, iris darker than on opposite side; slight opacity within the pupil; pain in the orbital region. Inflammation of joints of knee and foot came on in about seven weeks, the disease of urethra and eye still con- tinuing. 1st attack. The day following the appearance of a gonorrhoea, patient began to suffer from an " oph- thalmia" of both eyes and pain in one shoulder. The ophthalmia subsided under treatment. A re- lapse taking place, several joints were affected with rheumatism, the iris became inflamed, with hypopion. 2d attack. Ophthalmia appeared in five days, and rheumatism in eight, after gonorrhoea; iris in- flamed, several joints involved. Inflammation of the iris, followed by rheumatism, in each attack. In all the cases included in this table, the eye disease was pre- ceded, attended, or followed by rheumatism. In a majority of the attacks the ophthalmia preceded the rheumatism. In about two-thirds of the cases of which we have sufficient details to enable us to determine the seat of the ophthalmia, the sclerotica and iris were chiefly affected; in the remaining third, the conjunctiva. In the latter class, it is sometimes noted that there was purulent discharge and chemosis; but the inflammation does not appear to have assumed the severity of gonorrhceal ophthalmia from conta- gion, since only one (No. 6) terminated in ulceration of the cornea, and most of the cases yielded readily to treatment. We may conclude, therefore, that gonorrhoeal rheumatism, like rheumatic gout, may attack any of the ocular tunics, though it most frequently involves the sclerotica, from which it may extend to the conjunctiva, iris, or other tissues.1 It must be borne in mind 1 These cases do not confirm Rollet's statement, that gonorrhoeal rheumatic oph- thalmia is always a kerato-iritis. DIAGNOSIS. 211 that the vascular connection of all the tissues of the eye is very intimate, and that the inflammatory process is never wholly con- fined to one portion of the globe. It is highly probable, I think, that many cases of gonorrhceal rheumatic ophthalmia, which have been described as conjunctivitis, have in reality been instances of conjunctivo-sclerotitis, in which the injection of the conjunctival vessels has masked that of the sclerotica. The orbital and circum- orbital pain, which are often mentioned, would indicate this. At the same time, it must be confessed, that in some instances the chief seat of the disease has been the conjunctiva, and that the presence of a muco-purulent discharge and a certain degree of chemosis, have rendered these cases readily mistakable for gonorrhceal ophthalmia from contagion. The milder character of the disease, the history and habits of the patient, and the existence of rheumatism, are, in such instances, the chief elements on which to found a diagnosis. When a patient has had an affection of the eyes and joints in previous attacks of gonorrhoea, or when gonorrhoeal rheumatism coexists with an ophthalmia which does not present the severe symptoms of purulent conjunctivitis, there is a strong probability that it is of the rheumatic form, even though the conjunctiva appears to be chiefly affected. Not unfrequently, also, rheumatic ophthalmia, after entirely disappearing from one eye, involves the opposite eye, or returns a second time to the one first affected, a course never pursued by gonorrhoeal ophthalmia from contagion. In by far the larger proportion of cases, however, as shown by the above table, the symptoms of gonorrhceal rheumatic ophthalmia are those of sclerotitis, iritis, or kerato-iritis, either separate or com- bined. I shall not attempt to describe the characteristic features of these different forms, since they are identical with those of the same affections arising from other causes. I will merely remark that when the iris is involved, it generally appears to be so secondarily, and that the inflammation affects it to a less extent and more superficially than in other forms of iritis; hence that there is less danger of adhesions to the capsule of the lens and of atresia iridis, and that tubercular excrescences are probably never seen upon its surface. Diagnosis.—The admission of gonorrhoeal rheumatism as a dis- tinct disease, is by no means dependent upon the question whether it presents any symptoms different from those of ordinary rheuma- 212 GONORRHCEAL RHEUMATISM. tism. Inflammation of the epididymis, identical with swelling of the testicle attendant upon gonorrhoea, may be excited by other causes; and even if no diagnostic signs of the rheumatism caused by ure- thritis be admitted, we should still be warranted in using the term "gonorrhceal rheumatism " as indicating the connection between the two diseases. It is evident, however, that the disease now under consideration differs in some respects both from acute rheumatism and rheumatic gout, though much more closely allied to the latter than to the former. It differs from acute rheumatism in the absence or slightly marked character of its premonitory symptoms; in the less degree of constitutional disturbance which attends it; in being limited to a few joints; in its predilection for the synovial membranes; in rarely attacking the heart but frequently the eye; in its persist- ency ; and in seldom affecting women. It differs from rheumatic gout in the fact that hereditary influences, so far as at present proved, have no part in its production; also in the frequency with which it attacks the knee-joint; in its preference for the male sex, and in its rarely leaving any permanent traces of its invasion. Whether these points of difference are sufficient or not to con- stitute a distinct species of rheumatism, is a question which proba- bly cannot be decided with satisfaction to every mind. Even the laws of classification in the animal and vegetable kingdoms are as yet far from being settled; much less can it be said that there are fixed rules for determining how great a degree of difference will justify a distinct species in the natural history of disease. All that we can say with regard to gonorrhceal rheumatism, is, that in well- marked cases, it presents certain characteristic features sufficient to indicate its origin, even when before unknown. In some instances, its symptoms resemble those of other forms of rheumatism so closely, that we should not be led to suspect its character, unless aware that the patient was suffering from gonorrhoea. In a given case of this kind, therefore, it may at times be ex- tremely difficult to determine whether our patient has an affection of the joints dependent upon his urethritis, or whether his rheuma- tism is simply a coincidence; if, however, there be but little con- stitutional disturbance; if only a few joints, and particularly the knee, be affected; if the disease be chiefly confined to the synovial membrane—as shown by the articular effusion, and the slight NATURE. 213 degree of heat and redness externally—and if it exhibit but slight tendency to migrate from one joint to another, then there can be little question that the gonorrhoea and rheumatism bear to each other the relation of cause and effect. The probability will be still further strengthened, if the patient has never been subject to rheu- matism ; or, d fortiori, if he has had it only in conjunction with previous attacks of gonorrhoea. Nature.—The power of exciting rheumatism, exercised by gonorrhoea in certain cases, has often been advanced as an argu- ment to prove that the latter disease is a modified form of syphilis; and it has been asserted that the rheumatism is due to the absorp- tion of a specific poison from the urethra. This idea has probably derived additional weight from the supposition that no other satisfactory explanation could be given of the connection between these two diseases, and before such was found, the theory of a syphi- litic or gonorrhoeal virus was thought to be the only alternative. The question has been asked: If the rheumatism is not produced by the absorption of a specific poison, how is it produced ? But such a process of reasoning is founded on a gross over-estimate of our knowledge of cause and effect in disease. The connection between gonorrhoea and rheumatism is only one of many instances, in which the link which binds two diseases together escapes us, although the union is plain and unquestionable. Who, for instance, can account for the intermittent fever which is sometimes occasioned by a stricture of the urethra; or explain the connection between chorea and rheumatism—a connection so intimate that a large proportion of children who have the one will have the other; or the reason that disease of the supra-renal capsules causes bronzing of the skin ? And so throughout the etiology of all diseases, if for a moment we endeavor to divest our minds of the familiaritv whjch daily observation has given to the connection between them and the causes which produce them, in how few instances do we really understand the mechanism of the process! Facts which occur but rarely, excite wonder; if frequent or coinciding with other known phenomena, the mind receives them without distrust. Is it then an isolated fact that a local affection, entirely destitute of specific properties, is capable of exciting rheumatism? By no means. Dr. Fuller, who believes that the proximate cause of rheumatism is a poison generated in the sys- 214 GONORRHCEAL RHEUMATISM. tern (not absorbed from without) as the result of faulty metamor- phic action, thus speaks of the influence of local disease: " One part of the animal economy hinges so closely on the other, that local mischief occasions general disturbance, and under certain circumstances appears to induce a state of system favorable to the generation of rheumatic poison; a state of system arising, be it observed, not as a direct and immediate consequence of suspended secretion, but as a sequel of perverted function gradually taken on by the system generally, in consequence of imperfect or morbid local action. Excessive venery and long-continued debauchery are frequently productive of rheumatism, and so is immoderately protracted lactation. The phenomena of gonorrhoea afford an ad- mirable example of how local diseases may gradually give rise to general derangement of the system, and so to the production of the peccant matter of rheumatism."1 This connection between local diseases in general and inflammation of the joints is also fully recognized by other observers; it need not therefore surprise us, nor is there any necessity to suppose the absorption of a specific poison, when we find that rheumatism can be excited by inflamma- tion of the urethra. Moreover, evidence is not wanting to show that the phenomena of gonorrhoeal rheumatism cannot be explained on the ground that the syphilitic or any other specific poison has been taken into the system from without. In order not to extend this subject to too great length, I will merely enumerate the chief points of this evidence. 1. If gonorrhceal rheumatism were due to the absorption of a virus, it ought to be a very frequent disease, considering the multi- tude of patients affected with gonorrhoea; it is, however, quite infrequent. 2. On the same supposition, it ought to run a regular and definite course, like specific diseases in general. 3. One attack, also, should afford immunity from, or at least partial protection against subsequent attacks in the same person. 4. No evidence of the absorption of a virus is found in an ex- amination of the lymphatic vessels or ganglia in gonorrhoea, as in syphilis. Even in cases of gonorrhoeal rheumatism, the absorbents in the neighborhood of the genital organs retain their normal con- dition. Fuller on Rheumatism, p. 35. TREATMENT. 215 5. Gonorrhoeal rheumatism has repeatedly been known to occur in connection with urethritis which had been excited by the use of bougies, or by intercourse with women during the menstrual period. If it can thus be caused by a simple urethritis, why is it ever ne- cessary to attribute it to a "virulent gonorrhoea?" 6. None of the known symptoms of constitutional syphilis bear any more than the slightest resemblance to gonorrhoeal rheumatism. Treatment.—It is evident that we cannot deduce the treatment of gonorrhoeal rheumatism from that of acute rheumatism, as has sometimes been done by writers on this subject; nor, again, en- tirely from that of rheumatic gout, although here, it is not im- probable that a somewhat similar line of treatment may be found applicable. But if we recognize a special cause and certain peculiarities in the symptoms of gonorrhoeal rheumatism, the treatment of this disease demands investigation independent of any preconceived notions derived from our experience with kindred affections. The amount of constitutional disturbance attending the com- mencement of an attack of gonorrhoeal rheumatism is rarely sufficient to require active antiphlogistic measures. The adminis- tration of an emetic, or a free purge, as from five to ten grains of calomel, followed by castor oil or Epsom salts, is commonly suffi- cient to allay the febrile excitement, and has the additional advan- tage of correcting the condition of the digestive organs which are usually at fault. The patient should be kept quiet, and his diet be proportioned to the severity of the febrile action. The chief means of combating the local inflammation is to be found in the abstrac- tion of blood from the neighborhood of the joint. Cups or leeches should be applied, and repeated as often as the case requires. They afford marked relief to the pain, often arrest the progress of the disease, and hasten its resolution. After the more acute symptoms have been subdued, or even at the outset, when the disease is from the first of a subacute character, the greatest benefit will be derived from blisters. These are especially applicable, when a large joint, like the knee, is attacked, and when an effusion within the capsule is a prominent symptom. The vesicated surface may be dressed with simple cerate with the addition of five grains of morphine to each ounce, and so soon as the surface heals a fresh blister may be applied. If strangury 216 GONORRHCEAL RHEUMATISM. ensue, the daily application of strong tincture of iodine may be substituted for the unguentum lyttae. Velpeau recommends that the joint be kept constantly smeared with mercurial ointment, to which some preparation of opium has been added. Ricord and some other writers advise the internal administration of colchicum, alkalies, and the salts of potash, as in rheumatism dependent upon other causes, but the reports of cases in which these remedies have been employed are far from proving their efficacy. Diuretics of any kind are objectionable, since they tend to keep up the urethral discharge. The occasional use of an emetic or purge has in the hands of several surgeons been found to be of decided advantage. Rollet speaks highly of vapor baths. Copaiba and cubebs have no effect upon the rheumatism, and can only be required for the urethritis, which, in most cases, however, is more satisfactorily treated by local measures. Meanwhile, the treatment of the urethral discharge on which the rheumatism depends, should not be neglected. Unless this be entirely arrested, there is always danger of a relapse. In many of the cases reported, the rheumatism has repeatedly returned at intervals of several months, so long as the exciting cause continued. The measures already recommended for the treatment of gonorrhoea and gleet should, therefore, be actively employed, at the same time that attention is paid to the affection of the joints. When gonorrhoeal rheumatism occurs in persons of broken-down constitution, or when the general health becomes impaired by the continuance of the urethral and articular disease, it is necessary to resort to hygienic measures, and frequently to the administration of tonics, as preparations of iron, iodine, cod-liver oil, bark, etc. These remedies, together with fresh air and good diet, should by no means be neglected, as soon as the patient is found to be debilitated. A very efficacious method of treating the swelling which often remains after the acute symptoms have subsided, is by means of strips of adhesive plaster so applied as to exercise compression and at the same time render the joint immovable. Supposing the knee to be affected, the limb should be bandaged from the toes up to the point where the plaster is to commence, or just below the swelling. The strips should be of about two fingers' breadth, and each one, first passed behind the limb, be brought round in front, and its ends made to cross like the letter X. One strip after another is applied, each overlapping the preceding for about one- TREATMENT. 217 third its width, until the whole joint is covered, when four or five additional layers are superposed in the same manner, in order to insure a sufficient degree of stiffness, and the whole enveloped in a bandage. I can speak very decidedly of the good effects of this application in this and other chronic affections of the joints. When the eye becomes inflamed, local depletion by means of leeches or cups to the temples should be resorted to. If the con- junctiva be involved, the strictest cleanliness should be maintained by frequent bathing with tepid water. Astringent collyria are less frequently called for than in conjunctivitis independent of any rheumatic taint; if used, their effect should be carefully watched, and, if they fail to afford relief, they should be omitted. When the iris is implicated, the pupil must be dilated by atropine, and mercu- rials administered as in other forms of iritis. 218 VEGETATIONS. CHAPTER XII. VEGETATIONS. Vegetations are papillary growths springing from the skin or mucous membrane chiefly in the neighborhood of the genital organs, and identical in their nature with the'warts which are so common upon the hands. They are not, strictly speaking, venereal, since they are not necessarily connected with either of the diseases originating in sexual intercourse. It is true that they are most frequently observed in men and women who have been affected with gonorrhoea, balanitis, or chancres; but this is simply because the skin or mucous membrane has for a time been moistened with an acrid secretion which has favored the abnormal develop- ment of its papillae. They are found in young children, with regard to whose purity there can be no suspicion; and also in adults who have never suffered from any venereal disease whatso- ever. Again, they are not unfrequently met with during pregnancy; the increased secretion from the vagina and the determination of the blood to the pelvis at this time being highly favorable to their development. The importance of these growths has been very much exag- gerated. Thus, they have been regarded as syphilitic, and as an indication of the necessity of specific remedies; and this, too, in spite of the generally recognized fact that mercury has no effect whatever in their removal. Their only connection with primary or secondary syphilis is when they spring from the surface of a chancre, mucous patch, or other constitutional lesion, upon which they are a merely accidental formation. The sore which serves as their base may require a mercurial course, but the superadded vegetation in itself presents no such indication. Again, it is often said that they are contagious; and some semblance of truth for this supposition has been found in the fact that when situated upon one of two opposed surfaces, as the labia VEGETATIONS. 219 or upper and inner parts of the thighs, similar growths not unfre- quently spring up upon the opposite; and somewhat doubtful cases have been reported in which, as alleged, vegetations have appeared upon men after connection with women who were simi- larly affected. But, such instances are readily explained on the ground that the acrid secretion from vegetations, when applied to neighboring parts, and, possibly, when transferred to another indi- vidual, acts in the manner already explained, and gives rise to others. The very fact that their supposed contagion takes place upon the person affected, is sufficient to prove that they are not dependent upon the virus of true syphilis, the lesions of which are not auto-inoculable; and there is no reason whatever for ascribing them to the poison of the chancroid. Moreover, they present the same aspect, follow the same course, and are amenable to the same treatment, when occurring in young children and pregnant women who are otherwise healthy, as in persons affected with venereal diseases. Several varieties of vegetations have been admitted, especially by the French, founded upon their resemblance to various objects in nature. Thus, Alibert, who believed that vegetations were syphilitic, admitted them as one of three principal forms of the syphilodermata; and divided them into six varieties: "La syphilis vCjge'tante frambois^e;" "en choux fleurs;" "en crates;" "en poi- reaux;" and "en vermes;" to which he added the truly syphilitic lesion, mucous patches, under the head of "condylomes." No useful purpose, however, is attained by this classification, which serves only to confuse the mind; since the form of vegeta- tions is solely dependent upon accidental circumstances, as their position and the pressure of neighboring parts. It is sufficient to know that they are sometimes flat and but little elevated above the surface; while at others they are attached by means of a pedicle of variable diameter; and that they are chiefly developed in whatever direction they meet with the least resistance. When exposed to the air they are often dry and hard; when protected by an opposed surface, they are soft and smeared with a highly offensive secretion. Their microscopical appearances are thus described by Lebert: " A feeble power shows their internal vascular structure and numer- ous sebaceous follicles about their base. With a high power, the papillae appear to be composed of an outer rind consisting of con- centric layers, and of an internal substance; the two differ from 220 . VEGETATIONS. each other only in density; for, besides their vascular element, they consist only of epidermic cells. In the outer layers, these cells are more densely packed and present a longer and narrower outline, which, at first sight, gives them a fibrous appearance. The internal portion is also composed of epidermic cells in close juxtaposition, but round and finely dotted on their surface. Vegetations are nothing else than a development of the papillae of the epidermis, and, in their anatomical composition, do not differ much from certain papilliform warts." Vegetations are most frequently met with upon the internal sur- face of the prepuce directly back of the furrow at the base of the glans; they are also found upon the margin of the meatus, or within this orifice upon the walls of the fossa navicularis; upon the vulva in women, and especially in the neighborhood of the carunculse myrtiformes; and, in both sexes, around the anus, upon the tongue, velum palati, and even within the larynx. Treatment.—The treatment of vegetations consists simply in their removal by the knife, caustic, or ligature, and the destruction of the base from which they spring. With the vegetations upon the internal surface of the prepuce, I have found it most convenient to touch them with fuming nitric acid, and repeat the application upon the fall of the eschar as often as may be necessary; or, when the growth is prominent and pedunculated, it may be snipped off with scissors and the base thoroughly cauterized, although, when cutting instruments are used, the hemorrhage is sometimes a little troublesome. As soon as the tenderness produced by the applica- tion of caustic has subsided, it is desirable to keep the glans un- covered in order to harden the internal layer of the prepuce by exposure to the air and friction; and, unless the preputial orifice is very narrow, this may generally be accomplished by wearing for a few days a narrow bandage round the penis posterior to the glans. Special attention should also be paid to removing any collection of the smegma prseputii, and keeping the parts perfectly clean. The nitric acid acts so favorably, that I have seldom resorted to other caustics, with the exception of chromic acid, which has come into favor within a few years. A solution of this acid (one hun- dred grains to the ounce of water) is a powerful escharotic, and is especially useful in those obstinate cases in which the vegetation repeatedly returns after removal; but it should be applied with TREATMENT. 221 caution, simply moistening the surface of the morbid growth and * sparing the healthy tissues in the neighborhood, or otherwise it is apt to induce severe pain and inflammation. I have sometimes employed a mixture of equal parts of dilute muriatic acid and tincture of the chloride of iron, which is one of the best escharotics for warts upon the hands in children. Vegetations about the vulva may be treated in the same way as those upon the prepuce. When situated around the margin of the anus, they are generally of considerable size, and require to be snip- ped off wrfli scissors before the application of acid to the base. Vegetations during pregnancy may appear at quite an early period; they grow very rapidly, and often attain an immense size. I have seen a mass as large as a man's arm, extending from the mons veneris to the sacrum, and surrounding the vulva and anus. During gestation no operative procedure is admissible; but the pain, itching, and offensive odor may be palliated by careful atten- tion to cleanliness and lotions of diluted Labarraque's solution, or the application of some astringent powder, as equal parts of savin and burnt alum. After delivery, they often disappear spontaneously or may be removed by the knife or caustic; but when the mass is very large, only a portion should be attacked at a time. Vegetations situated upon a chancre or mucous patch cannot always be distinguished from those upon the sound integument; but the history of the case, and, especially, the coexisting symp- toms, will determine whether mercury is required to combat syphi- litic infection of the general system. 222 STRICTURE OF THE URETHRA. CHAPTER. XIII. STRICTURE OF THE URETHRA. Having considered the complications of gonorrhoea, it remains to speak of one of the most frequent and important results of the same disease, urethral stricture. ANATOMICAL CONSIDERATIONS. An acquaintance with the anatomy of the urethra—including the character of its lining membrane, the fibrous, muscular, elastic, and erectile tissues which surround it, its dimensions and direction—is essential to a proper appreciation of the pathology of stricture and the skilful execution of operative procedures requisite in its treat- ment. The male urethra is naturally divided into three portions, viz., the prostatic, membranous, and spongy. The prostatic urethra is the portion included in the prostate gland, and generally, but not always, traverses this body at the union of its middle and upper thirds. Its length in the adult is about one inch and a quarter; its posterior boundary is a promi- nence of the mucous membrane, called the uvula vesicae; its cavity is fusiform, largest in the centre and somewhat contracted towards either extremity. Upon its floor, a short distance in front of the uvula, is an abrupt elevation of the mucous membrane and subja- cent tissue, which forms a ridge three-fourths of an inch in length, and which gradually subsides as it approaches the membranous urethra. This prominence is known as the veru montanum, crista urethrse, or caput gallinaginis. It contains erectile tissue, connected with that of the corpus spongiosum, and is adapted to assist in the closure of the urethra at this point, and prevent the passage back- wards of the semen during coitus. Directly in front of the summit of the veru montanum, is a small sac or pouch, three or four lines ANATOMICAL CONSIDERATIONS. 223 Fig. 4. in depth, which is called the " sinus pocularis," and also, from its probable homology to the womb, the "uterus masculinus."1 The ejaculatory ducts traverse the walls of this cavity and open upon its margin. On each side of the veru is a depression called the "prostatic sinus," in which are found the orifices of the prostatic ducts, from twenty to thirty in number. The membranous urethra ex- tends from the apex of the pros- tate to the bulb, and is nearly or wholly included within the two layers of the deep perineal fascia. It is about three-fourths of an inch in length on its upper, but is shorter on its lower surface, owing to the encroachment of the bulb upon the latter. It is narrower than any other part of the urethra, except the meatus, and in consequence of the greater development and number of mus- cular tissues surrounding it, pos- sesses in a higher degree the power of contraction. This cha- racteristic has led some authors to give it the name of the " mus- cular region" of the urethra. The spongy urethra, inclosed in the erectile tissue of the corpus spongiosum, varies in length ac- cording to the degree of tumes- cence of the penis; in a state of relaxation, it usually measures about five inches; during erec- tion, it may attain seven or eight. rm , . .. n ,, . The bladder and urethra laid open. The posterior portion Of thlS from above. (After Geat.) C»«y«'/* Clanil Ort??fe allowed to project « 1 " Dilatation permanente" of the French. 288 STRICTURE OF THE URETHRA. into the bladder sufficiently to injure the vesical coats; its external orifice should be connected with a urinal or fitted with a plug which can be removed whenever a desire is felt to urinate, and the patient should be confined to the bed. Considerable pain and other un- pleasant symptoms are often experienced within a few hours, but unless these be severe the catheter should not be withdrawn, and the object in view be thereby defeated. The strength should be sup- ported by nutritious diet or even stimulants; pain may be allevi- ated by opiates given by the mouth, or preferably, in the form of suppositories, and rigors may be met by hot applications to the surface, and opium internally. The occurrence of fits of shivering for the first time after the catheter has remained in for several hours, or the appearance of considerable blood in the urine, are indications that the instrument should be at once withdrawn, and treatment suspended for a few days.1 In most cases, the catheter may be retained for twenty-four to forty-eight hours, not longer, lest it become incrusted with calculous deposit, or ulceration of the urethral walls be induced; the patient is then allowed to rest for a day or two, and a larger one inserted. After several such applications, the urethra will generally be suffi- ciently dilated to admit a No. 8 or 10 instrument without difficulty, but the treatment must not be allowed to rest here; there still remains a strong tendency to contraction, which must be overcome by frequent catheterism repeated at first every day or two, and subsequently at increasing intervals, as after gradual dilatation; by this means only can it be hoped to maintain the ground already gained, and to effect the removal of the contractile material which induces relapse. Rapid Dilatation.—Continuous dilatation above described, is also in a measure rapid, but it accomplishes its object indirectly, while the methods we are now briefly to consider aim directly at the speedy enlargement of the passage. It is to be distinctly under- stood at the outset that these methods are not recommended for general adoption; indeed they would not be referred to at all in the limited space we have allotted to this subject, were it not for a few exceptional cases in which it is believed they may prove of value. Even in gradual dilatation, if the surgeon attempt to advance too speedily so much irritation and pain are often excited that it becomes 1 Thompson, op. cit., p. 193. RAPID DILATATION.. 289 necessary to suspend the use of instruments for some days ; and to the treatment of no class of diseases is the motto " Festina lente" more applicable than to strictures. In addition to the arguments drawn from the pathology of stricture in favor of gentle and gra- dual dilatation, it should be recollected that haste and violence must necessarily induce inflammation, which will surely be followed by additional plastic deposit and increased contraction. "Violent measures of all kinds, though justifiable in rare instances for the relief of certain urgent symptoms, yet when applied for the cure of the stricture itself, are both unscientific and unworthy of the commendation which has been bestowed upon them. Rapid dilatation may be effected by means of conical sounds or bougies, the small extremity of which is introduced within the stricture and advanced by gentle but steadily continued pressure until the shaft, which is several sizes larger than the point, is fairly inserted; the instrument may then be allowed to remain for several hours, and a larger one substituted for it. This method may some- times be adopted when time is of paramount importance, but its liability to do injury should constantly be borne in mind, and the utmost caution observed. Several instruments invented for rapid FiS«18< dilatation are constructed upon the com- mon principle of a series of tubes varying in diameter, which slide one upon another. In the instrument of Mr. Thomas Wakley, a No. 1 silver catheter is employed as a guide, which is first introduced into the bladder, and the tubes passed in succes- sion over it. When the desired degree of dilatation has been accomplished at any one session, a flexible catheter may be inserted in place of the largest silver tube which has been used, and, the con- ductor having been withdrawn, be retained until the next visit. From the strong tes- timony adduced by Mr. Wakley in favor of his method, it would appear to be well worthy a trial in some cases. In the instrument invented by Dr. Buchanan, of Glasgow, the sliding tubes and a central conducting wire are united into a "com- 19 290 STRICTURE OF THE URETHRA. Fig. 19. pound catheter" (Fig. 18), which is first introduced as far as the ob- struction, when the guide is pushed on through it together with as many of the tubes as will effect the desired degree of dilatation. It is stated by Mr. Thompson that this instrument has been claimed as a modern invention in London within the last few years, and such has also been the case in this neighborhood. M. Maisonneuve has invented an ingenious method of treatment which he calls "catheterisme h la suite." A very slender and flexible bougie, well adapted to pass the longest and most tortuous strictures, serves as a pio- neer; when once this is introduced, various instru- ments may be screwed to its external extremity and passed through the obstruction, following the bougie as a guide, the flexibility of the latter permitting it to be coiled up in the bladder as fast as it enters this cavity. If, for instance, it is desired to draw off the urine, a hollow bougie with an eye upon its side is screwed to the conductor and passed into the bladder, while larger bougies or a urethrotome may be attached for the purposes of dilatation or internal incision.1 The guide is left in the urethra from one visit to another, so that there is no necessity for repeated introduction. Although this method is beautiful in theory, it can- not be said to have been fully tested in practice. It would appear probable that it may occasionally prove of value, especially in narrow strictures complicated with retention, when it is impossible to introduce any instrument but a filiform, flexible bougie, too small to draw off the urine; and when otherwise it would be necessary to puncture the bladder. Expansion.—Attempts have been made to expand strictures:— 1. By instruments made of some porous material which will dilate when moistened by the urethral secretions. Thus, bougies of "flexible ivory," or ivory deprived of its calcareous matter by immer- A. Filiform bou- gie. B. Flexible catheter with an opening upon the Bide, screwed to the former. # ' A catheter armed at the point with a bougie was employed for the relief of retention of urine by Dr. Physick, of Philadelphia, as early as 1796. Thompson's probe-pointed catheter is a modification of the same instrument. RUPTURE- CAUSTICS. 291 sion in a weak acid, have been used for this purpose by the French • bougies of slippery elm by Dr. Wm. A. McDowell,1 formerly of Downesville, and Prof. Nathan Smith, of Baltimore; and compressed sponge by Dr. Alquie",2 of Montpelier, and Dr. Batchelder,3 of this city. These attempts have not as yet, so far as I am aware, at- tained any satisfactory result, and in a trial of bougies of flexible ivory made by Ricord, the portion of the instrument which was introduced beyond the stricture dilated to such an extent that it was almost impossible to withdraw it, and the necessity of external incision became imminent. 2. By sacs of oiled silk, gold-beater's skin, or other impervious material, which may be introduced through the stricture by means of a stylet, and afterwards dilated with air or fluid, as proposed by Ducamp, and Dr. James Arnott.4 3. By various instruments with expanding blades. The employment of all these methods has been chiefly confined to their inventors, and cannot be recommended as superior or even equal to other modes of dilatation. Rupture.—Still less can be said in favor of the forcible rupture of strictures, which is accomplished by instruments with expanding blades; although Mr. Thompson, from the observation of six cases in the practice of Mr. Holt, states that this violent proceeding was productive of less unpleasant consequences than might have been expected on d priori grounds; the ultimate effect upon the stric- ture is not stated. Caustics.—Caustics, at times extolled as. the most efficient means of treating stricture, and at other times decried as useless and in the highest degree dangerous, have succeeded in maintaining a favorable position in the general estimation of the profession; not, however, as an exclusive mode of practice, but as an adjunct to dilatation. It should be observed that these two methods are inseparable, even when not, as is usually the case, intentionally combined; since the instruments employed in the application of caustics must necessarily distend the canal like bougies or sounds. 1 Gross, op. cit., p. 778. * Gazette des Hopitaux, 24 Juin, 1854, p. 300. 3 New York Journal of Medicine, May, 1859. 4 Stricture of the Urethra, London, 1819. 292 stricture of the urethra. This fact renders it somewhat difficult, in any case of successful treatment in which these remedies have been employed, to deter- mine what proportion of the credit is due to them and what to dilatation; but the general impression upon the minds of those who have given them a fair trial is sufficient to warrant the favora- ble opinion above expressed; which is founded not only upon the testimony of the warm advocates of this mode of treatment, Messrs. Whately and Wade, but also upon that of Mr. Henry Smith, Mr. Thompson, several personal friends in this city, in whose judgment I place the highest confidence, and my own ex- perience. It is necessary, however, to define with greater minuteness the position which caustics are believed to hold; and this may be done in the following terms:— 1. They are not to be used as escharotics for the purpose of destroying the plastic material which constitutes strictures; hence of these agents the milder forms should be preferred, or the stronger caustics should be employed in small quantities only. 2. They are especially adapted to cases of irritable stricture, in which they diminish sensibility and spasm, and permit of the freer use of dilatation; 3. To cases in which there is a strong disposition to hemorrhage, in which they control the vascularity of the part; and 4. To some cases of tough and fibrous contractions, in which they appear to assist dilatation by exciting absorption. The chief caustics employed in the treatment of stricture are nitrate of silver and caustic potash; to the former of which my own experience has for the .most part been confined. The mode of application is exceedingly simple. A depression is to be made in the extremity of a wax bougie, in which a small fragment of the solid nitrate is deposited, and the adjacent substance pressed around it, so as partially to overlap it and retain it in place. The instru- ment is then to be oiled, passed rapidly down to the anterior face of the stricture, or, if possible, within it, retained in position from one to two minutes, and then withdrawn. In the course of three or four days, a plug of coagulated mucus and epithelium may often be detected in the urine, the pain of micturition is lessened, and, on farther trial of dilatation—which should never be omitted—the sensibility of the canal is found to be much diminished. If the passage be of sufficient size, caustic may be applied to the interior CAUSTICS. 293 Fig. 20. 7 of the stricture by means of Lallemand's porte-caustique, or, better still, with the instrument devised by Leroy D'Etiolles, which is free from an objection to which the former is liable, viz., that of being forcibly retained by the spas- modic action excited by the application. The use of potassa fusa in the treatment of urethral stricture was first adopted and recom- mended by Mr. Whately,1 who employed a very small quantity, not exceeding one-twelfth of a grain in weight, nor in size " a common pin's head," and only in case a bougie at least a size larger than the finest could be passed into the bladder; that retention, if caused by the treat- ment, might be relieved by the passage of a catheter. A freer use of potassa fusa in imper- meable as well as permeable stricture has since been advocated by Mr. Wade,2 whose views, founded upon an experience of thirty years and supported by the details of a large number of successful cases, entitle this agent to a more extended trial than has yet been given it; for, although occasionally mentioned with approval by various writers, and among others by our countryman, Dr. Gross,3 it has not gene- rally met with much favor, and has been re- garded as too powerful and unsafe to be ex- perimented with. Mr. Wade not only believes it as harmless as nitrate of silver, when used with proper caution, but that it possesses powers far superior; that it is especially indicated in irritable and unyielding strictures, which of late years have been treated by incision; and that it is calculated to supplant urethrotomy altogether, or to confine it to a very few exceptional cases. The following extracts from his work will still farther explain his views, and his mode of practice:— " The caustic potash may be advantageously applied to strictures for two purposes: one to allay irritation, the other to destroy the a h Leroy D'Etiolles' instru- ment for "lateral retro- grade cauterization." (Af- ter Morland.) 1 An Improved Method of Treating Strictures in the Urethra. London, 1804. 8 Stricture of the Urethra, 4th edition, London, 1860, pp. 92-155. 3 Op. cit., p. 7b8. 294 STRICTURE OF THE URETHRA. thickened tissue which forms the obstruction. When used in the minute quantity employed by Mr. Whately, I believe its action to be simply that of allaying irritation, as, when mixed with lard and oil, combined with the mucus of the urethra, it can scarcely have any effect beyond a mild solution of caustic, which most probably causes a more healthy state of the lining membrane of the stric- ture. Before using the potash, a bougie should be passed down to the stricture, that its distance from the orifice of the urethra may be ascertained. A small piece of the caustic, about the size of a common pin's head to commence with, should be inserted into a hole made in the point of a soft bougie. The caustic should be broken just before it is required, and the inner or dark part se- lected, as the outer portion is usually less efficient, as it is com- monly converted into a whitish crust of carbonate of potash. Two notches should be made in the armed bougie, one marking the exact distance of the stricture; the other, an inch beyond; so that its progress, as it enters the obstruction, may be accurately ob- served. The bougie should be moulded with the finger round the potassa fusa, so that it may be securely fixed; but to insure the action of the caustic, instead of being below the level of the hole, as recommended by Mr. Whately, its points should be fairly ex- posed to enable it to act upon the stricture. " The armed bougie should, of course, be well oiled before its introduction; and if the points of the caustic be well covered with lard, there need be no fear of its acting before it reaches the stric- ture. The bougie should be gently pressed against the stricture for a minute or two. if impermeable, and then withdrawn. When the caustic is applied to permeable obstructions, the bougie should be passed three or four times over the whole surface of the stric- ture. To impermeable strictures, the caustic should be applied with greater caution than to such as are permeable; for should reten- tion of urine occur, it will be more easily relieved in the latter than in the former. It usually happens that, after one or two ap- plications of the caustic, the bougie will be found to enter the obstruction. Before applying potassa fusa to impermeable stric- tures, every precaution should be taken to guard against irritation. If convenient, the application may be made at bedtime, taking care that the patient passes his urine just before; and should he have been subject to rigors or retention, it will be best to administer an opiate injection an hour previous to the operation. INCISIONS. 295 " It appears to me, that the principal superiority of this caustic to the nitrate of silver, consists in its more powerful solvent effect in removing hard strictures, and that with perfect safety and com- paratively with but little pain. Potassa fusa, when used for the destruction of a stricture, instead of causing a solid slough, appears to exert its salutary effects by a process of inflammatory softening and dissolution of the thickened tissue forming the obstruction. " The periods at which it will be most advisable to repeat the application of the potassa fusa must depend upon its effects, and the nature of the cases in which it is used. In many old chronic strictures, I have used the potash advantageously every second or third day; and in some few instances, under peculiar circumstances, even oftener. When a stricture has been so far removed by the application of potassa fusa as to admit the introduction of a middle- sized bougie, it will be best to discontinue the use of the caustic, unless there should be difficulty in its subsequent dilatation, when an occasional application of the remedy will often be found service- able." Incisions.—It is often asserted that when any instrument what- ever can be passed through a stricture, dilatation is all-sufficient, and that it is never necessary to resort to cutting instruments; but although this statement is applicable to the majority of urethral contractions, it is not universally true; for strictures are occasion- ally met with which are so unyielding that dilatation has little if any power over them; or so irritable, that attempts at catheterism can only be made at long intervals; or so resilient, that relapses constantly occur. Cases presenting these characteristics constitute one class of strictures, in which urethrotomy may often be employed with decided benefit; another class includes certain impassable strictures, and those complicated with false passages. The question is sometimes asked: " How can incisions effect any permanent good in cases of stricture ? None of the adventitious deposit is removed by urethrotomy: the lips of the wound must eventually unite, and the condition of the parts as before the operation be restored: why expect any. more benefit than from simple incision of the bands of cicatricial tissue following burns, which are notoriously incurable by such a procedure?" The comparison is a good one, and may serve to show how far the power of urethrotomy extends. It is indeed true that unassisted by other 296 STRICTURE OF THE URETHRA. measures, it can ultimately add nothing to the calibre of the pas- sage, and is, therefore, alone incapable of effecting a permanent cure; but, by giving free exit to the urine for the time being, it affords a period of rest; the bladder recovers its tone; congestion and spasm are relieved; the vascularity of the part is decreased, and spontaneous absorption of a portion of the more recent deposit takes place. In this manner, great, though temporary, relief is obtained; but the opportunity is afforded for accomplishing still more. Instrumental dilatation may now be practised under the most favorable circumstances; much of the adventitious material of the stricture may be removed by thus exciting absorption, or, when this is too firmly organized to admit of resolution, the recent fibrinous deposit, which, as in other parts of the body, takes place between the edges of incisions not united by first intention, may be mechanically dilated by the occasional passage of an in- strument ; the disease is thus kept in abeyance, and comparative comfort afforded. In the view here taken, urethrotomy is regarded as the pioneer of dilatation, the companionship of the latter being essential to give permanency to any good result; and though much more than this has been claimed for this operation, such I believe to be its true office. Incisions may be internal, or from within; external, or from without; in the former, but little more than the substance of the stricture itself is incised ; in the latter, the whole thickness of the tissues between the canal and the surface is divided. Internal Division.—Internal incisions should rarely be prac- tised except for strictures in front of or within the scrotum, or, in other words, in the straight portion of the urethra; when division is required for strictures situated in the sub-pubic curve, external urethrotomy is generally to be preferred as safer and more satis- factory in its results. Non-dilatability, irritability, and resiliency, are the chief conditions which require internal incisions, and these are more frequently met with in strictures of the spongy than any other portion of the urethra. They are most marked in contrac- tions at the meatus, which can very rarely, if ever, be treated suc- cessfully by dilatation; but they also affect, to a less degree, those which are situated within three or four inches of the external ori- fice, and to this portion of the urethra, in the opinion of most sur- geons of the present day, should internal urethrotomy be confined. internal division. 297 Internal incisions should also be restricted to cases in which the whole thickness of the stricture can be completely divided by a cut of moderate depth; the danger of hemorrhage and of infiltra- tion of pus and urine from deep intra-urethral incisions is too great to admit of the internal division of thick masses of induration, which are more safely treated by external urethrotomy. The dis- tance between the point of the blade when fully projected, and the back of the instrument should rarely exceed four-tenths of an inch, which is the extent of the projection in Civiale's urethrotome, and in that of Mr. Thompson it is even less. A great variety of instruments have been proposed for internal incisions, some of which are intended to cut from before backwards by means of a projecting blade, which either has or has not a rod in front of it as a guide; while others are designed to be passed through the stricture and then withdrawn, cutting from behind for- wards ; they are either straight or curved to correspond with the portion of the canal in which they are intended to be used. Urethrotomy from before backwards without a guide should never be performed except in the spongy portion of the urethra, and then only to prepare the way for the introduction of other instruments. In the deeper portions of the urethra it is highly dangerous, since the direction of the incision cannot be determined with accuracy, important parts may be wounded, or an outlet formed for the escape and extravasation of urine. Internal divi- sion from behind forwards should in all cases be preferred, both because it is safer, and because the edges of the cut are smoother and less jagged than when made in the opposite direction. Of the many urethrotomes which have been invented, Civiale's instrument, figured in the adjoining cut, is probably the best. It is designed to pass through the stricture, and divide it during its withdrawal, after the blade has been made to project. The termi- nal bulb, in which the blade is concealed, equals in diameter a No. 5 catheter, and hence the instrument cannot be employed when the passage is of less size; for such cases, Mr. Thompson's urethro- tome, which is a modification of Civiale's, and the bulb of which docs not exceed No. 2| or 3, is admirably adapted.1 1 The Value of Internal Incisions in the Treatment of Obstinate Strictures of the Urethra, London Lancet, Am. ed., Jan. 1860. Many practical suggestions con- tained in this section have been derived from this valuable paper, to which the reader is referred. 298 STRICTURE OF THE URETHRA. The bulb at the extremity of the instrument will serve to deter- mine the extent of the stricture; and the incision, implicating the Fig. 21. . use™ r o ' when the passage is much recommended its adoption in a large contracted, and which -, . .i • • n ,i „ „ „p may be detached and the —and, in the opinion of the mass of p(/t B screwed on the profession, an unjustifiable— proportion of urethral contractions. Since this time, perineal section upon a guide has been called "Syme's operation," or Charriere's u r e t h r o - La nee tt ed catheter. (Af- ter Gross.) 1 Stricture of the Urethra, Edin., 1849, p. 58. 300 STRICTURE OF THE URETHRA. "perineal division," while the names "boutonniere operation," "perineal section," and "external urethrotomy," have been restricted to the same operation without a guide. While acknowledging the Fig. 27. (After Phillips.) credit due to Mr. Syme for having carefully studied the various steps of this operation, and for the introduction of certain improve- ments in the manner of its performance, it is yet difficult to explain on what grounds this innovation in name has been made; for, should Civiale's statement be called in question, that a staff was employed by Tolet two centuries ago, it is certain that one was frequently used by many operators, both abroad and in this country, long before the appearance of Mr. Syme's essay; and, waiving the question of priority, the difference in the two methods is not sufficient to warrant the proposed distinction, which will be ignored in the present volume as it has been by many other writers.1 1 With reference to the history of external urethrotomy, see an interesting article entitled: " Note historique et critique sur I'urethrotomie externe ou section des retrecissements de dehors en dedans, avant le 18c siecle," by Dr. Verneuil, in the Archives Generates de Med., Sept. 1857. PERINEAL SECTION. 301 Perineal section was adopted in America in the early part of the present century, and, for the last forty or fifty years, has been the favorite mode of treatment for advanced cases of stricture which could not be benefited by other means. In the registry of cases in the New York Hospital, which was at first so meagrely kept, that vol. i. extends from 1808 to 1831, I find a record of its performance, Aug. 30, 1811, upon James Waram, for the relief of a stricture "nearly three inches in length;" the name of the ope- rator not given, but probably Dr. N. Seaman. Nothing is said which would lead to the supposition that the operation was re- garded as unusual or novel at that time, and according to the testimony of several of our older surgeons, among whom I would mention the venerable Dr. Alexander H. Stevens, it was frequently adopted prior to 1820. Dr. II. G. Jameson, Surgeon to the Baltimore Hospital, published a valuable paper on perineal section in the American Medical Re- corder, for 1824.1 His first successful operation was performed Dec. 2, 1820, and its conception appears to have been original with him, for he speaks of it as " an operation which I had long pro- jected, but which I felt unwilling to hazard without some prece- dent." At the close of his paper he gives the following summary: "I have reported ten cases in which I opened the urethra, and thereby cured the most deplorable strictures, and one case attended with a relapse, in which mortification took place, and yet the pa- tient recovered; making of course eleven successful cases. Among these cases there have been four of mortification of the scrotum, one accompanied with fistula in the perineum, two in which the urethra was opened both through the penis and the perineum. And it is further to be understood, that no unfortunate cases have been concealed, and that from the time I commenced my operations upon the urethra, I have not lost a single patient." Dr. Jameson expresses the opinion that, in all cases of retention of urine, peri- neal section should be substituted for puncture of the bladder. Dr. Edward Hartshorne, writing in 1855, speaks of perineal section as an " operation which has long been a familiar one in Philadel- phia."'8 But in no place in America has there been a greater, nor, it is ' Vol. vii. p. 251. 2 Review of Thompson on Stricture, Am. Journ. of the Med. Sci., July, 1855. 302 STRICTURE OF THE URETHRA. believed, so great an opportunity for studying the performance and the results of perineal section as in New York, where this operation, for the last forty or fifty years, may be said to have been identified with the City Hospital and the surgeons connected with this institution. This fact is one of common notoriety, and is at- tested by the elder men of the profession in this neighborhood; though it is to be regretted that this field for observation has not been made more productive to science by the publication of the valuable material which might here have been gathered by men so well qualified for the task. An honorable exception to this general neglect is to be found in two papers by Dr. Lente, Surgeon to the West Point Foundry, formerly House Surgeon of the New York Hospital, the first of which, entitled " Surgical Statistics of the New York Hospital," was published in the Transactions of the American Medical Association, vol. iv. 1851; and the second, on " Perineal Section for Stricture of the Urethra," in the New York Journal of Medicine, March, 1855. Dr. Lente gives a tabular state- ment of twenty-seven cases of perineal section, most of which occurred during his three years' residence as house surgeon at the hospital, and of which number three died, six were relieved, and eighteen were cured. " In most, if not all of the cases, the opera- tion was regarded as the only means of effecting a cure, all other means having failed; and, in many instances, it was necessary, not only for the purpose of rendering the patient's life more comfort- able, but for saving it." The principles which should determine the surgeon in deciding upon perineal section, may be stated as follows:— 1. It should not be regarded as applicable to any considerable proportion of the whole number of strictures, but be reserved for exceptional cases, in which milder means have failed. 2. It should not be employed in a low state of the vital powers, nor when extensive disease of the kidneys is present, since, under these circumstances, the danger of a fatal result is materially in- creased. 3. It is advisable in impassable, unyielding, highly irritable or resilient strictures, which have proved incurable under a thorough and persevering trial of dilatation. The presence of false passages is an additional inducement for its performance, since the abnormal channel may be cured at the same time that the stricture is re- lieved. PERINEAL SECTION. 303 4. It is justifiable in some cases of retention of urine dependent upon stricture, although in most instances puncture of the bladder is to be preferred. It is highly desirable that the patient should be prepared for the operation by a period of rest, during which he should be confined to the house, and, for the most part, to the horizontal posture, his secretions be regulated, and his system placed in as favorable a condition as possible. The perineum should be shaved, and the rectum evacuated by an enema. The stricture may present three degrees of contraction; it may be entirely impervious to any in- strument ; it may admit a fine elastic bougie; it may be possible to introduce a grooved sound. In the first case, a catheter of full size is required for insertion in the urethra; in the second, the largest possible bougie should be passed into the bladder and a metallic tube, open at the extremity, introduced upon it as a guide as far as the obstruction; in the third, the staff employed by Mr. Syme, and which will presently be described, is very serviceable, although a similar combination of a sound and catheter, as in the last case, will answer every purpose. The patient, having been brought under the influence of an anaes- thetic, is placed upon the edge of a table, facing a good light, in the position for lithotomy, with the hands bound to the feet by bandages, and an assistant supporting each knee. The assistant on his left takes charge of the instrument introduced into the ure- thra, and elevates the scrotum out of the way of the operator; the metallic sound or catheter is to be pressed firmly against the#ob- struction in such a manner as to render its extremity somewhat prominent. The surgeon, sitting upon a low stool, makes an inci- sion, an inch and a half or two inches in length, exactly in the median line of the perineum, and dividing the tissues by successive strokes of the scalpel, opens the urethra upon the extremity of the instrument in front of the obstruction; and here it is to be observed that it is better to extend the incision upwards a short distance above the extreme point of the catheter, in order to insure the com- plete division of the stricture in this direction. The urethra having been opened, the facility of completing the operation will depend very much upon whether a guide has been, or can be, passed through the contraction. When a bougie or staff has been introduced into the bladder at the commencement, the division of the stricture upon it is comparatively easy. If this was 304 STRICTURE OF THE URETHRA. found impossible, the next undertaking is to endeavor to pass an instrument through the perineal opening. For this purpose, the edges of the incision should be held apart by the fingers of assist- ants, or by means of hooks, or, as proposed by Mr. Avery, a liga- ture may be passed through the urethral mucous membrane on either side, in order to afford a clearer field of view, and indicate the position of the channel; and the blood should be removed by constant sponging. The most desirable instrument to insert is a grooved director; if this cannot be passed, a fine, flexible bougie, or even a bristle, may be tried. Considerable time, patience, and perseverance are required in this part of the operation, which often occupies from fifteen to thirty minutes, but in most cases, one of the above instruments may eventually be passed. Dr. Gurdon Buck, whose experience in perineal section has been extensive, informs me that he has never met with a case of failure, but I have known other surgeons to be less fortunate. If success be attained, the stricture should be divided from below upwards,1 taking care to in- clude its whole extent, but avoiding making the incision so far back- wards as unnecessarily to wound the deep perineal fascia, whereby the danger of extravasation of urine would be increased. Mr. Syme states positively that he has " never found it necessary to cut farther back than the bulbous portion, for the conveyance of a full- sized instrument into the bladder," and that he has never met with a contraction situated posteriorly to this point; but that strictures do exist in the membranous portion, there can be no question, although' Mr. Syme's statement is probably nearer the truth than has sometimes been admitted, since the universal tendency has been to assign a seat posterior to the true one, and the oblique direction of the perineal fascia which shortens the inferior aspect of the membranous region is liable to lead into this error. While, there- fore, we cannot always expect to avoid opening the deep perineal fascia, it should be guarded against, if possible, and need not fre- quently occur. In some cases, as already intimated, it is found impossible to introduce any guide whatever through the obstruction. It then becomes necessary to search for the urethra posterior to the stric- ture, by carefully dividing the tissues in the median line; if a 1 Lest, if made in the opposite direction, the knife, after severing the stricture and ceasing to meet with resistance from the mass of induration, unnecessarily wound the deeper tissues. PERINEAL SECTION. 305 fluctuating point be felt, it is probably the dilated urethra, and should be opened. It is evident that under these circumstances it must often be impossible to trace the contracted and thread-like passage through the intervening mass of induration; and much time need not be expended in the attempt, if it be not readily found; since the new channel opened by the knife has, in nu- merous instances, supplied the place of the original canal in a very satisfactory manner. A free passage having been opened into the bladder, a full-sized catheter should be introduced from the meatus and retained. When a bougie and sliding tube were passed at the commence- ment of the operation, the latter is readily pushed on to the blad- der upon the former as a guide. Otherwise some difficulty may be experienced in introducing the catheter, the point of which is liable to protrude through the perineal opening, and should be guided in the proper direction upon a broad director first inserted through the incision. After the introduction of the catheter, it should be ascertained if it be freely movable ill the canal; if it is felt to be "held," some fibres of the stricture probably remain uncut, and should at once be incised; since their complete division is essential to the success of the operation. The catheter is retained by means of a bandage around the waist, to which two perineal straps are attached before and behind, and the rings of the instru- ment are connected with the latter by threads. The catheter should not be inserted so far that its point will press against the mucous membrane of the bladder. It is better that its external extremity should not be closed, but be connected with a urinal by means of an India-rubber tube, in order that the urine may find free exit and less escape through the wound. The patient should now be put to bed with the thighs elevated and the bedclothes supported by a cradle. Pain may be relieved by suppositories of opium. Subsequent hemorrhage sometimes occurs which it is difficult to arrest by ligature, since the thread does not retain a • firm hold upon the gristly tissue of the stricture; it may, however, be effectually controlled by inserting a piece of compressed sponge between the edges of the wound, or firmly plugging it with lint, and bandaging the thighs together. The catheter may be allowed to remain two or three days, but never more than four, unless in rare instances, when an elastic 20 306 STRICTURE OF THE URETHRA. should be substituted for the metallic instrument, or the former may be employed from the first. This rule is an important one. The danger of prolonged retention lies in the liability to produce ulceration of the mucous membrane and subjacent tissues in con- sequence of pressure of the instrument. This most frequently occurs at two points: one, that portion of the vesical walls which comes in contact with the extremity of the catheter; the other, the lower surface of the urethra just in advance of the scrotum, at the commencement of the sub-pubic curve, where the penis is upheld by the suspensory ligament, and where any straight in- strument, like the shaft of a catheter, necessarily presses upon the inferior wall of the canal. A number of cases illustrating these ill effects have been exhibited at various medical associations of this city within a few years. In one instance death occurred after the catheter had been retained a fortnight, and at the post-mortem examination there was found a small but deep ulceration of the bladder, and another, quite extensive, of the inferior wall of the urethra in front of the scrotum, which was only separated from • the surface by the integument. A few years since a man, who had been operated upon by perineal section in California, and in whom a silver catheter had been retained for three weeks, applied to a surgeon of this city for the relief of urinary fistula at the angle between the penis and scrotum, consequent upon this prolonged retention. The injurious effects of such ulceration must be more than local; in subjects so debilitated as patients with stricture often are, they must contribute to the fatal result which sometimes ensues. The idea sometimes advanced that perineal section is alone suffi- cient for the cure of stricture, is, with a few very rare exceptions, unquestionably erroneous. Unless catheterism be subsequently practised as after other modes of treatment, a relapse is almost sure to occur. I have been impressed with this fact in conversing upon the operation with different surgeons; having found that those who did not resort to the subsequent passage of instruments were inva- ' riably disappointed, while those who did, were as constantly pleased with the results. One gentleman, who has performed it in nine cases, but who has never followed up the treatment with repeated catheterism, tells me that in every instance the disease has returned with its original severity. In this city this principle is well un- derstood ; dilatation is usually commenced the day following the PERINEAL SECTION. 307 withdrawal of the catheter, and is repeated every twenty-four hours, the instrument being left in about half an hour on each occasion. By the time the peri- neal wound is healed the patient may be taught to pass a catheter upon himself and be dis- missed, impressed with the importance of con- tinuing it for a long period. When an entirely new passage for the urine has been opened, or when the stricture was extensive and firm, direc- tions should be given to pass an instrument daily, either just before going to bed or early in the morning, and leave it in the urethra half an hour; this is to be continued for at least six months, after which period catheterism is to be repeated at gradually increasing intervals for several years. Unless these directions are faithfully carried out no one need expect the slightest permanent benefit from perineal section. When perineal section is followed by a fatal termination, it is in most cases due to pyaemia; sometimes to urethral fever, attended or not with suppression of urine; and at other times to hospital gangrene, erysipelas, or urinary in- filtration. A large proportion of the deaths have occurred in hospitals; in private practice, perineal section is found to be a comparatively safe operation, especially if confined, as it in- variably should be, to patients endowed with that amount of vigor which is always requisite when the knife is to be used. In performing "external division," Mr. Syme employs a staff with a slender grooved extremity, which equals in diameter No. 1 or 2 of the catheter scale, and is intended to pass through the stricture; while the main shaft, corresponding in size to No. 8, unites abruptly with the former, and is arrested at the anterior edge of the stricture (Fig. 28). Mr. Thompson uses a similar instru- ment, but "constructed with a hollow throughout, by which the urine issuing when it arrives at the bladder, the operator knows that the slender point is in its proper place, a satisfactory assurance fl 308 STRICTURE OF THE URETHRA. when false passages exist, and render the right route rather diffi- cult of access." Mr. Syme gives the following directions respecting the mode of performing the operation: " The patient should be brought to the edge of his bed, and have his limbs supported by two assis- tants, one of them standing on each side. A grooved director, slightly curved, and small enough to pass readily through the stricture, is next introduced and confided to one of the assistants. Fig. 29. (After Thompson.) The surgeon, sitting or kneeling on one knee, now makes an inci- sion in the middle line of the perineum or penis, wherever the stricture is seated. It should be about an inch or an inch and a half in length, and extend through the integuments, together with the subjacent textures adjacent to the urethra. The operator then taking the handle of the director in his left, and the knife, which should be a small straight bistoury, in his right hand, feels, with his forefinger guarding the blade, for the director, and pushes the point into the groove behind, or on the bladder side of the stric- ture (Fig. 29), runs the knife forwards, so as to divide the whole of PERINEAL SECTION. 309 the thickened texture at the contracted part of the canal, and with- draws the director. Finally a No. 7 or 8 silver catheter is intro- duced into the bladder, and retained by a suitable arrangement of tapes, with a plug to prevent trouble from discharge of urine.1 The process having been thus completed, the patient has merely to remain quietly in bed for forty-eight hours, when the catheter should be withdrawn and all restraint removed." In a clinical lecture, published in the London Lancet (Am. ed.), Nov. 1848, Mr. Syme recommends that a catheter through the ure- thra should be entirely dispensed with after perineal section, and that a short tube through the perineal incision should be substituted for it, the better to protect the edges of the wound from contact with the urine, which appears to be the exciting cause of the rigors, vomiting, rapid pulse, and delirium, which, known as "urethral fever," sometimes follow this operation. The short catheter recom- mended by Mr. Syme, "is about nine inches in length, slightly curved in opposite directions at its extremities, and having a couple of rings just behind the anterior bend for securing it in its place. In addition to the great advantage of affording perfect secu- rity, this catheter is much less irksome to the patient than the one hitherto in use, and cannot, like it, produce any bad effect by press- ing upon the coats of a contracted bladder." Mr. Syme boldly takes the ground that this operation, even when not absolutely required by the obstinacy of the case, " is pre- ferable to dilatation, as affording relief more speedily, permanently, and safely." Holding these views, it is not to be wondered at that his operations amount to between one and two hundred, but the freedom with which he resorts to perineal section is justly censured by the almost unanimous voice of the profession. Eecently, Mr. Syme has declined to give the exact number of his cases, or the results. He had previously stated that not one of his first seventy operations was fatal, but since then several deaths have been known to occur in his practice. It may readily be conceded that his suc- cess, so far as regards mortality, has been unusually great, when it is recollected that he performs the operation in cases of a mild character, which must for the most part be free from renal disease and general depression of the system; but results thus obtained ' Mr. Thompson, expressing, as it would appear, Mr. Syme's latest views, says that the end of the inlying catheter should not be closed. 310 STRICTURE OF THE URETHRA. cannot be taken as an indication of the safety of perineal section in advanced cases of stricture. Mr. Thompson gives a list of 219 cases by thirty operators, among which there were fifteen deaths; of these he would exclude two which were not chargeable to the operation, leaving fourteen, or about six per cent. This amount of mortality is sufficient to forbid perineal section whenever milder, though perhaps slower, measures can be successfully employed. Consequences of Operations upon Stricture.—Either of the modes of treatment now described may be followed by rigors and other unpleasant symptoms, which in most cases subside without evil result, but which sometimes become serious, and terminate in speedy death. The exciting cause may be simple over-distension of the urethra by a larger bougie than has before been used; abra- sion or laceration of its walls by rough handling of the instrument; the application of caustic; or the employment of the knife in in- ternal or external incisions. The patient is suddenly seized with a chill, vomiting, acceleration of the pulse, and in severe cases with great prostration and delirium. These symptoms are most likely to ensue upon the first act of micturition succeeding the introduction of a sound, or the withdrawal of the catheter after urethrotomy; in other words, they follow, and appear to depend upon, contact of the urine with an abraded surface, through which urea or pus finds entrance into the general circulation; in other instances they are apparently due to the shock impressed upon the nervous system alone. This combination of symptoms, which is known as " urethral fever," is but one form of surgical fever, in the etiology of which the absorption of septic matter from the neigh- borhood of wounds plays so important a part, and which has been so ably and thoroughly described by Professor Simpson, of Edin- burgh.1 In most cases, urethral fever terminates in resolution, either with or without treatment, in the course of a few hours; but, especially in persons affected with renal disease, and in some instances with- out apparent cause, a typhoid condition with delirium sets in, abscesses may form in different parts of the body, and speedy death ensues. Complete suppression of the urine is an occasional symp- tom, and is to be regarded as of very serious import. Mr. Thomp- 1 Med. Times and Gaz., April 23, 1859. consequences of operations upon stricture 311 son relates a " case of old standing and narrow stricture, in which death was thus caused within fifty-four hours of the passing of an instrument, the same that had been habitually employed on at least a hundred occasions before, no damage whatever having been in- flicted by it upon the urethra, as verified by several careful observ- ers on close post-mortem examination of the parts. Eigors and vomiting commenced about an hour after the catheterism, and not another ounce of urine was secreted from that until death. In this case the kidneys were found congested to an extraordinary degree, and their substance was so soft and friable as to give way under gentle pressure." In a case of perineal section reported by Mr. Syme, "the patient suffered nothing from the operation; had the catheter taken out on the second day; was quite well on the third, and on the fourth was lying dressed upon the sofa in the best of spirits. In the afternoon of that day, during the act of micturition, he felt an acute pain in the perineum, and in walking from one room to another, fell on the passage so as to graze his forehead and the outer side of his knee; at the same time he had a violent rigor, followed by quick pulse and great pain in the injured parts. As the urine passed freely and entirely by the urethra, I expected that these symptoms would soon subside, but they continued and went on to suppuration of the knee, with destruction of the eyeball, and terminated fatally at the end of several weeks. I felt quite unable to account for this case until the following one gave me additional light on the sub- ject: The patient suffered nothing from the operation, which was of the simplest kind, and as he did not complain at all of the catheter, was allowed to retain it three days. When it was then removed, he expressed perfect comfort, and afterwards wrote to his friends at home the most satisfactory account of his progress. At three o'clock of the afternoon he passed urine, and felt some pain in doing so, which was attended by a slight discharge of blood. Immediately afterwards he had a violent rigor, followed by delirium and insensibility. There was no pulse, no secretion of urine, and he died the next day. On examination there was not the slightest trace of urinary extravasation, or any other sign of local mischief; but the kidneys were gorged with blood to an extreme degree; and it was plain that death had resulted from a sudden shock to the nervous system."1 As already stated, so fatal a result of operations London Lancet, Am. ed., Nov. 1858. 312 STRICTURE OF THE URETHRA. upon the urethra is not frequently met with, but the possibility of its occurrence should always be borne in mind, and lead to the observance of due caution. In order to conduct the treatment of stricture with safety, the general system should be in as favorable a condition as possible; the digestive organs in good order; and the patient should avoid excess both in diet and exercise. It is important also to abstain from any operative procedure during the persistence of raw and damp weather, or when the patient is fatigued or mentally de- pressed. Let the bladder be evacuated immediately before the introduction of the catheter, or the use of caustic or the urethro- tome, that the succeeding act of micturition may be deferred for several hours, when the abraded surface of the stricture shall be in a measure protected by an effusion of lymph. If rigors occur, they should be met by the external application of heat and rube- facients, as bottles of hot water to the extremities, sinapisms to the spine and abdomen, hot blankets, etc.; and internally by stimulants and opiates. A full dose of the latter should be administered at the outset, and a smaller quantity be repeated every few hours, so as to maintain a steady narcotic action and lull the irritability of the nervous system. The reaction which generally follows should not be treated by active depletion; a tendency to general depres- ' sion soon supervenes, in which the vital powers must be supported by stimulants and nourishment until nature shall have eliminated the toxical materials which have found entrance into the system. TREATMENT OF RETENTION OF URINE. Retention of urine, as already stated in this chapter (p. 264), chiefly occurs either during the acute stage of gonorrhoea, when it is due to inflammation and spasm; or at some period of organic stricture, when, in addition to the causes just mentioned, perma- nent contraction of the canal plays a more or less important part in its production. It is less frequent in the former case than in the latter, and presents less difficulty in the way of treatment. Eeme- dial measures must vary somewhat with the condition of the patient, and be determined by the judgment of the surgeon. When dealing with a subject of full habit, or if there be much heat and swelling of the genital organs, or general febrile excite- ment of a marked character, it is best to commence with the appli- TREATMENT OF RETENTION OF URINE. 313 cation of cups or leeches to the perineum. The former are pre- ferable, as they abstract blood more rapidly, and about ten ounces of this fluid may be regarded as an average quantity to be drawn. If the latter be employed, they should not be less in number than ten or twelve. Either with or without this preliminary local deple- tion according to the circumstances of the case, the patient should be immersed in a hot bath, the temperature of which should be raised to the neighborhood of 102° F., which will probably require the addition of hot water after his entrance, since the bath cannot at first be borne at so great a degree of heat, and is moreover cooled by contact with the body. It is even desirable that a state of syncope should be induced, which will greatly favor the reduc- tion of spasmodic action. In most cases, the patient will pass his urine during immersion; otherwise, before his removal and while still in the water, a medium sized catheter, as, for instance, No. 5, should be well warmed and oiled, and an attempt be made to introduce it; following the rules already laid down, adhering closely to the upper surface of the urethra, stopping for a moment whenever an obstruction is met with, and endeavoring to overcome it by gentle but continuous pressure: by observing these directions, and avoiding the employment of force, no fear need be entertained of doing injury to the inflamed and sensitive mucous membrane. In the rare instances in which these measures do not succeed, the patient should be put to bed, maintained in a state of perfect qui- etude and rest, and other means of an antiphlogistic and antispas- modic character adopted. A brisk purgative, as croton oil or a full dose of calomel and jalap, may be administered at once, and be assisted by the following mixture repeated every two or three .hours, in order to keep the stomach nauseated and the bowels free:— R. Antimonii et potassae tart. gr. iv. Magnesiae sulphatis §ij. Tincturae opii gtt. xl. Aquae camphorae §viij. M. Dose.—A tablespoonful. Excessive catharsis should, however, be avoided: two or three free evacuations are sufficient; and any tendency to too great.action may be controlled by opiate enemata. Indeed, it is always desirable and not inconsistent with the measures just advised, to allay irri- 314 STRICTURE OF THE URETHRA. tability and spasm by keeping the system under the influence of opium, and this can be accomplished in no better way than by rectal injections or suppositories containing laudanum or morphine. If the urine fail to pass in the course of twenty-four hours, an attempt at catheterism may be repeated while the patient is again immersed in a hot bath, or, better still, after the administration of an ansesthetic. It can never be necessary to resort to puncture of the bladder when retention of urine is dependent upon inflamma- tory stricture. After relief has been obtained, the catheter should be withdrawn, to be reintroduced if found requisite, and a condition of rest should be maintained for several days after the urine has regained its normal freedom. But retention of urine is most frequently observed as a com- plication of organic stricture, when its symptoms are generally more alarming and with greater difficulty relieved. The remedial measures required vary somewhat from those above given. Unless the case has already been subjected to instrumental interference, an immediate attempt should be made to introduce a catheter, which will be greatly facilitated by placing the patient under the influence of ether. First, however, if he have not previously been seen by the surgeon, the necessary questions should be asked to learn the history of his case; the degree of contraction of his stric- ture; what instruments it will admit, or, in default of this, the size of his stream of urine, the duration of the retention, etc. etc. The effect of anaesthetics in relaxing the sphincter of the bladder is fre- quently observed when these agents are employed for other pur- poses, as the stains upon the lounge and carpet of a surgeon's office can testify. In retention of urine, the contraction of the muscles in the neighborhood of the bladder and urethra is excessive, being, not only stimulated by the will, but rendered spasmodic and in- voluntary by irritation of the afferent nerves; and thus arises one chief obstacle to the natural or artificial evacuation of the bladder, which can be removed far more speedily and effectually by the modern application of ether or chloroform, than by hot baths and opium, which were formerly solely relied on for the purpose. The patient having been rendered insensible and his muscles thoroughly relaxed, the situation of the stricture should be ascer- tained by the introduction of a full-sized instrument; after which gentle and persevering attempts should be made to pass the ob- struction with a small metallic or gum-elastic catheter. If not sue- TREATMENT OF RETENTION OF URINE. 315 cessful with this, a small bougie of gum, whalebone, or catgut may be insinuated within the orifice, and allowed to remain a few moments, when its withdrawal will often be followed by a fine stream of urine; and by repeating the process, if necessary, the entire contents of the bladder may be evacuated. The same result may sometimes be ob- tained, though with less certainty, by pressure against the anterior face of the stricture. Again, in strictures so contracted that noth- ing but a filiform instrument will pass, or at least none large enough to admit of being hollow, the inge- nious contrivance of " cathe'terisme a la suite," as employed by MM. Maisonneuve and Phillips, may be adopted, if the proper instruments be at hand (see p. 290).1 Mr. Thompson2 has also invented a catheter "combining tubular con- struction with minute size," the extremity of which can be made as small as the finest metal probe, and is solid up to about two and a half inches from the point, where the eye is situated; while the hollow shaft above gradually enlarges, first to No. 1, and then nearly to No. 2. A steel rod, capable of being screw- ed in during the introduction of the instrument, gives it solidity, and prevents the eye from becoming ob- structed with mucus or blood. Fig. 30. Thompson's "probe-poi catheter.' 1 An instance of the successful application of this method for the relief of reten- tion, in the hands of Dr. Phillips, is recorded in Championniere's Journal of Prac- tical Medicine and Surgery, for Dec. 1859, p. 552. 2 Op. cit., p. 181. 316 STRICTURE OF THE URETHRA. After the successful introduction of a catheter in cases of reten- tion dependent upon organic stricture, the instrument should be retained in place to obviate subsequent trouble. Attempts at catheterism may be prolonged to such an extent as to irritate and abrade the canal, even if no violence be used. This should be avoided; and if success be not attained after a reasonable length of time, other measures should be resorted to. Many cases also come under the care of the surgeon, in which instruments have already been used to excess by unskilful hands and in no gentle manner, and in which the urethral walls have been lacerated or false passages opened. Under these circumstances it is best to defer any further instrumental interference for a time. The patient should be immersed in a hot bath to the verge of syncope and removed to bed, and flannels wrung out of laudanum and hot water applied to the genital organs and hypogastrium; but the most reliable remedy at this time is opium, with respect to which Sir Benjamin Brodie says: " From half a drachm to a drachm of lau- danum may be given as a clyster in two or three ounces of thin starch. If this should not succeed, give opium by the mouth, and repeat the dose, if necessary, every hour until the patient can make water. According to my experience, the cases in which the stricture does not become relaxed under the use of opium, if administered freely, are very rare. The first effect of the opium is to diminish the distress which the patient experiences from the distension of the bladder. Then the impulse to make water becomes less urgent; the paroxysms of straining are less severe and less frequent; and after the patient has been in this state of comparative ease for a short time, he begins to void his urine, at first in small, but after- wards in larger quantities." The testimony of this distinguished surgeon is confirmed by the experience of nearly every practi- tioner ; at the same time it is proper to remark that the effect of this drug should be carefully watched, and that it should'not be pushed to excess. The muriated tincture of iron is also a valuable remedy in cases of retention, and is much employed, especially at the New York Hospital, where it is given in doses of fifteen to twenty drops every half hour. Some doubt has been thrown upon the action of this agent, from the fact that it is commonly administered in conjunction with opium, to which the credit in successful cases has been ascribed. I have used it alone in several instances with very favorable results, TREATMENT OF RETENTION OF URINE. 317 and am disposed to assign it a position second only to opium in the treatment of retention. In every case of this affection, the perineum should be subjected to a careful examination, since the obstruction may be caused by an abscess or urinary infiltration, the evacuation of which will at once afford relief. When such collections form posterior to the triangular ligament, the external symptoms are often very obscure. If any swelling or doughy hardness can be detected, a free incision should at once be made in the median line with a bistoury. This can do no harm, and is likely to be of essential service. Any collection of feces in the rectum should be avoided, and the bowels, if not open, must be moved by an enema or cathartic. In subjects of a full habit, it may sometimes be advisable to draw blood from the peri- neum by means of cups or leeches. In the main, however, our reliance must be placed upon the measures previously referred to; and, if the patient be seen at a sufficiently early period, relief may almost always be obtained within twelve or twenty-four hours, either by the catheter, or by rest, the hot bath, opium and tincture of the chloride of iron. No definite rules can be laid down to determine how long, in cases of retention of urine, it is safe to defer puncture of the bladder. Each case must be decided by itself from a consideration not only of the time retention has lasted, but also of the patient's age, strength, and general condition, the urgency of his symptoms, the danger of rupture of the bladder or urethra, and the risk of injury to his kid- neys. Mr. Thompson has the following excellent observations on this point: "There are some surgeons who appear to think as long as a patient, under the influence of complete retention, presents no very urgent constitutional symptoms, it matters little how much his bladder be distended, an almost indefinite amount of endurance being ascribed to that organ. That this is very great, is not to be denied, and the extreme rarity of rupture from this cause, which at length takes places, as we have seen, rather by ulceration than by mechanical extension of its coats, is invariably referred to as evidence in favor of such an opinion. But it is certain that very mischiev- ous consequences may result from extraordinary distension (rupture of the urethra and extravasation of urine being passed over, as suffi- ciently obvious), in its effects upon the kidney, not merely in the way of temporary interference with the performance of its function as a depurating organ; but in the lasting injury it is conceived that 318 STRICTURE OF THE URETHRA. a few hours of extreme pressure and dilatation may exert on its structure. This is so much the more readily susceptible of injury, as compared with the bladder, as the secreting organ exceeds the muscular reservoir, in complexity, delicacy, and intricacy of con- struction. We may not, therefore, continue safely our baths, opium, purgation, &c, to the extreme limit of endurance on the part of the bladder. Our care for the patient must extend beyond that point, and if from his history or condition we have reason to believe in the existence of organic renal disease, or only to suspect its presence, we shall not be warranted in quietly waiting beyond the time neces- sary for the exhibition of appropriate medicinal treatment, and the careful use of the catheter, for all of which a very few hours will suffice; supposing, it is of course understood, that his powers of life at first permitted of the pursuance of that course." But while admitting the importance, and even the necessity of resorting to an operation, when such interests are at stake, it must not be supposed that the cases in which it is required are numer- ous. It would probably be very near the truth to say, that is never necessary when the patient has from the first been under the care of an intelligent and competent surgeon; and that retention can always be relieved, within a certain period of its commencement, by other and milder measures. Unfortunately assistance is not always sought from those competent to give it, until this period has been passed either in neglect or mismanagement. It having been decided that an operation is necessary, four methods are at the option of the surgeon: puncture of the bladder by the rectum; opening the urethra through the perineum; punc- ture above, and puncture through the symphysis pubis. "Forcing the stricture" is sometimes enumerated as a fifth method, but is justly discarded from modern surgery. Puncture of the bladder through the perineum is also obsolete. Puncture by the Kectum— This operation is generally admis- sible, readily performed, comparatively safe, affords the most speedy relief, and is consequently the one most frequently adopted. It is inadmissible in case the prostate is much enlarged from hyper- trophy or the presence of a tumor, on account of the danger of wounding this body; also if the bladder be much contracted, since the trocar may perforate its anterior as well as posterior wall. Compared with opening the urethra in the perineum, it has the dis- PUNCTURE BY THE RECTUM. 319 advantage of not aiming at the relief of the stricture as well as of the retention; but this is in a measure compensated for by the facility with which the obstruction generally yields to dilatation when once an artificial outlet from the bladder has been established, and the urethra is no longer irritated by the passage of urine. Eecto-vesical puncture may be performed with an ordinary curved trocar and canula, about eight inches in length, but it is an advan- tage to have the former grooved, so as to indicate with certainty by the flow of urine when the point has entered the bladder. Fig. 31. Fig. 32. Fig. 31. Side view of canula and trocar. 1. Eye in the former communicating with the groove in the latter. 2. Rings for the purpose of attachment. 3. Channel for the escape of urine Fig. 32. Trocar seen on its convex aspect, and showing the groove, which is converted into a tube by insertion in the canula. (After Phillips.) The patient is to be placed as in the operation for lithotomy, with an assistant supporting each extremity. The lower bowel having been emptied by an enema, the surgeon introduces his left forefinger, well oiled, into the rectum, and feels for the recto-vesical wall just back of the posterior margin of the prostate. A tap upon the hypogastric region with the opposite hand should communicate a 320 STRICTURE OF THE URETHRA. sense of fluctuation to the point of the finger in the rectum, and this is to be regarded as indispensable before proceeding with the operation. The canula and trocar are now to be introduced along the finger as a guide, and, while an assistant compresses with both hands the lower part of the abdomen, the point is directed forwards exactly in the median line, and, by depressing the handle, made to penetrate into the bladder, the accomplishment of which may be known by its freedom in this cavity. The canula, carefully kept in place during the withdrawal of the trocar, is to be fastened by a T -bandage, and may be retained until the permeability of the Fig. 33. Recto-vesical and supra-pubic puncture. (After Phillips.) urethra is re-established. The risks of this operation are: wound- ing the peritoneum or vesiculae seminales; consequent peritonitis, or inflammation of the appendages and substance of the testicle; persistence of the opening; and abscess between the rectum and bladder. In practice, however, these results rarely follow. The peri- toneum is too high up to be much exposed, and the vesiculae semi- nales may be avoided by adhering closely to the median line. The OPENING THE URETHRA. 321 recto-vesical puncture has been known to remain fistulous for life, but generally exhibits a strong tendency to close; and the formation of abscess is rare. This operation has been a favorite one Avith Mr. Cock, of Guv's Hospital, London, who has performed it in twenty-four instances, and has seen it performed in some fourteen others. He speaks of it in very high terms in the Medico-Chirur- gical Transactions, vol. xxxv., where he also gives a plate of a trocar, capable of expansion at its extremity, to avoid its slipping from the bladder. Opening the Urethra.—An incision into the urethra, which may be made to include the stricture, and thus lay the foundation for subsequent treatment of the latter, is undoubtedly the most advisable operation for the relief of retention, whenever the oper- ator possesses the requisite skill and anatomical knowledge, and provided the perineum be not too deep, nor its tissues too much altered from their normal condition. There are two methods of performing this operation. In one, which is identical with perineal section already described, considerable difficulty and delay are often encountered in finding the canal back of the obstruction, owing to the thickening and oedema of the perineal tissues. In the other, the knife is at once directed upon the urethra pos- terior to the stricture, without any previous attempt at division of the latter, which may afterwards be accomplished or not at the sur- geon's option. This method was favorably mentioned by Mr. Lis- ton,1 and highly recommended by the late Mr. Guthrie.2 The same preparation of the patient is to be made as for rectal puncture. The left forefinger is then introduced into the rectum, and a narrow, sharp-pointed bistoury, held in the opposite hand, with its back towards the bowel, made to penetrate the superficial tissues of the perineum to the depth of about an inch a little above the verge of the anus, and, cutting upwards in the median line, to form an inci- sion an inch and a half to two inches in length. Fluctuation may often be detected by a finger inserted in the wound thus made, espe- cially if the patient be directed to strain; and, when present, will serve to guide the point of the knife, which should open the ure- thra back of the obstruction, in the membranous portion, or possibly 1 Practical Surgery, 4th ed., p. 484. 2 Lettsomian Lecture, 1851. 21 322 STRICTURE OF THE URETHRA. as far back as the apex of the prostate. Before withdrawing the blade, a director should be passed into the bladder to facilitate the subsequent introduction of a female catheter, which, in case the operation is to rest here, must be fastened in place by a bandage; or a probe may be insinuated through the stricture from behind forwards, to meet a catheter introduced from the meatus, and the obstruction divided upon it; when the subsequent steps will be the same as after perineal section. Puncture above the Pubes.—This operation, which was a favorite with Abernethy, and according to Dr. Wilmot,' is prac- tised by Dublin surgeons in preference to recto-vesical puncture, has not been so generally adopted in this country as the pre- ceding methods. It is entirely inadmissible when the bladder is contracted, and difficult of performance when the patient is corpu- lent ; though in spare subjects, with the bladder much distended, its execution is very easy. The chief danger attending it is from infiltration of urine, which should be guarded against by making a free external incision, and by leaving the canula in place for twenty-four or thirty-six hours, and until lymph has been effused around it, before substituting a gum-elastic instrument. Fatal re- sults have sometimes ensued from sloughing of the edges of the wound, and also from perforation of the peritoneum. In performing this operation, the patient should be placed in a semi-recumbent posture, with the hair shaved from the pubes; an incision is to be made above the symphysis involving the integu- ment and cellular tissue to the extent of about two inches in a ver- tical direction; the pyramidal muscles may now be separated with the handle of the scalpel, and the bladder felt for by a finger intro- duced into the wound; the trocar, either straight or slightly curved, with its concavity downwards, should be inclined towards the lower portion of the sacrum, and a gum-elastic catheter substituted for the canula at the end of one or two days. Puncture through the Symphysis.—This operation has been too infrequently practised to admit of an expression of opinion regarding it. It was first proposed by Dr. Brander,2 in 1825, and 1 Stricture of the Urethra, 1858. 2 Seances de l'Athenee de Med., Paris, 1825 ; referred to by Thompson. TREATMENT OF' EXTRAVASATION. 323 since performed by him; by Dr. Leasure,1 of New Castle, Pa., and a few others. Its execution is very simple, consisting merely in introducing a trocar, by a rotatory motion, either with or without a previous incision through the integument, between the pubic- bones, in the direction of the promontory of the sacrum, and after- wards inserting a piece of flexible catheter through the canula. Should its safety be proved by farther experience, it will possess the advantage, as suggested by Dr. Leasure, of enabling the sur- geon, in the absence of other instruments, to relieve retention by means of a simple hydrocele trocar. TREATMENT OF EXTRAVASATION. The general principles upon which the treatment of extravasation of urine is to be conducted are: To give free exit by incisions to the escaped fluid and disorganized tissues; to support the vital powers by nourishment and stimulants; to remove and render inert the noxious products of decomposition by cleanliness and antisep- tics. At the earliest moment that any external symptoms of ex- travasation can be detected—nay, before this, if constitutional shock and deep-seated pain lead to the suspicion of the escape of urine, although its presence behind the deep perineal fascia be indicated by no sign appreciable upon the surface—a free incision should be made in the median line of the perineum, where there is but little danger of wounding important vessels. When the extravasation has attained more superficial parts, numerous incisions are required in the scrotum, and wherever else there is distension and a tend- ency to sloughing or gangrene. We are generally called upon to sustain the sinking powers of life by the free exhibition of nourishment and stimulants; as beef tea, brandy, milk punch, carbonate of ammonia, quinine, etc. Opium is of value when there is much pain or nervous irritability. Nothing can be done for the relief of the stricture during the continuance of the shock consequent upon rupture, but usually, as this passes off, catheterism may be successfully performed. In case this cannot be accomplished, and if the bladder be found on percussion to be still distended, owing to the small size of the rupture, it is desirable to resort to puncture at once, or to extend the incision in the peri- 1 Am. Joum. of the Med. Sci., April, 1854, p. 403. 324 STRICTURE OF THE URETHRA. neum to the urethra behind the obstruction. The discharge is fetid and ammoniacal from the first, and especially so as the disorganized tissues are cast off by suppuration; hence frequent ablutions, poul- tices with the addition of Labarraque's solution, or bags of pow- dered charcoal, and antiseptic lotions are required. TREATMENT OF URINARY ABSCESS AND FISTULA. Urinary abscess, as already observed in the present chapter, may arise from ulceration of the urethra and consequent escape of urine, often in minute quantity, into the cellular tissue, in which case it communicates with the canal from the outset; or it may be pro- duced by simple irritation of the neighboring parts, and, although isolated at first, eventually open into the urethra. In both cases the sooner the abscess is evacuated by external incision, the better; in the former, in order to quiet the constitutional disturbance which ordinarily ensues/ and prevent the extension and burrowing of matter; in the latter, to effect the same purpose, and also to avoid, if possible, any lesion to the urethral walls and the formation of urinary fistula; for when once the urine has found an abnormal outlet, it acts as a constant irritant, and renders difficult the closure of the passage either by nature or by art. When matter is. pent up behind the triangular ligament, it is often exceedingly difficult to detect its presence by external examination; there is usually, however, even in obscure cases, some degree of hardness and tender- ness on pressure, and if its existence is rendered probable by the general symptoms, as a chill, nausea, rapid pulse, etc., an incision should at once be made in the median line of the perineum in front of the anus; even if pus be not at first found, a passage will be formed for its subsequent exit, and the tension of the parts will be relieved. In some exceptional cases, urinary abscess assumes a chronic character and- is attended by little febrile excitement or inconvenience; thus, a small tumor, formed by an abscess commu- nicating with the urethra, sometimes exists for months before being discovered by the patient or surgeon, unless a careful examination of the perineum be made. Urinary fistulse, in most cases, contract and close spontaneously when the stricture has been thoroughly dilated, especially if the general condition of the patient be maintained at a proper standard of health. Assistance may be derived from stimulating applica- TREATMENT OF URINARY ABSCESS AND FISTULA. 325 tions to the sinus; as of nitrate of silver, nitric acid, tincture of cantharides or iodine, etc. The end of a probe may be coated with nitrate of silver and passed along the fistulous track; one of the tinctures just mentioned, either pure or diluted with water, may be injected; and plugs of compressed sponge may occasipnally be inserted to advantage. Fistulae in front of the scrotum frequently require plastic operations, a description of which may be found in works on general surgery. PART II. THE CHANCROID, ITS COMPLICATIONS; AND SYPHILIS. CHAPTER I. INTRODUCTORY REMARKS. Syphilis is one of the class of diseases called " infectious," the characteristics of which are the following:— 1. The presence of a morbid poison or virus, which transmits the disease from one individual to another. 2. The immunity which one attack generally confers against a second. 3. A "period of incubation," during which the virus is latent and gives no external manifestation of its presence in the system. 4. A degree of order and regularity in the evolution of the symptoms. It will be well to take a general view of syphilis under each of these aspects before proceeding to consider its various symptoms in detail. SYPHILITIC VIRUS. The existence of a syphilitic virus has sometimes been called in question,1 but at the present day is established beyond a doubt. 1 Chiefly by the following authors: Brit, Methode Nouvelle de traiter les Ma- ladies Veneriennes par les gateaux toniques mercuriels, t. i., chap. 3, p. 45. Paris, 1789. Carox, Nouvelle Doctrine des Maladies Veneriennes. Paris, 1811, p. 33. Richond des Buus, De la Non-existence du Virus Venerien. Paris, 1826, t. i. p. 76. Jourdan, Traite complet des Maladies Veneriennes, t. i. p. 388. 328 INTRODUCTORY REMARKS. The thousands upon thousands of successful inoculations performed by Kicord and others, including those employed in the modern practice of syphilization, as well as the daily experience of every surgeon, demonstrate that in syphilis there exists a contagious ele- ment, by means of which the disease is communicated; and though this morbid poison has never been detected by the senses, the microscope, or chemical analysis, its presence is fully proved by its effects. An ardent investigator has occasionally imagined himself the fortunate discoverer of the essence of this hidden principle, but time has invariably shown his error. It has frequently been re- garded as a caustic, by some of an acid, by others of an alkaline nature. Didier1 supposed it to consist in minute worms, which were constantly multiplied by the process of reproduction, and thus propagated the disease; while more recently Donne has ascribed it to the vibrio lineola, an animalcule often found in pus which has been exposed to the air. The latter idea, however, is disproved by the fact, that the vibriones in virulent pus may be. killed by the addition of a very weak acid, and yet the power of contagion be preserved; moreover no animalcules can be detected in the inocu- lable matter of virulent buboes when first opened, and infusoria may be found in any purulent secretion, which for a short time has been exposed to the air. Again, an attempt made by M. Castano,2 in 1855, to prove that syphilis is due to the introduction, germina- tion, and development within the system of a parasitical fungus, was equally unsuccessful. Thus the essential element of this dis- ease has always remained concealed, and probably always will, until our knowledge in general of the principle of life and the nature of disease is very much greater than now. Is THERE MORE THAN ONE KIND OF SYPHILITIC VlRUS ?—The unity or duality of syphilis—for no one at present claims that there are more than two affections comprehended under this name, as commonly employed—has of late years been the chief topic of discussion, in the surgical world, connected with venereal; and its importance with reference to all the remaining portions of this work demands for it special attention. A few preliminary remarks are necessary to the proper -understanding of this subject. 1 Dissertation Med. sur les Maladies Veneriennes, 7C edit., Paris, 1710. 2 Seance de l'Acadeniie des Sciences de Paris, 26 Fev. 1855; Gaz. des Hop., 1855, p. 107. SYPHILITIC VIRUS. 329 For a long period prior to the great revolution, which, during the last ten years, has taken place in the generally received opinion respecting the unity or duality of the syphilitic virus, it had been a matter of common observation that some chancres, even when not subjected to treatment, were limited in their action to the part upon whi ch they were situated and its immediate neighborhood; while others were followed by infection of the general system. Mr. A., for instance, would have a chancre upon the penis and a suppurating bubo in the groin, but, after these were healed, no further trouble; while Mr. B. would contract a primary sore, which would be fol- lowed by a train of constitutional symptoms, extending over a period of years, and perhaps affecting his offspring. This remark- able difference was explained on the ground of a diversity in the constitutions of the two individuals. The seed was supposed to be the same in both cases, but some peculiarity of soil in which it was implanted produced a different mode of germination. There was an unknown something in the system of Mr. A. which protected him from constitutional infection, while the absence of the same in Mr. B. exposed him to it. If either of these men should communi- cate his chancre to a woman, her primary sore, it was thought, would be attended by systemic syphilis or not, according to her peculiar idiosyncrasy, and independently of the source from which the virus came. The unsatisfactory nature of these views had attracted attention and awakened doubts of their correctness in the minds of several surgeons. Hunter devotes Part VII. of his work on Venereal to a consideration of " Diseases resembling the Lues Venerea, which have been mistaken for it," and which he is often evidently at a loss to classify. But although frequent misgivings as to the cor- rectness of his views are to be found in his writings, he still main- tained that " there is no difference in the kind of matter, and no variation can arise in the disease from the matters being of different degrees of strength; the variations of the symptoms in different persons depend upon the constitution and habit of the patient at the time."1 Abernethy was also at a loss to account for many syphilitic phenomena, and especially for the development or non- development of constitutional syphilis after primary sores which closely resemble each other. In his work entitled " Surgical Dis- 1 Ricord and Huxter on Venereal, 2d edition, p. 47. 330 INTRODUCTORY REMARKS. eases resembling Syphilis," when speaking of venereal ulcers, he says: " It is from, their effects upon the constitution alone that we can judge whether they are syphilitic or not." (p. 59.) Carmichael,1 in 1814, took a decided stand in favor of a plurality of poisons, of which he admitted four, but he believed that they were all capable of affecting the constitution, though some were susceptible of spontaneous cure without mercury. The distinctions which he drew were grounded more upon the character of the eruption than upon the appearances of the ulcer, as will appear from the following summary:— " 1. The scaly eruption which appears under the form of lepra and psoriasis, and terminates in ulceration, is alone produced by the syphilitic primary ulcer, characterized by its slow progress, and its indurated edge and base; and we find that both local and constitu- tional symptoms yield with almost invariable certainty and celerity to the action of mercury. " 2. The papular eruption which terminates in exfoliation of the cuticle may either be" occasioned by the smooth superficial ulcer, without induration or ulcerated edges, or by a purulent discharge from the surface of the glans and prepuce (balanitis); or, thirdly, by a gonorrhoea virulenta; and we have found that these different species of the same disease are alike capable of a spontaneous cure, or of being removed by external astringent applications; and that the constitutional disease they produce is, like the primary, also capable of a spontaneous cure, which is promoted by antimony and decoctions of the woods. " 3. The pustular eruption which terminates in ulcers, covered by crusts, is either occasioned by the phagedenic or sloughing ulcers. These distinctive venereal complaints, in their primary stage, are best treated by such means as subdue inflammation and sympto- matic fever, and by anodyne medicines, such as cicuta and opium. In their secondary stages, the decoctions of the woods, antimony, and mercurial salts, in alterative doses, are the means most to be depended upon; but change of air, and such measures as may tend to strengthen the constitution, are also of unquestionable moment. " 4. The tubercular eruption which terminates in deep, irregular ulcers, has been traced, in one instance only, to a primary sore, which, from the manner it undermines the skin, has been named the bur- 1 Essay on the Venereal Diseases which have been confounded with Syphilis. SYPHILITIC VIRUS. 331 rowing ulcer. But until other cases concur to demonstrate this connection, it would be premature to conclude that the one always occasions the other. The treatment is the same as for the phage- denic ulcer. "5. The diseases likely to be confounded with syphilis, which arise spontaneously from a disordered state of the constitution, fre- quently assume the form of the tubercular eruption. But after ulceration, the sores do not continue so extensive, jagged, and ob- stinate, and particularly under the means recommended, as those of venereal origin. Treatment: nitrous acid, the woods, and alterative doses of mercury." These views were never generally adopted, even in Dublin, where Carmichael resided, and after a brief notoriety were almost entirely forgotten. But Eicord appears to have had the clearest anticipations of the discovery which was destined to emanate from his "school," or from among his pupils and followers. In the absence of proof to the contrary, this surgeon advocated, in general, the unity of the syphi- litic vf-us, and explained its different effects on the ground of con- stitutional differences already referred to; but Mr. Victor de Meric1 states that Eicord remarked to him many years ago: " You may rest assured that some day distinct origins will be found for the infecting and non-infecting chancres;" and in the first edition of his Letters on Syphilis, published in 1851 (p. 257), when referring to the fact that in experiments upon syphilization, inoculation of the matter of soft chancres had always produced soft chancres, while in the single instance that pus from a hard chancre had been em- ployed, a hard chancre was the result, this author says: " If these results were constantly obtained, we should be forced to conclude, that there are differences in syphilis which do not depend alone upon the condition of the individual upon whom the cause acts, but upon differences in the cause itself." With this brief history of opinion regarding this important ques- tion, we come down to the year 1852, when the first successful assault was made on the old doctrine of idiosyncrasies and tempera- ments, and led to its final overthrow and the establishment of the duality of the chancrous virus. At this time, M. Bassereau, a former pupil of Eicord, published his "Traite des Affections de la Peau, 1 Lettsomian Lectures, 1858, p. 9. 332 INTRODUCTORY REMARKS. Symptomatiques de la Syphilis," a work characterized throughout by such originality of thought and accuracy of investigation that its perusal is essential to every one who would be thoroughly in- formed on venereal diseases. Although nominally a treatise upon syphilitic eruptions alone, many other subjects connected with syphilis are discussed, and among them the unity or duality of the syphilitic virus. Justice to the author, the intrinsic and historical interest of his remarks, the manly and cogent style of his reasoning, and the absence, so far as I am aware, in the English language, of any suitable exposition of his views expressed at this early day, demand a somewhat extended quotation, which I shall give in the form of a free translation, with such abridgment as my limits as to space require. It is necessary to premise that this question is discussed by M. Bassereau in his chapter on syphilitic erythema, which, being one of the earliest symptoms of constitutional syphilis, affords a better opportunity for tracing the connection between primary and second- ary lesions than any other. The cases of erythema, to which fre- quent reference is made, number 170, if we exclude twenty-eight in which the absence of information regarding the primary ulcer precluded any comparison. In the tenth section of the chapter upon this subject, entitled: "Eecherche des causes qui ont pu determiner le developpement de l'erytheme, c'est-a-dire la generalization des symptomes syphilitiques dans l'economie," M. Bassereau says:— " There can be no question of the fact that there are chancres which may be treated by the most simple remedies without the employment of any mercury whatsoever, and yet never be followed by the symptoms of constitutional syphilis. Any one may convince himself of this truth by inquiring of old men, many of whom will state that they had chancres several times in their youth, which were treated with simple cerate, lint, or other means destitute of specific action, and, though they have never taken mercurials, there has not been the slightest appearance of constitutional syphilis during the thirty or forty years which have since elapsed. Many persons also will repeatedly have chancres and escape infection, but will finally contract another which will be followed by a syphilitic eruption. Why this difference ? What should limit the action of the chancre in the one case and in the other extend it to the whole system ? This is an interesting problem, and I will proceed to give SYPHILITIC VIRUS. 333 the results of my attempts to solve it. Let no one who is wont to pay respect to opinions which have received the stamp of authority take umbrage at the novelty of the propositions which I am about to present, or be hasty in rejecting them. The question at issue is so important that it deserves serious examination. It is not to be decided by an appeal to the vague impressions left on the mind by former experience, or by the doctrines of this school or that; it can only be settled by new investigations undertaken for the very pur- pose. I ask therefore of unbiassed men to devote the necessary time to verify the facts which I am about to present, and to give them their most scrupulous attention. "Among the causes which I have investigated, I have endeavored to ascertain if age has any influence in the extension of syphilis to. the general economy, and I have satisfied myself that it has none. From birth to the most advanced years, man may have chancres, which, at any age, may be followed by constitutional syphilis; and though infection is more common among the young, it is simply because they are more exposed. Sex is equally devoid of influence. Eicord states that chancres are less frequently indurated in women than in men, which is equivalent to saying that women are less liable to constitutional syphilis, since it can easily be shown that infection follows in most cases indurated chancres. I do not believe, however, that Eicord carries the induction thus far. For my own part, I think that the rarity of induration in women is only appa- rent. Indeed, in an examination of the same number of chancres in the two sexes, I have found nearly the same proportion indurated in the one as in the other; with this difference, that the induration was generally poorly marked on the vulva, while it was very de- cided upon the penis. Just as the skin of various parts of the body is not equally susceptible of the development of induration, so this symptom is less frequent upon the genital organs in women than in men. But women are not on this account less exposed to constitutional syphilis. Though fewer persons of this sex are affected with this disease, it is because the number who are addicted to debauch is incomparably less than of men; whence venereal affections of all kinds, constitutional syphilis included, are less com- mon among them, and the difference cannot be attributed to mere sex. "Again, idiosyncrasy will not explain the fact that a chancre produces only local effects in one person, while in another it infects 334 INTRODUCTORY REMARKS. the system at large. This is proved by the number of persons who, after having numerous simple chancres, contract another which becomes indurated and is followed by constitutional manifesta- tions. " Can such different results from two acts of contagion by a virus reputed the same be accounted for by the changes which frequently take place in the constitution, and by virtue of which a man is not affected in the same manner by the same agent at times very nearly approximated? Doubtless such dissimilar effects might depend upon the particular disposition existing at the time of contagion; but this explanation is admissible only in default of a better, espe- cially as it is opposed to what we know of the action of specific causes, which always tend to produce the same results. "I have carefully studied the temperament and constitution of persons affected with syphilitic erythema, in order to discover if any one of these organic modifications of the system might not influence the development of constitutional syphilis, but such inquiry has led to no positive result. I have found all tempera- ments affected in nearly equal proportion; none can therefore be regarded as peculiarly conducive to the extension of syphilis throughout the economy; and the same may be said of difference of constitution. "An insufficient amount or the bad quality of food, which is a powerful aggravating cause of syphilitic symptoms, has been so rarely observed in the cases of erythema which have come under my notice, that it is impossible to ascribe to it the development of general syphilis. The abuse of alcoholic stimulants, changes of temperature, and intercurrent diseases appear to have had no more effect. I have merely noticed that chancres contracted during warm weather are more rapidly followed by syphilis than during cold. "The above remarks clearly show that neither age, sex, idiosyn- crasy, temperament, constitution, hygienic influences, nor coexisting diseases which might be supposed to have depressed the system at the time contagion took place, can, each by itself, be regarded as the determining cause of infection; and if we group them all together instead of considering each singly, my statistics will show that they will not account for one-third of the cases of constitutional disease. The better to appreciate the etiological value of these influences, I have examined the condition of those persons whose chancres, in spite of the absence of all treatment capable of retarding or destroy- SYPHILITIC VIRUS. 335 ing a tendency to secondary symptoms, have not been followed by constitutional syphilis. I have compared one hundred such cases with an equal number of patients affected with syphilitic erythema, and have found in each nearly the same proportion of lymphatic temperaments, feeble constitutions, bad hygienic influences, etc., thus confirming my opinion of the necessity of searching for other than physiological and hygienic causes of the generalization of syphilitic manifestations. "I have also sought for the solution of this question in the chan- cre itself. I have endeavored to ascertain if repeated acts of con- tagion might not favor the appearance of secondary symptoms. On examination of the cases cited, I found that in 112 cases the eruption appeared after several successive chancres, and in 86 after a single chancre. Notwithstanding the predominance of the former, it cannot, I think, be admitted that the repetition of primary symp- toms is the cause of constitutional infection. The idea that the action of a virus must be accumulated to produce its utmost effect is but little in accordance with the medical knowledge we already possess. In a number of my cases, also, there was so long an in- terval between the chancres that it appears to me difficult to attri- bute to the first contagion any influence whatever in the production of the constitutional syphilis which followed the last exposure. "Again, I have inquired if individuals affected with several chancres at one time, were not more exposed to constitutional in- fection than those having only one, and who consequently bore upon their persons a smaller surface secreting contagious matter; but I found this could not be the case, for of the 170 instances of syphilitic erythema, 141 had had but one, and only 29 multiple chancres; whence I conclude that neither the plurality of primary sores nor the extent of the secreting surface can be regarded as the cause of the constitutional manifestations which sometimes appear. These results are analogous to those obtained by Kirkpatrick, Dimsdale, and Gatti in experiments with the virus of variola, from which it appears that there is no connection between the number of inoculated points and the copiousness of the consecutive eruption. Girot even observed that the eruption of variola was milder and more discrete after inoculating in six places than when only two punctures were made. "An analysis of these cases of syphilitic erythema shows that the development of constitutional syphilis is not affected by the 336 INTRODUCTORY REMARKS. situation,1 degree of ulceration, or duration of the primary sores. General symptoms may supervene, on whatever part of the body a chancre is situated; and the intensity of the former is not increased when the primary ulcer is at a distance from the genital organs, as was once supposed by Bcerhaave. A decided tendency to extend by ulceration is also innocent of the development of constitutional syphilis; for I have often seen the mildest and most superficial ero- sions followed by infection, while phagedenic sores proved in- nocuous. Chancres which last for a long period are not more likely to terminate in secondary syphilis than those which cicatrize within a moderate or short space of time, as may also be seen from an examination of these 170 cases. " On the other hand, induration is so frequent a symptom of these primary ulcers2 that it is impossible not to admit that it bears an intimate relation to the syphilitic erythema which ensued. But even if it could be shown that all infecting chancres are indurated, must we necessarily say that induration is the cause of infection ? By no means; for this would only be avoiding the question instead of solving it, since the cause of the induration would still remain to be discovered. ' "Finally, in my investigations I have endeavored to ascertain if any relation existed between the symptoms presented by my patients and those of the persons from whom they contracted their disease. Such inquiry is often difficult, for men are frequently infected by women whom they never see but once, and of whose name and address they are ignorant. Some have intercourse with several women within a short time preceding the appearance of the chancre, so that the source of the virus is doubtful; others refuse to give any information with regard to the persons with whom they have had connection. In some cases, however, we are able to compare the symptoms in the two sexes. Patients often bring to me for examination the women who infected them, or else put me in the way of visiting them at their homes. Frequently, also, at the Hopital des Vencriens, I have found two or three, or even a larger number of men who contracted their disease from the same woman, either on the same day or at a few days' interval. Finally, in 1 At the time this was written, the fact that soft chancres are never met with upon the head or face was not known. z Of the 170 chancres, 157 were known to be indurated ; in 13 induration was douUful. SYPHILITIC VIRUS. 337 several instances I have seen both a wife and husband, and even their children, all affected with syphilis which had been introduced into the family through one of its members. " These repeated confrontations of persons infected by each other —undertaken at first to determine what syphilitic lesions are con- tagious and what are not; to show what symptoms may succeed others, and what modifications the same symptom may undergo by transmission between individuals of different sex and tempera- ment—have led to the discovery of that hitherto mysterious cause by virtue of which chancres sometimes limit their action to the part on which they are situated and the neighboring ganglia, and at other times extend their effect to the system at large and are followed by constitutional syphilis. The following propositions embody the results obtained from the confrontation of patients affected not only with erythema, but also with other syphilitic eruptions and primary sores, with those persons from whom their disease was derived:— "If we compare persons who have had chancres followed by constitutional symptoms with those persons who inoculated them, or with those whom they in turn have inoculated, we find that all, without exception, have had constitutional syphilis; never, in any case, has the action of the chancre been merely local. "On the other hand, by the comparison of individuals who have had chancres which did not result in general manifestations with the individuals who infected them, or with those whom they have infected, we find without exception that the latter, equally with the former, have had chancres, the action of which was limited to the part first inoculated. Thus a chancre followed by constitutional syphilis never gives rise to a merely local chancre; and a purely local chancre cannot produce a chancre which will be followed by the general manifestations of syphilis. The uniformity of the facts which have come under my observation—none but apparent ex- ceptions having ever been met with—fully justifies me in enun- ciating the following proposition as a law:— " Whenever a person has a chancre and afterwards constitutional syphilis, the generalization of the syphilitic phenomena is first of all due to the fact that the person from whom the contagion came had a chancre which was necessarily followed by constitutional symptoms. " Of thirty-four cases of syphilitic erythema, in which I have been able to confront the patients with those who infected them, 22 338 INTRODUCTORY REMARKS. and in some instances with those whom they had afterwards infected, in thirty-one, conformably to the law just enunciated, all the indi- viduals thus confronted presented lesions of the same character; all without exception had chancres which were followed by constitu- tional syphilis. In only three, from the absence of symptoms of general infection, did there seem to be any exception, but indura- tion was found at the site of the primary sore, showing that the exception was only apparent; moreover, the mercury which had been administered for the latter fully accounted for the absence, or delay in the appearance, of constitutional manifestations." The immutability of these two chancres being thus established by clinical experience, it is evidently necessary to admit that they constitute two species. The question then remains whether or not they bear any relationship to each other. One of two alternatives must be true: the virus of each must be the same, but of greater intensity in one than in the other; or there must be two poisons totally and radically distinct. Two years after the publication of M. Bassereau's work, the first mentioned supposition was adopted by M. Clerc,1 another pupil of Eicord, who maintained that the virus of the soft was a modifica- tion of that of the hard chancre; the former bearing the same rela- tion to the latter that varioloid does to variola, and the false to the true vaccine pustule; and in accordance with this view the name of "chancroid" was given to the first, while the term chancre was exclusively reserved for the second ulcer. This modification, as M. Clerc believed, was produced by the passage of the virus through the system of a person already under the influence of the syphilitic diathesis; the poison, thus materially changed in its nature, was capable of indefinite transmission by contagion, but could never recover its original power of infecting the constitution; just as the false vaccine pustule may sometimes2 (not always) be inoculated from one individual to another without affording protection against ' Memoire du Chancroi'de Syphilitique, Paris, 1854. 2 The theory of M. Clerc appears to be as defective in its analogies as in the absence of direct proof, for the false vaccine pustule is not always perpetuated as such; and there is abundant evidence—cited very fully by M. Fournier (Lecons sur le Chancre, p. 168)—to show that varioloid may give rise to variola and vice versa in subjects unprotected by vaccination or previous attacks. The assumed permanence of these forms of disease, when once established, cannot therefore be sustained. SYPHILITIC VIRUS. 339 variola, or, in other words, without exerting any influence upon the general system. M. Clerc's theory was sufficient to explain all the phenomena hitherto stated in the quotation from M. Bassereau, and it only remained to demonstrate by direct observation whether or not the transmission of the syphilitic virus through a system already in- fected would produce such modification as was claimed in its nature. At the time M. Clerc's essay appeared, the necessary facts were wanting to determine this point, but they have since been met with and have proved the theory without foundation. In several in- stances, a man laboring under the symptoms or diathesis of consti- tutional syphilis has contracted a chancre from a woman having an infecting chancre, and although, under these circumstances, as will be seen hereafter, the chancre in the male closely resembles a soft chancre in appearance, yet if it be communicated to a third person as yet free from constitutional taint, the result will be a hard chancre and general syphilis. We thus have positive proof that no such modification takes place as asserted by M. Clerc; and his theory is at present generally abandoned, although the term " chan- croid" is conveniently retained to distinguish the non-infecting from the infecting chancre. Bassereau regarded the first alternative above mentioned, of which Clerc's theory is the only representative, as deserving of rejection from the absence of any proof in its favor; and boldly advocated the second, viz., that the virus of the soft chancre is radically distinct from that of the hard. A careful study of the older writers on medicine afforded additional evidence in support of this opinion, by showing that simple venereal ulcers have been known from the earliest times of which we have any record; that the hard chancre and its consequent constitutional symptoms was first observed in the latter part of the fifteenth century, during the Italian epidemic; and that for twenty or thirty years afterwards these two species of ulcer were never confounded; the duality of the chancrous virus is not therefore a modern discovery, but was familiar to those who witnessed the first irruption of syphilis into Europe. In the introductory chapter of this work, I have already given an extended account of these historical researches, which have been confirmed by those of Langlebert and Chabalier; and I shall at present merely refresh the reader's memory by stating in Bassereau's own words the conclusions at which he arrived. 340 INTRODUCTORY REMARKS. "When we read all that ancient and modern authors have written on the diseases of the organs of generation, we find that gonorrhoea, chancres, buboes, and vegetations are mentioned as late as the last years of the fifteenth century, as diseases requiring only local treat- ment ; up to this time there is not the slightest allusion to any symptoms consecutive to the diseases of the genital organs. The end of the fifteenth century, according to all the contemporary au- thors, was marked by the appearance of a new disease. This dis- ease commenced by indurated ulcers upon the genital organs, which were speedily followed by pustular eruptions over the whole body, and by frightful pains in the head and limbs. The physicians who were eye-witnesses of the new disease did not at first confound the callous ulcers in which it commenced with the ulcers of the genital organs which had been known for ages. Thus these two species of ulcers occupy in their writings separate chapters, and even separate books. But, twenty or thirty years after the appearance of syphilis in Europe, many physicians not knowing, as those did who witnessed its first ravages, how to distinguish the symptoms by which the new disease commenced from those which had no relation whatever with it, assumed by degrees the habit of submitting to mercurial treat- ment, without distinction, all persons affected with gonorrhoea, chancres and buboes; for it had already become a general practice to administer mercury, not only for the purpose of modifying ex- isting syphilitic symptoms, but also as a prophylactic agent against future symptoms, as soon as the first signs of contagion began to appear. The confusion which reigned in practice was soon intro- duced into the works of the day; the writers on syphilis in the middle of the sixteenth century included, one by one, under the name of syphilis all those venereal symptoms which had been known from the earliest antiquity, and which the physicians who exercised their art in the last years of the fifteenth century had taken care to separate from the symptoms of the new disease." The attention of the profession being thus directed anew to the important question of the unity or duality of the chancrous virus, other observers immediately set to work to test the accuracy of M. Bassereau's observations, and new facts soon began to appear, all of which were found to point in the same direction. In 1856, M. Dron1 was able to collect one hundred and eleven instances of con- frontation, including those of Bassereau relating to the hard chancre, 1" Du Double Virus Syphilitique," these de Paris, 1856. SYPHILITIC VIRUS. 341 those of M. Clerc relating to the soft chancre, and others relating to both varieties furnished by Diday, Eollet, Eodet, and Fournier, and in all, without exception, the type of the ulcer remained unchanged in passing from one individual to another. Farther investigations, under the supervision of Eicord and with the same result, were made by MM. Fournier and Caby, who availed themselves of the unequalled facilities for such examination afforded by the chief venereal hospitals of Paris—one (du Midi) devoted to men, the other (St. Lazare) to women—and of the vigilance of the French police. These observations were published in detail by M. Four- nier in his edition of Eicord's Lecons sur le Chancre* and also in a pamphlet entitled, Recherches sur la Contagion du Chancre,2 and comprise fifty-nine cases of transmission of the infecting, and thirty- nine of the non-infecting chancre. The value of many of these cases was materially enhanced by the fact that two or more men were con- taminated by the same woman, and thus the testimony in favor of the duality of the chancrous virus was multiplied. In one, two friends, who shared the favors of the same woman having an infect- ing chancre, caught, each of them, an infecting chancre followed by constitutional symptoms; and the father of one of them, an old man aged seventy-three, had connection with his son's mistress, and met with a similar fate. Again, six persons were infected from the same source, and the consequences in all were identical, viz., infecting chancres and constitutional manifestations. So with the non-infecting or simple chancre; in several of Fournier's cases, two, three, or four men, bearing simple chancres, were found together in the wards of the Hopital du Midi, all of whom ascribed their conta- gion to the same woman; who, on examination, was proved to have the same species of primary sore; and in none did constitutional symptoms appear during several months that they were kept under observation. Thus far in our account of Fournier's investigations, we find that they merely confirm the observations of Bassereau, since they all relate to the transmission of primary sores between persons free from previous syphilitic taint. It remains to be proved what effect, if any, is produced in each species of chancre by being communi- cated to a system already under the influence of the syphilitic diathesis. The solution of this question was also undertaken by Fournier, who found, as regards the simple chancre, that the sore was 1 Paris, 1858. * Paris, 1857. 342 INTRODUCTORY REMARKS. in no way modified; that if, for instance, a woman having a simple chancre, communicated it to a man whose constitution was already infected with the virus of true syphilis, and he gave the same to a woman free from such taint, the resulting sore would in no respect be changed in consequence of the general infection of the man through whom it had been transmitted. This result might have been predicted beforehand, from a consideration of the distinct nature of the two kinds of virus, neither of which will directly influence the other, any more than syphilis will affect the course of gonorrhoea,*or vice versa. With regard to the hard or infecting chancre the results were more novel and interesting. A chancre of this species, communi- cated to a subject already infected with syphilis, does not present its usual characteristics; it is destitute of specific induration and unaccompanied by induration of the neighboring lymphatic gan- glia; in'short, it so closely resembles an ordinary soft chancre that it cannot be distinguished from it by any outward sign. If, how- ever, this sore—in appearance a soft chancre, but in reality a hard chancre, modified by the constitutional infection of the person bear- ing it—be communicated to a third person free from constitutional taint, it will resume its normal characteristics, will become indu- rated, be accompanied by induration of the neighboring lymphatic ganglia, and followed by the general manifestations of syphilis. The evidence on which the statement just made regarding the infecting chancre is based, is sufficient, though not so great in amount as that relating to the transmission of chancres between individuals free from constitutional infection; since facts capable of solving the question under consideration are necessarily rare. For, in the first place, the virus of an infecting chancre rarely takes effect at all upon a subject already infected; one general attack protecting against even local manifestations of the poison, just as vaccination is without result upon a system once imbued with the vaccine or variolous virus; and, in the second place, supposing contagion to occur, the disease must be again communicated to a person who has always been free from constitutional taint. These numerous and complex requirements, however, have all been present in seven cases, of which Cullerier,1 Melchior Eobert,2 and Diday,3 each observed 1 Fournier, Contagion du Chancre, p. 57. 2 Dron, These, already referred to. 3 Annuaire de la Syphilis, annee 1858, p. 277. SYPHILITIC VIRUS. 343 one, and Fournier and Caby four; and they all concur in showing that, contrary to M. Clerc's theory, the virus of an infecting chancre is not modified by being communicated to a system already in- fected, and although it produces a sore apparently identical with a soft chancre, its essential attributes are unchanged. Another point to which Fournier directed his attention was whether phagedenic ulceration of a chancre is due to any pecu- liarity inherent in the virus—a question which the confrontation of patients answers in the negative. The origin of phagedena is probably complex, being attributable in some cases to noxious principles in the primary pus of contagion, more frequently to constitutional cachexia in the recipient, and sometimes to both causes combined; but without entering fully into its etiology, it is sufficient for our present purpose to say that the virus of phage- denic chancres is not a distinct species, since this form of ulcer may owe its origin to an ordinary chancre either of the simple or infect- ing variety. The results thus far attained by comparison of the symptoms of •those giving and those receiving primary ulcers may be summed up in the following propositions:— 1. Among persons free from previous'syphilitic taint, each of the two species of chancre is transmitted in its kind: the simple chancre as a simple chancre limited in its action to the neighborhood of its site; the infecting chancre as an infecting chancre, followed by constitutional manifestations. 2. A primary sore with a soft base, and unaccompanied by indu- ration of the neighboring lymphatic ganglia, in a subject already infected with syphilis, will, when communicated to a person free from syphilitic taint, give rise to a soft or hard chancre, according to the nature of the virus which occasioned the first mentioned ulcer. 3. The virus of the non-infecting chancre is a poison distinct from that of the infecting chancre. 4. Phagedenic ulceration of a chancre does not depend upon a specific difference in the virus. In reviewing the labors, of which a somewhat full account has now been given, we find that the duality of the chancrous virus is established upon the same evidence as naturalists determine the identity of species in the animal and vegetable kingdoms; viz., by the immutability of certain traits in successive generations. The 344 INTRODUCTORY REMARKS. " immutability of species" lies at the foundation of all classification in natural history; it is the groundwork upon which the whole superstructure rests; and although we cannot always expect to fol- low out the same laws in the arrangement of the protean forms of disease that we do in nature, the simple principle referred to is unquestionably as applicable to one as to the other; nay, when pre- sent in morbid manifestations, it may be regarded as of the greater value, from the very fact of their general inconstancy. The cha- racteristics, the immutability of which is relied upon to establish the duality of the chancrous virus, are the limitation of the power of a chancre to mere local action on the one hand, and, on the other, its necessary influence upon the general system; and no one will fail to see that, if these can be proved to be constant, they are suffi- cient to establish a distinction of species. It should be observed that the external appearance of primary ulcers does not enter as an element into this consideration. The proof would be equally valid, even if it could be shown that the two species of chancre are never distinguishable by any outward sign. It is sufficient to establish the fact that the action of the virus in one series of cases is local, and in the other general. Na- turalists, in many instances, ground their classification of species upon differences confined to one period of their existence. The young of many forms of animal life closely resemble each other, although the adults are widely different. From the study of em- bryology alone, Agassiz has derived the most correct system of classification which has ever been advanced. While, therefore, as will hereafter appear, the soft and hard chancres do present, in most cases, differences recognizable by the sight and touch, these must be regarded as additional, but not essential, evidence of the distinct nature of the two forms; and their absence, as occurs in some instances, and perhaps in all, when the virus of a hard chancre is implanted upon a system already infected, does not invalidate the proof of the existence of two kinds of chancrous virus. The new doctrine upon this subject, which, as shown by Basse- reau, is an old doctrine revived, appears to me to occupy an impreg- nable position. The confrontations of the observers whose names have been mentioned, alone amount to 137, and among them all, not a single instance of interchange between the two forms of chancre has been met with. Nearly every physician has the oppor- tunity to satisfy himself of the truth of this doctrine by personal SYPHILITIC VIRUS. 345 observation; let him but take note of the not infrequent cases in which a husband gives a chancre to a wife whose fidelity cannot be called in question, and he will find that they will both escape, or both incur constitutional infection. Thus, every one can contribute his quota to the statistics on this interesting subject. For myself, in a somewhat extended field of observation during ten years of practice, I have never seen an instance of interchange of the two species of chancre, and I can recall .fourteen cases—six of simple, and eight of infecting chancres—in which the transmission of each in its kind was unquestionable. In pursuing these investigations, it is of course necessary to guard against all sources of error; the fact should be well estab- lished that the person supposed is really the one who gave the dis- ease ; it should be ascertained with certainty that neither the man nor woman has been previously infected, otherwise he or she is incapable of receiving a second infection; and the influence of a mercurial course in preventing, or more frequently in retarding, constitutional manifestations, should be borne in mind. Nor is mer- cury the only agent capable of delaying the appearance of second- ary symptoms; the same effect may be produced by a course of iodide of potassium, sudorifics, or other medicines which increase the excretions from the body. The important subject which has occupied our attention is sug- gestive of many considerations, of which our limited space will permit only a few to be sketched in outline, as follows:— 1. From the existence of two kinds of chancrous virus, it does not follow that there are two kinds of syphilitic virus. The term " syphilis" implies not only a local, but a general disease; conditions which are alone fulfilled by the hard chancre, and its consequent constitutional symptoms. The soft chancre and its attendant bubo should not, properly speaking, be described under the head of syphilis, but be considered apart like gonorrhoea. It is also desir- able to adopt a different name for this ulcer, as, for instance, the term " chancroid," which is already much employed, especially by the French, and which will frequently be used in the following pages as synonymous with "soft" and "non-infecting chancre." The complete separation, however, of these two forms, in describing chancres and their attendant symptoms, would perhaps at the pre- sent time be objectionable, while yet the new doctrine on this sub- 346 INTRODUCTORY REMARKS. ject is not familiar to all, and I shall, therefore, follow the usual course and describe them together. 2. The distinction which is now drawn between the non-infecting and infecting chancres explains in a great measure the variance which has long existed with regard to treatment between the " mer- curialists" and "anti-mercurialists." The soft chancre, being a strictly local disease, requires no constitutional remedies, unless, in exceptional cases, as adjuvants, to local treatment. Mercury is of value only in cases of hard chancre and general syphilis. Since the number of soft chancres greatly exceeds the number of hard chancres, it is evident that the general results of treatment may be made to sustain either the use or disuse of mercury, if exclusively applied to both forms in common. 3. A comparison of the three poisons of gonorrhoea, the soft and hard chancre, so far as we are at present able to understand their nature, leads to the following conclusions. The only property common to them all is their communication, for the most part, by contact of the genital organs. The poisons of gonorrhoea and of the chancroid are alike in that their action is limited and never extends to the general system; nor does one attack afford the slightest protection against a second. They differ in that the poison of gonorrhoea may arise spontane- ously, while that of the chancroid, so far as we know, never thus originates; that gonorrhoea chiefly affects the surface—true ulcera- tion being rarely induced—and, in its complications, most frequently attacks parts connected with the original seat of the disease by a continuous mucous surface, as the prostate, bladder, and testicle; while the soft chancre, on the contrary, is an ulcer, involving the whole thickness of the integument or mucous membrane, and its complications are seated in the absorbent vessels and ganglia. It would also appear that the poisons of these two affections are limited to one common vehicle, viz., pus. Van Eoosbroeck, on the authority of Eollet, has proved by experiment that if the discharge of gonorrhoeal ophthalmia be deprived of its pus-globules by fil- tration, the remaining fluid is innocuous; and Eollet states that he has obtained like results with the pus of soft chancres. If these experiments can be relied on, they prove that the virus is not dif- fused throughout the purulent secretion, but is confined to the pus- globules which it contains. This conclusion is sustained by the fact that neither the poison of gonorrhoea nor that of the chancroid SYPHILITIC VIRUS. 347 ever reaches the general circulation, and it is well known that pus- globules are not capable of absorption. When the purulent matter of a soft chancre enters the absorbent vessels, as occurs in the formation of a virulent bubo, it is arrested by the first chain of lymphatic ganglia, and goes no farther. The paint used in tattooing is sometimes conveyed to a ganglion in a similar manner;1 but nei- ther in this case nor the former is there complete absorption.2 The virus of the hard chancre is alone capable of infecting the system at large, and of affording protection by its presence against subsequent attacks. Unlike the poisons of gonorrhoea and the chancroid, it is not limited to purulent matter, but exists in the blood, in the fluids of secondary lesions, in the semen, and probably in other secretions. The secretion of one form of the hard chancre (the superficial variety), as shown by microscopical examination, is often entirely destitute of pus-globules;3 and the presence of the virus in secondary symptoms is proved by their power of contagion, and in the semen by the occurrence of hereditary syphilis in the offspring when the father is alone infected. There is no opposition whatever between these three poisons; they may all coexist in the same person, who may at the same time have gonorrhoea, a chancroid, and a chancre; hence we may explain a case related by Acton in which each of three students contracted one of these diseases from intercourse with the same woman on the same day. Two of these poisons may be present in the same fluid, as when the secretion of a hard or soft chancre mingles with that of gonorrhoea; or as in the "mixed chancre" resulting from inocu- lation of the same part, either at the same time or successively, by ' Virchow has given a beautiful plate of the deposit of pigment matter in the axillary gland of an arm, the skin of which had been tattooed, and describes the process of absorption as follows: "A certain number of particles find^their way into lymphatic vessels, are carried along in spite of their heaviness by the current of lymph, and reach the nearest lymphatic glands, where they are separated by filtration. We never find that any particles are conveyed beyond the lymphatic glands and make their way to more distant points, or that they deposit themselves in any way in the parenchyma of internal organs." (Cellular Pathology, English translation, p. 184.) 2 Rollet, De la Pluralite des Maladies Veneriennes, Gaz. Med. de Lyon, No. 8, 1860. 3 Mr. Henry Lee believes that the infecting chancre is always an ulcer affected with specific adhesive inflammation, and, unless irritated, destitute of pus-globules. Of 95 cases examined by the microscope at King's College Hospital, in none was the secretion purulent. (Medico-Chir. Trans., vol. xlii. p. 450.) 348 INTRODUCTORY REMARKS. the virus of the chancroid and that of the chancre. The secretion of the soft, or that of the hard chancre and its consequent secondary symptoms, may also mingle with other animal poisons, as the vac- cine virus, and each will produce its usual effects unmodified by the presence of the other. Apparent exceptions to some of the above statements are met with in the practice of syphilization, and will be explained in an- other chapter. The severity of the symptoms produced by syphilis on its first appearance in the latter part of the fifteenth century, compared with its greater benignity at the present day, affords some ground for believing that its virus is slowly but gradually losing in intensity, in the same manner as the vaccine virus is supposed to become weaker after many successive removes from the cow. This fact was noticed by Astruc1 in the middle of the last century, who says: " Whatever might formerly be the power and efficacy of the venereal disease when it was new and in vigor, while the undivided poison violently effervesced, there is nothing like it, I imagine, to be feared from it now, as it is weakened, become old, and its force almost quite spent." Another explanation advanced by some writers is, that the syphilitic virus retains its power, but that a preservative influence is transmitted to posterity by those who have the disease, which, like some vegetables, gradually exhausts the soil from which it springs of the materials necessary to its support. There are other considerations relative to the syphilitic virus, as, for instance, the circumstances under which contagion takes place, both in the primary and constitutional forms of the disease, which will naturally come before us when treating of chancres and secondary syphilis. Constitutional Syphilis rarely occurs more than once in the same person.—It will now be evident that the analogy which was drawn at the commencement of the present chapter between syphilis and other contagious diseases is exclusively applicable, ex- cept so far as relates to the presence of a virus, to the infecting chancre and the constitutional disease of which it is the initiatory symptom. The second point of resemblance referred to was the " immunity which one attack generally confers against a second." 1 English translation of Astruc, London, 1754, p. 102. constitutional syphilis. 349 It is true of all diseases which are both contagious and constitu- tional, that a person who has once had them is indisposed to con- tract them again. Smallpox, scarlet fever, measles, the hooping cough, and vaccine disease, all follow this law; and in the rare ex- ceptions which sometimes occur, the symptoms are generally so modified as still to evince the protecting influence of the first attack. The applicability of this law to syphilis was first announced by Eicord in 1839, and, in spite of frequent denials, may now be regarded as unquestionable. Some explanation is desirable of what was called by its discoverer the "unicity" of syphilis. Soft chancres, like gonorrhoea, favus, and the itch, are contagious, but not constitutional diseases, and one attack confers no immunity against a second. Setting aside foiHhe present the phenomena of syphilization, which, as we shall see hereafter, may be explained on other grounds, a person may contract a soft chancre any number of times. It is also compatible with the law of "unicity," that the true syphilitic virus should be capable of producing a chancre upon a system previously infected; although, in most cases, as shown by artificial inoculation, when the virus is implanted beneath the epi- dermis, no effect whatever takes place. Yet, sometimes, inoculation succeeds; and instances are also met with in practice in which a person already infected presents a chancre derived from a primary ulcer of the infecting type; but in nearly all such cases, the sore fails to present the usual features of a hard chancre; it is destitute of induration, unaccompanied by an indurated bubo, and, above all, has no effect upon the general system. In a similar manner, the vaccine virus sometimes occasions an imperfectly developed, or "false" pustule, upon a system already thoroughly protected against vaccinia. The immunity, therefore, which is said to be conferred by one attack of syphilis, relates only to the constitutional disease, includ- ing the hard chancre in its full development. Yet many cases occur in practice which are apparent exceptions to this law. After contracting an infecting chancre, but few persons escape with only one outbreak of constitutional symptoms; however thorough their treatment may have been, one or more relapses usually occur, and if one of these has been preceded by a newly caught chancre, the second- ary symptoms which follow are frequently ascribed to its influence, especially if the second chancre happened to be situated upon the ♦ remaining induration of the first, and thus simulated the complete 350 INTRODUCTORY remarks. infecting ulcer. Fortunately, we are able in most instances to re- cognize a recent attack of constitutional syphilis by the following signs, and in their absence to ascribe the symptoms to an old infec- tion :— 1. By the induration of the preceding chancre and neighboring lymphatic ganglia. 2. By the time elapsing between the appearance of the suspicious ulcer and that of the constitutional symptoms; the interval, in the absence of general treatment, and when the latter are dependent upon the former, being very uniformly about six weeks, and rarely exceeding three months. 3. By the character of the symptoms, whether belonging to an early or late stage of constitutional syphilis. 4. In some cases, by the influence of treatment; the early symp- toms of constitutional syphilis yielding most readily to mercury; the later to iodide of potassium. If attention be paid to these circumstances, it is found that excep- tions to the immunity conferred by one attack of syphilis are very rare, and their existence in any case is by many called in question. But I am inclined to think that the " unicity" of the syphilitic virus is not so universal as has sometimes been asserted. Not a few cases have been reported as exceptions to the law,1 which have been severely, and sometimes, I think, unfairly criticized; nor can I regard the explanation of Diday2 as satisfactory, who, while main- taining that the law is always true, still admits "constitutional syphilis in two fasciculi" ("ve*role en deux livraisons comple*- mentaires"); by which he means that one mild attack of syphilis may only partially exhaust the susceptibility of the system, and a second attack accomplish what the first left undone. M. Diday endeavors to show by a recital of cases, that in these instances of double infection, the constitutional symptoms of each are the coun- terpart of those of the other; that if, for example, in the first attack, the skin was chiefly affected, the most prominent symptoms in the second will be seated upon the mucous membranes; that if febrile symptoms ushered in the eruption in the former, they will be ab- sent in the latter, etc.; so that to this surgeon the "unicity of 1 Follin, Revue Critique, Arch. Gen. de Med., Jan. 1856, p. 86. Gamberim, Gaz. Med. de Paris, 21e annee, p. 1. Rodet, Gaz. Med. de Lyon, 1857, p. 212. 2 Nouvelles Doctrines sur la Syphilis, Paris, 1858, p. 345. CONSTITUTIONAL SYPHILIS. 351 syphilis" signifies, not that syphilis never affects the same person twice, but that it " never affects the same person twice in the same manner." This explanation, .although ingenious, can be regarded as little more than begging the question. For my own part, I cannot regard this law as absolute, though it is doubtless more nearly so than in kindred contagious diseases, as variola, vaccinia, etc. I believe it to be true as a general rule, but that, in rare instances, two attacks are possible, as in the affections just alluded to. Eicord, who first announced the general truth of this law, has always stated that he believed exceptions possible and was anxious to admit them, since they would show that the syphi- litic diathesis did not necessarily last as long as the life of the indi- vidual ; but up to the time of the publication of his last work, in 1858, he had met with none which were satisfactory.1 Eecent French journals, however, report the following case, which is said to have carried conviction to the minds of Eicord, Puche, and Cul- lerier, and in which, it will be observed, Diday's theory is at fault, since the symptoms were nearly identical in the two attacks. Case. The patient, a brush-maker, 45 years of age, entered the Hopital du Midi, in 1838, with an induration remaining after the cicatrization of a chancre; red spots upon the chest, abdomen, and internal surface of each arm; and mucous patches upon the cicatrix and the scrotum. Ricord's diagnosis, as noted in the hospital record, was: "Chancre; syphilis." Under the administration of the protiodide of mercury, the symptoms disappeared. The patient had a suspicious connection in the month of June, 1859; three weeks after a chancre appeared on the integument of the penis, and in two or three days two others, one on the skin in the neighborhood of the first, the other on the site of the old cicatrix in the groove behind the corona glandis. The first chancre was not seen, but the other two presented all the characteristics of indurated chancres; the glands in each groin, aud in the post-cervical region, were also indurated. No local treatment was prescribed, and the patient was directed to appear at the consultation at the hospital once a week for further observation. Two months after the appearance of the chancres, rose-colored papula? ap- peared on the abdomen; a week afterwards, the chest, arms, and belly were covered with a papulo-lenticular syphilitic eruption ; scabs were found in the hairy scalp, and mucous patches on the uvula. All these Lecons sur le Chancre, p. 159. 352 INTRODUCTORY REMARKS. symptoms disappeared in three weeks under the administration of the protiodide of mercury.1 The doctrine we have been discussing has its practical as well as theoretical bearings. 1. Its all but universal truth shows that, as a general rule, one attack of constitutional syphilis leaves its impress upon the system for life, in the same manner that the vaccine virus does; and that any attempt to eradicate the diathesis by medication would proba- bly be as fruitless in one'case as in the other. The syphilitic " disposition," as Hunter called it, being once formed, the power of mercury is limited to retarding, preventing, and suppressing its "action," but "it does not destroy the disposition."2 The cure of constitutional syphilis, if by that term is meant the restoration of the patient to his original condition, is impossible; though we may still hope to prevent by treatment any farther activity of the latent poison. If this can be accomplished, Eicord suggests that the patient will be left as after variola, simply protected from future attacks. 2. The exceptional cases of double constitutional syphilis show that, in a few fortunate instances, the diathesis becomes very much weakened or dies out in time. 3. If a man who was once known to have constitutional syphilis contracts a fresh chancre, there is but little danger of a second infection of the system; and even those who believe in the necessity of specific treatment on the first appearance of a primary sore, may consistently abstain from employing mercury. Diday relates an instance in which he permitted a patient to marry immediately after the cicatrization of an ulcer suspected of being an infecting chancre, on the ground that he had formerly had constitutional syphilis and was not likely to have it again. No evil consequences ensued. In another case reported by this author, a man who had been very dissipated in his youth married and became the father of several cachectic children, whom the family physician, knowing 1 Gazette Hebdomadaire, 27 Janv. 1860, from the Moniteur des Sciences, 14 Janv. 1860. [Since the above was written, the second edition of Ricord's Lemons sur le Chancre has appeared, in which the author acknowledges having met with two instances in which constitutional syphilis was contracted twice by the same per- son.] 2 Ricord's Notes to Hunter, 2d ed., p. 417. It would be well if we could also say with Hunter that " mercury hinders a disposition from forming, or, in other words, prevents contamination." CONSTITUTIONAL SYPHILIS. 353 the man's antecedents, suspected of being affected with hereditary syphilis, and was preparing to treat them with a course of mercury. At this juncture, the father contracted an indurated chancre, followed by fully developed constitutional syphilis, and his children, no sus- picion being attached to the mother, were exempted from specific treatment, in the belief that if the father had now become infected he could riot have been infected before.1 It may not appear that sufficient caution was exercised in these cases considering the risk at stake, but they will serve to show the assistance to be derived from the law of " unicity" in some difficult cases of diagnosis. The two remaining points of analogy between syphilis and other infectious diseases, viz., the period of incubation, and the regular order in the appearance of the symptoms, will more properly be considered in the chapter introductory to constitutional syphilis. I would also request the reader's attention to some remarks in the chapter on chancres relative to the question whether the infecting species is preceded by incubation. If this be admitted, there are two periods of incubation of the virus; one between the act of contagion and the appearance of the chancre, another between the latter and the outbreak of general symptoms. Independently of the points of resemblance traced in this analogy, syphilis possesses certain characteristics peculiar to itself, and which are found in no other contagious disease. No other affection to which man is liable so powerfully modifies the constitution for the remainder of life, nor exercises so great an influence upon posterity. In man as well as the lower animals, peculiarities of structure and of character are transmitted from parents to their offspring; but what acquired disease other than syphilis can be conveyed by the sperm to the ovum, and through it contaminate the mother and her children by another father ? The classification and nomenclature of syphilis, as we have received them from preceding generations, are extremely faulty, and require complete revision. Syphilis is commonly divided into "primary," and "constitutional" or "general." Primary syphilis is made to include all chancres, whether simple or infecting, and buboes. Constitutional syphilis comprises the general symptoms which follow infection of the system, and which are separated from the primary by a period of incubation. 23 1 Nouvelles Doctrines sur la Syphilis, p. 350. 354 INTRODUCTORY REMARKS. General symptoms are subdivided into secondary and tertiary. The term " consecutive," which is applied by some authors to gen- eral symptoms, is used by Eicord to denote a subdivision of the primary, and is made to include those lesions which immediately succeed the first developed chancre, and which are similar to it in character, viz., chancres which spring up in the neighborhood from subsequent inoculation, and buboes. It is evident that this classification does not distinguish between the simple, and the infecting chancre and its consequences; and is thus attended with great confusion;—not to say, absurdity. For instance, we may well call the infecting chancre "primary," because it is the first symptom which appears after contagion, and, after a period of incubation, is followed by lesions which may be called secondary. But why give the name of " primary" to the chancroid, which is not the first of a series, and which has no secondary ? Again, the term " primary" is commonly used as synonymous with local syphilis; and this is implied by the name of "constitu- tional" being given to the next division. But an indurated chancre is a primary symptom, and yet induration is undoubtedly an effect of .general infection of the system. To avoid this difficulty, Mai- sonneuve and Montannier have endeavored to make a distinction between the sore itself and its induration, by classifying the former among primary and the latter among secondary symptoms; and they would thus make a secondary symptom coexist with a primary and be separated from all other secondary symptoms by a period of incubation! * I shall in the next chapter adduce proof to show that the infecting chancre from the earliest period of its existence is not a local but a constitutional lesion. When using the term primary, therefore, as applied to the first period of true syphilis, I shall by no means intend to imply that any symptom included in that division is a local affection. With this explanation the term may be retained, since its application to the indurated chancre and its accompanying indurated bubo, which are separated from other consequences of infection by an interval of incubation, is most appropriate. I would also remark that, in accordance with custom, I shall sometimes employ the term constitutional as synonymous with general, symptoms, but without meaning to assert that these are the only results of infection of the system. CHANCRES. 355 CHAPTER II. CHANCEES. A " chancroid" is the local and contagious ulcer, which, being most frequently transmitted in sexual intercourse, chiefly affects the genital organs. A " chancre" is the initiatory lesion of acquired syphilis, arising at the point at which the virus enters the system, and separated from the general manifestations of constitutional infection by a period of incubation. It has been generally supposed that the virus of a chancre could alone give rise to a chancre; recent investigations, however, appear to show that the conditions of the above definition are fulfilled, whatever may have been the source of the virus, whether derived from a primary or secondary lesion. In common parlance, both the chancroid and the true syphilitic sore are included under the name of " chancre." I propose, in the first place, to consider the two together in respect to their situation, the circumstances under which contagion takes place, and the forms which they assume, and afterwards to describe each in detail. • Seat of Chancres.—Chancres are most frequently seated in the neighborhood of the genital organs, simply because these parts are most exposed to contagion and not in consequence of any peculiar aptitude which they possess. If the chancrous virus be inserted beneath the epidermis of any other part of the body a chancre is equally the result. Nor is this the limit to the seat of primary sores: they are also found within the various mucous canals—as the urethra, vagina, rectum, and buccal and nasal cavities—opening upon the surface, at as great a depth as these passages can be ex- plored by the senses during life; and post-mortem examinations have proved the possibility of their presence in the bladder, though such instances are extremely rare. The whole external integument, 356 CHANCRES. and whatever portions of the mucous membranes are accessible to the implantation of the virus, are therefore exposed to become the seat of chancres. The frequency with which they are met elsewhere than upon the genitals, depends in a great measure upon the habits and cleanliness of persons exposed to contagion. Among the situations in which chancres have been observed, but where they may readily pass unnoticed, are the following: the margin of the anus and cavity of the rectum; the vaginal walls, os uteri, and cervical cavity; within the urethra and bladder; under the nails of the fingers and toes; upon the breasts; on the hairy scalp and conjunctiva oculi; upon the lips, internal surface of the cheeks, and the mucous membrane of the fauces and pharynx. The following table exhibits the seat of 814 chancres, comprising all that were observed at the Hopital du Midi, in the year 1856.1 Indurated. Simple. Chancres on the glans and prepuce.....314 296 " on the skin of the penis ...... 60 15 " on various parts of the penis.....11 17 " involving the meatus......32 9 " within the urethra (not visible on forced separation of the lips of the meatus, but recognized by in- oculation, palpation, inflammation of the lym- phatics, etc.).......17 3 " on the scrotum and peno-scrotal angle . . . 11 " of the anus........Q 2 " " lips........12 " " tongue.......3 " " nose ••...... 1 " " pituitary membrane.....1 " " fingers ........ 1 \ "leg........1 To the statement above made relative to the extent of the possi- ble seat of chancres, there is an important exception, viz., that the non-infecting primary ulcer is rarely, if ever, met with upon the head or face. By whom this fact was first noticed, is not known, but it began to attract attention while the duality of the chancrous virus was under discussion, and was used as a strong argument against the new doctrine by those who maintained the unity of syphilis. "If there are two species of chancre," it was said, "both should be met with indiscriminately upon all parts of the body; but all chancres upon the lips, tongue, face, and head, are indurated 1 Fouknier, Lecons sur le Chancre, p. 252. SEAT OF CHANCRES. 357 —none are simple; does not this prove that induration is depend- ent upon the seat of the sore, and not upon the nature of the virus ?" The important bearing of this question led to an exten- sive investigation for the purpose of ascertaining if the alleged exemption was founded on fact. Fournier1 took a prominent part in this labor, and, from a diligent search through medical works and inquiry of those who made a special study of venereal, was able to collect 150 cases of primary sores upon the head and face, » all of which, however, with the exception of 5, were hard chancres. These five exceptional cases, in which the ulcer was supposed to be a chancroid, were observed by MM. Eicord, Venot, Devergie, Bas- sereau, and Diday; but Eicord confessed that his case, a chancre at the base of one of the superior incisor teeth (figured in his Icono- graphie, pi. 21), was unreliable, and the other four were all imper- fectly reported; and thus there could remain no doubt of the rarity, if not of the entire absence, of the soft chancre upon the region in question. This discovery led to considerable speculation, and various theo- ries were offered in explanation, of which the one advanced by MM. Diday and Fournier was perhaps the most probable, viz., that the absence of the soft chancre upon the head and face is due to local idiosyncrasy, similar to that which leads many other diseases to select certain regions, and avoid others of the same anatomical structure. Thus, gonorrhoea, croup, and rheumatism, attack respec- tively the eye, larynx, and pericardium, and spare the nose, oeso- phagus, and peritoneum; and scabies is never met with upon the face. Fournier was also able in several instances to trace out the origin of hard chancres upon the head and face, and found that there was never an interchange of the two species, but that they invaria- bly arose from hard chancres; hence, admitting the absence of the chancroid upon this region in clinical experience it constitutes no argument against the duality of the chancrous virus. It has been since ascertained that the chancroid can be developed upon the head and face by artificial inoculation. Puche2 and Eol- let3 have inoculated its virus with success upon different parts of 1 Etude sur le Chancre Cephalique, Union Medicale, Feb. and March, 1858. 2 Nadau des Islets, De l'lnoculation du Chancre mou & la Region Cuphalique, These de Paris, 1858. 3 Gaz. M5d. de Lyon, Dec. 1857. 358 CHANCRES. the head in 20 instances; Bassereau1 and Prof. Huebbenet,2 of Kieff) upon the lips and cheeks in five, and in all the sore so produced was entirely free from induration and was not followed by second- ary symptoms. The ease with which the chancroid was developed does not favor the idea of local inaptitude, and it may be necessary to seek for another explanation of the great preponderance of the hard chancre upon the cephalic region. Such may readily be found if we suppose, with Eollet, that it originates in many cases in a secondary lesion, which, as is now believed, communicates a chancre by contagion. Contact is no less frequent and intimate between mouth and mouth than between the genital organs of the two sexes, and the former region is almost as peculiarly the seat of secondary manifestations as the latter are of primary. I shall content myself with this brief sketch of the discussion relative to the "cephalic chancre," which for a time attracted no little attention, but which assumes less importance now that it is known not to conflict with the duality of the chancrous virus. Its only practical bearing is this: that the rarity, if not the entire ab- sence of the chancroid upon the head and face, furnishes strong ground of belief that any primary sore met with upon this region is of the infecting species, and may, therefore, assist in forming a diagnosis. Contagion.—Simple contact of the syphilitic virus with a raw sur- face is sufficient to give rise to a chancre. The most favorable condi- tion for contagion to take place is the presence of abrasions or other solutions of continuity, such as are frequently occasioned by violence during coitus, and through which the poison may penetrate beneath the epidermis or epithelium. The application of virulent matter to the sound external integument hardened by exposure and friction, is as innocuous as the deposit of vaccine virus upon the skin without previous puncture. The surgeon frequently soils his fingers with the secretion of chancres, and this with impunity so long as their surface is intact, but if abraded in the slightest degree, he is liable to contract a primary sore. Numerous instances of this accident are recorded, and one has occurred within my own circle of acquaint- ance, in which a young surgeon thus became infected with consti- tutional syphilis. Cullerier's experiments relative to mediate contagion establish 1 Buzenet, Du Chancre de la Bouche, These de Paris, 1858, p. 41. 2 L'Union Medicale, May 20, 1858. CONTAGION. 359 the fact that virulent pus may be retained for some time in the vagina without effect upon the delicate mucous membrane lining its walls. As a general rule, however, mucous surfaces offer a much less effectual barrier to contagion than the external integument, and are, therefore, most frequently the seat of chancres. Even when no solution of continuity has prepared the way, the virus de- posited in some fold of the membrane or in an open follicle, may act as an irritant, produce a superficial erosion, and thus gain en- trance beneath the surface. The greater or less time occupied by this process will account in a measure for the variable period after exposure at which chancres appear, though in the case of the infect- ing chancre there are other and more important influences bearing upon this point which will be considered hereafter. It would appear that the virus of the chancroid when applied to the human tissues takes effect more readily than that of the syphi- litic chancre. The pus of the soft chancre may be inoculated with almost absolute certainty of success, if the operation be properly performed. On the contrary, inoculation of the secretion of a hard chancre sometimes fails even in the most expert hands and upon subjects free from syphilitic taint. According to Fournier,1 M. Puche was unsuccessful in three attempts to implant the indurated chancre upon healthy individuals, and Eicord and Ouvry in a fourth. Four- nier adds that instances of escape from contagion after exposure are not uncommon with the infecting, but are rare with the simple chan- cre ; and that most of the reported cases of mediate contagion belong to the former species. The chancrous virus, like the poison of gonorrhoea employed in inoculations for the relief of pannus, retains its power of contagion for a considerable length of time. Eicord states that he has inocu- lated it with success after preserving it in glass tubes hermetically sealed for seventeen days. Sperino relates a remarkable instance of the preservation of the virulent properties of the chancroidal virus. A lancet which had been employed in artificial inoculation had been laid aside for seven months, when it was observed that a small quan- tity of dried pus had been left upon its point. The instrument was moistened, and three punctures made with it gave rise to as many soft chancres. The transfer of matter necessary to contagion most frequently 1 De la Contagion Syphilitique, Paris, 1860, p. 106. 360 CHANCRES. takes place during coitus, but may be accomplished through the intervention of almost any agent, as the fingers, household utensils in common use, etc. I have recently seen an infecting chancre upon the upper eyelid of a boy whose father had a similar sore, and who probably was infected by using the same towel. Eeliable cases are reported in which a pipe, tumbler, pen, or pencil was the vehicle of transport. Such instances are perfectly in accordance with the phe- nomena of contagion in other infectious diseases, and cannot be ignored, although they should not induce a blind confidence in all the statements of patients, who often wish to escape the responsibility of their own acts. Much tact and judgment on the part of the sur- geon are often requisite to arrive at the truth. It sometimes happens that the origin of a chancre is clearly trace- able to a man or woman who is found, on the most careful exami- nation, to be entirely well. A man, for instance, has connection with a woman of the town who has cohabited with several men within a short time, and contracts a chancre; the woman is submitted to a speculum examination, and her genital organs, to their utmost visi- ble recesses, are found to be intact. Again, a husband visits a prostitute, and, returning home, has intercourse with his wife, who becomes infected while he escapes. The observation of facts like these led the earlier surgeons after the appearance of syphilis, to believe in the possibility of " mediate contagion," or the transport of virulent pus from one person to another by the genital organs of a third, which merely serve as a vehicle and are not themselves inoculated; and this supposition, which has often been rejected as fanciful by modern authors, has been proved to be not only possible but highly probable by some interesting experiments of M. Culle- rier, one of which is reported as follows:— Louise Yaudet entered the Lourcine Hospital Oct. 10, 1848, to be treated for an ulcer of a grayish aspect and with sharply cut edges in each groin, which had already persisted without treatment for a month. There was considerable surrounding inflammation, which was subdued by rest and poultices, when the genital organs and anus were carefully ex- amined and found to be free from ulceration. The vagina was reddened and smeared with an abundant muco-purulent secretion, hut its mucous surface was intact and the os uteri healthy. The inguinal ulcers were dressed with charpie moistened in aromatic wine, and vaginal injections of a solution of alum ordered; under which treatment the sores and vaginitis rapidly improved. FORM OF CHANCRES. 361 Nov. 25, after finding on a second examination that the mucous mem- brane of the vulva and vagina was, as before, intact, and after inoculating without success the vaginal secretion, M. Cullerier collected upon a spatula a considerable quantity of pus from the chancres in the groins and deposited it in the vagina. The patient was then directed to walk about under surveillance lest she should touch the parts, and at the end of thirty- five minutes was again placed upon the bed, and some of the fluid found in the vagina was inoculated upon her thigh. The vagina and vulva were then freely washed with water, dried, and washed a second time with a solution of alum. Two days after, the inoculation had produced the char- acteristic pustule of a chancre, which was left another twenty-four hours to confirm the diagnosis and then destroyed with Vienna paste. Repeated subsequent examination showed that no ulceration had been caused in the vagina, which was not even more inflamed than before. In two months the patient left the hospital cured of both her vaginitis and* inguinal ulcers. In a second case in which this experiment was performed, the pus was allowed to remain in the vagina for nearly an hour and did not take effect.1 Form of Chancres.—When we recollect that the essential difference between a chancre and any other sore is the presence in the former of a virus which has never been made manifest to the senses—that contagious pus inoculates the whole of any solution of continuity, whatever its form, which has opened a door of entrance into the economy—that chancres like other ulcers are exposed to the com- mon causes of irritation and extension, as friction, the stagnation and concretion of matter, etc., we cannot be surprised that primary sores do not always present the same external aspect; indeed, we may rather be astonished that they are ever recognizable except by their power of contagion. Again, if we examine the symptoms which have commonly been received as characteristic of a chancre, we find that they may nearly all be produced by non-specific causes; that they therefore owe their diagnostic value simply to their greater frequency in primary sores; and that they may be present to a greater or less degree in ulcers other than those which secrete a specific virus. Take for instance the simple chancre; its circular outline is but the effect of ulceration advancing with equal rapidity in all directions from a common centre when the sore is situated upon homogeneous tissues; 1 Quelques Points de la Contagion mediate. Memoires de la Soc. de Chir., quoted in Lecons sur le Chancre, p. 255. 362 CHANCRES. if the seat of the chancre include structures of different density, as the prepuce and glans penis, the rounded form is lost; its sharply cut edges and grayish floor are also results of the same progressive ulcerative action inducing superficial gangrene of the submucous cellular tissue; its areola is only the hyperemia of the surrounding capillary vessels. Again, the plastic inflammation which charac- terizes the infecting chancre tends to limit the ulcerative process, to diminish the depth of the sore, give it sloping edges, and ap- proximate the appearance of its surface to the normal color of the tissues upon which it is situated; if subjected to irritation, how- ever, it extends in surface and in depth, its edges become more sharply defined, its floor covered with a grayish secretion, and its general aspect approximates to that of a soft chancre. In fact, the induration surrounding and underlying the infecting chancre is the only feature to be found in the two species of primary sore, which, in its well defined outline, cartilaginous hardness and persistency, differs from the ordinary effect of common inflammation. I do not wish by these remarks to underrate the objective symp- toms of chancres, nor to deny that, in the great majority of cases, they are sufficient to indicate the nature of the ulcer; but the ten- dency has undoubtedly been to regard certain characters, which are not constant, as essential, and hence have arisen many errors of diagnosis. For example, the classic chancre or chancre-type, was for years described as a rounded ulcer, with sharply cut edges and a grayish aspect; whereas it is now known that the form of primary sore which is most frequently followed by constitutional syphilis, is not an ulcer at all, but a superficial erosion, which has unquestion- ably, in numerous instances, been overlooked in consequence of implicit faith in certain symptoms which this variety does not possess. The inconstancy of chancres is not so great, however, but that they may nearly all be included under the following forms, viz: 1. Superficial erosions; 2. Pustules; 3. Simple ulcers; 4. Phage- denic ulcers; 5. Gangrenous ulcers. Both the simple and infecting chancre may assume either of these forms, but each has its favorite. The superficial erosion is almost exclusively confined to the in- fecting chancre. It does not involve the whole thickness of the skin or mucous membrane, and heals without leaving a cicatrix. A pustule is always observed after successful inoculation of the chancroid, when the inoculated point is protected from abrasion; if ARTIFICIAL INOCULATION. 363 left unbroken, it is soon covered by a dark scab under which the pus burrows and extends; if ruptured, the following form is found beneath it. The simple excavated ulcer belongs especially to the simple chancre, but is not unfrequently assumed by the infecting primary sore, par- ticularly when subjected to irritation. It involves the whole thick- ness of the skin or mucous membrane, and, on healing, leaves a cicatrix behind. Phagedenic ulcers are much more frequently simple than infect- ing chancres. The ulcerative action varies greatly in different cases, and thus occasions wide differences in the aspect of the sore. Gangrene may attack either species of chancre in consequence of excessive inflammation of the neighboring tissues. A dark-colored eschar is formed, and when this is detached the chancre is generally found to be transformed into a simple ulcer, as after the application of a powerful caustic. With the exception of some phagedenic chancres, all primary ulcers will sooner or later heal spontaneously. Either with or without treatment, they gradually lose the characteristics of a spe- cific sore, and, before cicatrization takes place, their power of con- tagion ; in short, they are transformed from specific into simple ulcers. The existence of a chancre has, therefore, been divided into two periods: the first including the time during which the ulcer— still progressing or stationary—secretes contagious pus; the second the final stage during which its secretion is innocuous. The divid- ing line between these two periods cannot always be determined with accuracy; it is, however, important to recollect that in the latter portion of the existence of a ahancre inoculation is no longer of value as an assistance to diagnosis. Artificial Inoculation.—To artificial inoculation, which was first employed to any great extent by Eicord, we are indebted for much of the progress which has been made in our knowledge of syphilis since the commencement of the present century; and I make this statement fully aware of the fact that this valuable means of inves- tigation has sometimes led into error, and that its application is much more limited than it was supposed to be before the recent dis- covery that infecting chancres, like the secretions of constitutional syphilis, cannot be inoculated upon the person bearing them. In performing artificial inoculation, some convenient part of the integument, as the arm, thigh, or abdomen, is selected, and a super- 364 CHANCRES. ficial puncture made beneath the epidermis, as in inoculating the vac- cine virus. The lancet employed should be new, or freshly ground, and little, if any, blood should be drawn, lest it wash away the virus, and invalidate the experiment; if more appear than is barely sufficient to redden the part, a fresh puncture should be made. Some of the secretion which it is desired to test should now be in- serted in the wound, and the inoculated point covered with a watch- glass to protect it from abrasion. The glass is retained in place by strips of adhesive plaster arranged around its margin, and leaving the centre free through which the effect may be observed. If the inoculation be successful, the point of puncture becomes red in the course of a few hours; by the second or third day, it has swollen, and forms a small papule, surrounded by a reddish areola; on the third or fourth day, the epidermis is raised by an effusion of serum which soon becomes turbid from an admixture of pus; by the fifth day the fluid is decidedly purulent, and forms a pustule, the sum- mit of which is often umbilicated like the pustule of variola; mean- while, th& surrounding areola has been increasing in width and depth of color, and has now attained its height. The pustule thus formed is often termed the " characteristic pustule" of a successful inoculation, and is identical in appearance with the pustule of ec- thyma ; if any doubt remain as to its nature, its secretion may be tested by a second inoculation. If the pustule be left unbroken, the contained matter concretes, and forms a scab of a conical form, which increases by additions to its circumference. If this scab be removed, an ulcer is found beneath it, which* has been regarded as the type of a chancre. Its peculiarities are, that it penetrates the whole thickness of the skin or mucous membrane, so that its floor is formed by the subjacent cellular tissue; its edges are abrupt, jagged, and often slightly undermined; its outline is circular; its surface is of a grayish color, and uneven, presenting slight eleva- tions and depressions which are best seen through a magnifying glass. The tendency of this ulcer is to extend, or, at least, not to diminish, for weeks; and in this it again differs from the pustule and more superficial ulceration, which may be'induced by the ino- culation of simple but irritant matter. Such is the evolution of a chancre after artificial inoculation, as observed by Eicord and others, in many thousand instances. From the immediateness with which the morbid process uniformly fol- lowed the insertion of the virus, Eicord was led to deny that a ARTIFICIAL INOCULATION. 365 chancre has any period of incubation, and to explain the reported cases of its tardy appearance, on the supposition that it had passed for some time unnoticed. This and other inferences from experi- mental inoculation have, however, been invalidated, so far as they have been applied to both species of chancre indiscriminately, by the discovery that the secretion of a hard chancre is not inoculable upon the individual bearing it, or upon any person whose system is already under the influence of constitutional syphilis. Singular as it may appear that this fact was never known before, its truth is fully established by the recent experiments of numerous observers. But Eicord's inoculations were always performed upon the pa- tient's own person, and never upon healthy individuals; hence, the virus employed when the result was positive must necessarily have been, with rare exceptions, that of a soft chancre, and the con- clusions which were drawn can only be admitted as true of this species of primary sore. To obtain an equal amount of informa- tion relative to the evolution of infecting chancres, would require a repetition of these experiments with the virus of true syphilis upon persons free from syphilitic taint, but such a course, so inevi- tably detrimental to the constitution for life, cannot be justified, and has never been attempted, except in a few instances, by Wallace, Waller, Yidal, Einecker, and some others. We shall presently see that clinical observation teaches the existence of a period of incu- bation for infecting chancres, which is wanting in the chancroid. A consideration of these facts also leads to the conclusion that the unsuccessful inoculation, upon a person already infected, of the secretion of any sore, is no proof of its simple nature; and hence that the value of this test in the diagnosis of primary ulcers has been greatly exaggerated, since it fails in those very instances in which it is most important that it should be reliable. "Auto- inoculation"—as it has sometimes been called—can only be em- ployed to indicate the presence or absence of the chancroidal virus. Artificial inoculation of the secretion of a chancre upon the person bearing it does not increase the danger of constitutional infection, which is never dependent upon the number or extent of the ulcerations. It has, however, been known to develope phage- denic ulcers of an exceedingly troublesome character and which were a long time in healing. I have myself seen two cases; one in the New York Hospital, in which artificial inoculation, performed before the patient's entrance, had given rise to an extensive ulcer 366 CHANCRES. upon the thigh of several years' duration; and another in the Pennsylvania Hospital, Philadelphia. Other cases are reported in works on venereal. With due caution, however, this accident may be avoided, and artificial inoculation be employed with safety for the purposes to which it is applicable. So soon as the pustule is developed—on the third or fourth day after inoculation—it should be destroyed by a strong caustic, as Vienna paste or nitric acid; if cauterization be deferred till the fifth or sixth day, the neighboring tissues may have become so infiltrated with the virus that the most thorough application will fail to include them all and to transform the specific into a simple ulcer. CLASSIFICATION OF CHANCRES. The only radical distinction between chancres sufficient to con- stitute distinct species is that existing between the simple and infecting chancres; there are, however, several sub-varieties. Both kinds of chancrous virus may be present in the same sore, which is then denominated a " mixed chancre;" and either species of chancre may be attacked by violent inflammation terminating in gangrene, or by phagedena; whence arise "gangrenous" and "phagedenic chancres." We have therefore to consider:— 1. The simple chancre. 2. The infecting chancre. 3. The mixed chancre. 4. The gangrenous chancre. 5. The phagedenic chancre. Comparative Frequency of the Simple and Infecting Chancre.— Simple chancres constitute by far the larger proportion of primary ulcers. Of 341 chancres observed at the Hopital du Midi in the course of three months, 126 were infecting and 215 simple. M. Puche has prepared a table of all the primary sores under treat- ment at the same hospital during ten years (1840—1850), forming a total of 10,000 chancres, of which 1955 were infecting and 8045 were simple -} in other words, the ratio of the former to the latter was nearly as 1 to 4. The statistics of other observers vary some- what from the above, but they all concur in showing the greater frequency of the soft chancre. Eicord explains this difference on 1 Fournier, Lecons sur le Chancre, p. 15. SIMPLE CHANCRE. 367 two grounds: first, that the chancroid furnishes a more copious secretion, and generally for a longer period, than the chancre; and, secondly, that an attack of the former, unlike one of the latter, affords no protection against subsequent contagion. The greater difficulty also of inoculating the infecting ulcer is probably not without influence. Simple Chancre.—This species of primary sore is also known as the "chancroid," "soft chancre," "non-infecting chancre," and " contagious ulcer." The phenomena following artificial inoculation as above de- scribed, exhibit the mode of evolution of the soft chancre and the various forms it may assume. It is not preceded by a period of incubation. The ulcerative process commences immediately upon implantation of the virus, and is sufficiently advanced to attract the notice of the patient in from two to eight days after contagion. The late period at which a few soft chancres are observed is to be ascribed to the contagious matter having remained for some time upon the surface before penetrating beneath the epidermis or epi- thelium, or else to the sore having been overlooked. When the part inoculated is the internal surface of a follicle or fissure, the mouth or edges of which close over the imprisoned virus, the resulting chancroid first appears as a pustule or small abscess, which remains intact for a longer or shorter period, according as it is protected, or not, from abrasion. The pustular form of chancre is, however, not common, except as the result of artificial inocula- tion—or, rather, the pustule is usually ruptured before the patient comes under observation, and only the ulcer-beneath it remains. When contagious matter has inoculated a previous solution of con- tinuity, the chancroid is from the outset an open sore, at first corre- sponding in shape and size to the fissure, rent, or abrasion, in which it is developed, and gradually assuming the more marked characters of a specific ulcer. The soft chancre, when fully formed, presents the following symptoms: its outline is circular, unless modified by the shape of the solution of continuity in which it is implanted; by a differ- ence in the density of the tissues beneath it, as when seated upon the margin of the glans penis and prepuce, when it extends most rapidly in Avhatever direction the tissues are most lax; or, by the union of several adjacent chancroids, when the resultant ulcer 368 CHANCRES. may be very irregular. Chancroids upon the free margin of the prepuce appear like slits or fissures, while the glans is covered, but when the latter is exposed, are found to be nearly circular. The rapid perforation of the skin or mucous surface by the chancroid, appearing as if .a portion of the membrane had been punched out, is highly characteristic of this species of primary sore. The edges are jagged, abrupt, and sharply cut, and do not adhere closely to the subjacent tissues. The floor of the ulcer is uneven, studded with minute elevations, " worm eaten," and covered with a pseudo-membranous secretion of a grayish-yellow color, which cannot be removed without violence. The fluid secretion is copious and purulent; under the microscope it is found to consist of pus- globules mixed with organic detritus. The simple chancre is surrounded by an areola which varies in width and depth of color with the degree of attendant inflammation. The condition of the tissues around and beneath the chancroid is one of the most important elements of diagnosis between this and the infecting chancre. In the form we are now considering, the parts always preserve their normal softness and suppleness, unless subjected to some irritant, or attacked by simple inflammation. Inflammatory engorgement, however, is not well defined like the specific induration of the infecting chancre, but gradually subsides into the normal suppleness of the neighboring tissues, to which it is adherent; it is also less firm, and of a more doughy feel, and dis- appears shortly after the cessation of the inflammation which occa- sioned it. The application of any astringent lotion, or caustic, as nitrate of silver, potassa fusa, nitric acid, etc., may cause hardness which so closely resembles specific induration, that it cannot be distinguished from it, except by its shorter duration; and, for the time being, the diagnosis must be founded upon other symptoms. Still another source of error is the possibility of a chancroid being situated upon the persistent induration of a previous infecting ulcer. Simple chancres are more frequently multiple than single. Of 254 patients in the Hopital du Midi, 48 bore one, and 206 several simple chancres; and of the latter, 116 had from three to six; 41 from six to ten; 8 from ten to fifteen; 4 from fifteen to twenty; and 5 over twenty.1 Of 118 patients in the Antiquaille Hospital at Fourkier, op. cit., p. 41. INFECTING CHANCRE. 369 Lyons, affected with soft chancres, 50 presented one, and 68 several.1 When but one chancroid appears at the outset as the immediate result of contagion, others are apt to spring up around it from suc- cessive inoculation, since the original ulcer pours out an abundant secretion, and its presence confers no immunity against others. A simple chancre is very persistent. Unless it can be destroyed by a strong caustic or otherwise, it will generally last for weeks or months, however skilfully it may be treated either by local or con- stitutional remedies. Fournier has shown that it may be inoculated upon the person bearing it up to the time when cicatrization is nearly complete: as Eicord expresses it, the specific period of the chancroid absorbs nearly the whole of its existence. During the reparative period, a simple chancre sometimes fills up with granu- lations to a level with the surrounding surface and simulates a .mucous patch or tubercle, a symptom of constitutional syphilis. The absence of other general symptoms and the condition of the neighboring ganglia are generally sufficient to establish the diag- nosis ; or the sore may be tested by inoculation. If it be a soft chancre, it can be inoculated upon the person bearing it, but not if it be a true mucous patch. An examination of the neighboring lymphatic ganglia affords assistance of the highest value in distinguishing the two species of chancre, for the details of which the reader is referred to the chapter upon buboes. The soft chancre may or may not affect the condition of these ganglia. Of 267 cases of chancroid observed at the Hopital du Midi in one year, 65 were attended with bubo, and 142 were not.2 Of 140 patients in the service of M. Eollet at Lyons, 52 were free from inguinal reaction, while 83 had buboes of which 60 were virulent.3 The affection of the lymphatic ganglia attendant upon the simple chancre is limited to but one of these bodies, is always inflammatory, and tends to suppuration; and this alone of the two species of chancre can give rise to a suppurating bubo the pus of which is inoculable. Infecting Chancre.—This species of primary sore, from its exclusive right to the appellation, is called " the chancre;" some- times also the " true," " hard," " indurated," and " Hunterian" chancre, or " primary syphilitic ulcer." 1 Debaoge, Traiteinent des Chancres Simples, etc., These de Paris, 1858, p. 6. 2 Fournier, op. cit., p. 34. 3 Debauge, op. cit., p. 72. 24 370 CHANCRES. Has the infecting chancre a period of incubation? This is an important question, since it involves two others of great practical interest: 1. Whether the true chancre is a local or constitutional lesion. 2. Whether its abortive treatment can prevent systemic infection. The solution of this question by experimentation is impracticable, since inoculation of the hard chancre upon persons already infected is impossible, and upon healthy individuals un- justifiable. We can, therefore, refer only to clinical observation, and, even here, no slight difficulty is encountered. Patients may not come under observation until some days or weeks after con- tagion ; they have often had sexual connection repeatedly at short intervals; and their statements as to the time of infection and the appearance of the chancre are not always reliable. But many careful observers have noticed the fact that, as a general rule, advice is sought at a later period for infecting chancres than for the chancroid, and the interval between contagion and the appearance of the ulcer is represented by patients as longer in the former than in the latter. Thus Diday made minute inquiry of twenty-nine persons whose chancres were of recent origin; who appeared to be trustworthy, and certain of the facts which they stated; who had been exposed but once, and who had had no previous connection for at least a month, and found that the average interval between the sexual act and the appearance of the sore was fourteen days.1 M. Chabalier, in an examination of ninety cases of infecting chancre, found an average period of incubation of from fifteen to eighteen days; and states that the chancroid, on the contrary, is visible within thirty-six or forty-eight hours after contagion.2 M. Clerc has especially insisted upon the presence or absence of incubation as diagnostic of the two species of primary sore, and has reported several cases of infecting chancre which were preceded by a period of incubation of thirty days. I have myself met with a number of cases in which the interval between a single exposure afnd the appearance of an infecting chancre exceeded ten days, and in one there is every reason to believe that it was of much longer duration. A gentleman of this city, of high social position, whom I know so intimately that I can vouch for the truth of his statements, visited Paris unaccompanied by his wife, and, while under the influence of wine, for the first time during fifteen years of married life, had 1 Gaz. Med. de Lyon, March 1, 1858. 2 These de Paris, No. 52, 1860, p. 111. INFECTING CHANCRE. 371 connection with a woman of the town. This was on the eve of his return to America, and his subsequent remorse and anxiety were so great that on his voyage home he examined himself daily with the greatest care to see if he had contracted any disease. His pre- puce was very short, so that the glans was habitually uncovered and no lesion was likely to escape observation, yet he found nothing until the day of his arrival home, the thirty-fifth after exposure, when he noticed a slight excoriation upon the internal surface of the prepuce. He showed it to his family physician, a Homoeopath, who told him that it was a mere abrasion which would heal in a few days, and that he might with safety have connection with his wife. As the promised cicatrization did not take place, on the fourth day after his arrival he applied to me, and I found a super- ficial chancre with well-marked parchment induration and attendant indurated ganglia. Since then he has had several attacks of con- stitutional syphilis, and his wife, who was in the fifth month of pregnancy, contracted an indurated chancre, had a syphilitic erup- tion, alopecia, iritis, etc., and gave birth to an infected child at term, which, under homoeopathic treatment, died at the age of one month. While writing these pages, my advice has been sought by a very intelligent physician, who was exposed but once to contagion on the night of August 16, and a well-marked indurated chancre which he now bears upon the internal surface of the prepuce first appeared, September 1; making an interval of sixteen days. I have also at the present time under my care a merchant, who has been subject to herpes, and has been in the habit of watching his genital organs very closely after exposure. He now has an infect- ing chancre, which he is positive did not show itself until five weeks after his last coitus. Castelnau reports a case communicated to him by the physician of a venereal hospital, who was himself the subject of the observa- tion, in which an infecting chancre appeared thirty-three days after an impure intercourse.1 But we have still more conclusive evidence of the incubation of the hard chancre in three cases in which the inoculated point was watched from day to day. The first is reported by Eollet. This surgeon, desirous of testing the character of a sore, inoculated its 1 Annales des Maladies de la Peau et de la Syphilis, t. i. p. 212. 372 CHANCRES. secretion without success upon the person bearing it. He then repeated the inoculation upon several persons who were affected with constitutional syphilis, and with the same negative result. This was previous to the discovery of the fact that the infecting chancre is not auto-inoculable; hence Eollet believed it safe to inoculate the secretion of the same sore upon still another indi- vidual, who *was free from true syphilis, although affected with simple chancres and a suppurating bubo. The inoculation proved successful and gave rise to an infecting chancre, which did not make its appearance until the eighteenth day.1 In two other cases of artificial inoculation of the infecting chancre, one performed by Einecker and the other by Gibert, the period of incubation was 25 and 24 days respectively. When speaking of the abortive treatment of chancres, I shall also adduce facts to show that destructive cauterization of an infecting chancre, at a very early period of its existence, does not prevent secondary symptoms, and hence that the system must be regarded as infected from the first. Moreover, the analogy of other infectious diseases, as vaccinia, glanders, etc., leads us to infer that the absorp- tion of the syphilitic virus is instantaneous. Farther observation is required fully to determine why the infecting chancre sometimes appears at an early, and at other times at a late period; although it is probably due to accidental differences in the conditions under which contagion takes place; the virus being implanted in a wound which in some cases continues patent and in others closes until .constitutional reaction is felt. The following table, prepared by M. Bassereau,2 of the chancres which preceded 170 cases of syphilitic erythema, will indicate the various forms which an infecting chancre may assume, and afford some idea of their comparative frequency in the milder cases of the constitutional disease, of which the more severe instances are preceded by a larger proportion of excavated ulcers :—3 Superficial erosions........'. . . 146 Circumscribed ulcers, with abrupt edges, involving the whole thickness of the skin or mucous membrane ......... 14 Circumscribed phagedenic ulcers, with a pultaceous floor, involving the tissues a short distance beyond the skin or mucous membrane . . 10 Total 170 1 Archives Gen. de Med., Avril, 1859, p. 409. 2 Op. cit., p. 140. s gee section on Phagedenic Chancres. INFECTING CHANCRE. 373 It appears from this table that the infecting chancre has no exclusive form, but that it most frequently assumes one which differs widely from the chancre-type as heretofore described by most authors. The frequency of the superficial form of infecting chancre excited my attention several years before I had met with any description of it in books, and the first cases which came under my notice were mistaken for mere abrasions until the appearance of secondary symptoms corrected the diagnosis. Within the last year, a physician, well instructed in the literature of venereal, applied to me with a superficial chancre so closely resembling a simple abrasion that I could not persuade him of its specific cha- racter, and therefore advised him to examine the woman with whom he had had connection and see if she did not present symptoms of syphilis. A few weeks after, they both called at my office; the physician, with syphilitic erythema; his mistress, with syphilitic papulae. The superficial form of infecting chancre is most marked on the internal surface of the prepuce, by which it is protected from the air and friction, and kept free from scabs; and it is in this situation that I have most frequently met with it. It has generally a circular or ovoid, but sometimes irregular, outline. Its floor is but slightly, if at all, excavated, and occasionally is even elevated above the surrounding integument by the subjacent induration. Its surface is smooth, often looking as if polished, destitute of the consistent and adherent exudation of the chancroid, and of a red or grayish color. Its secretion is a clear serum—free from pus-globules, unless the sore has been irritated—which may often be seen issuing from minute pores, after the previous moisture has been wiped away. It has no surrounding areola, and leaves no cicatrix to mark its site. Barely one-third of the chancres in Bassereau's 170 cases, left any visible trace aside from induration. When situated upon the external integument, as the sheath of the penis—where most chan- cres are of the. infecting species—and exposed to the air, it becomes covered with scabs, which give it the appearance of a pustule of ecthyma, or a. patch of scaly eruption, and which may readily lead to an error in diagnosis. The characters of the chancrous erosion are also modified by the application of irritants, or by a want of cleanliness; its secretion may become purulent, and its surface re- semble that of the chancroid; but its normal appearance may be restored by applying a water-dressing for a few days. 374 CHANCRES. Frequent as is the chancrous erosion, it must not be regarded as the exclusive form of the infecting chancre. I am inclined to think it more common among patients of the better class who observe habits of cleanliness, and whose favorable hygienic condition is not conducive to ulceration. Between this form and the indurated ex- cavated ulcer, known as the Hunterian chancre—which was so long and so erroneously supposed to be the especial harbinger of con- stitutional syphilis—there may exist many gradations which it is unnecessary to describe in detail. Ulcerative action may, though rarely, go beyond this point, and terminate in phagedena; but, generally, it is limited by the plastic inflammation of the surround- ing tissues, as is evident from an examination of the edges of nearly all the forms of infecting chancre, which are sloping, somewhat pro- minent, and adherent, unlike the abrupt and detached margins of the chancroid. A pustular form of the infecting chancre is certainly rare in prac- tice, and its occurrence after artificial inoculation, owing to the small number of successful results, doubtful. It would appear, at least in most instances, that the papule which is first developed does not become a pustule, but takes on superficial ulceration. Mr. Henry Lee believes that this is invariably the case, and that a pustule, the result of artificial inoculation, is diagnostic of the chancroid.1 In performing inoculation with the virus of the hard chancre, the lengthy incubation of this species of sore should not be forgotten, nor the result be pronounced negative, until after the lapse of a month or six weeks. We have yet to consider those characters which are common to all the forms of infecting chancre. Induration was recognized at a very early period in the history of syphilis by John de Vigo,2 Gabriel Fallopius,3 Leonard Botal," and Ambrose Pare",5 as a prominent symptom of the chancre which 1 British and Foreign Med.-Chir. Rev., Oct. 1856. 2 "Nam ejus origo in partibus genitalibus, videlicet in vulva in mulieribus et in virga in hominibus, semper fuit cum pustulis parvis, interdum lividi coloris, aliquando nigri, non nunquam subalbidi, cum callositate eas circumdante." (John de Vigo, Practica copiosa in Arte Chirurgica, etc. Rome, 1514, lib. v.) 3 Tractatus de Morbo Gallico, Patavium, 1564. 4 Luis Venerese curandae ratio, Paris, 1563. 5 " S'il y a ulcere a la verge et s'il demeure durete au lieu, telle chose infaillible- ment montre le malade avoir la vairole." (Pare's works, first published at Paris. 1575, Book 19th.) INFECTING CHANCRE. 375 precedes constitutional syphilis; nearly forgotten by subsequent writers, though occasionally mentioned, as by Nicholas Blegny,1 it has again assumed importance in modern times from the teachings of Hunter,2 Bell,3 and especially Eicord, and is now justly regarded as the most characteristic feature of the infecting chancre, when seated upon a person exempt from previous syphilitic taint. The induration of a chancre is a peculiar hardness of the tissues around and beneath the sore. Simple inflammation may occasion an effusion of plastic material and consequent engorgement about any sore; but specific induration is of an entirely distinct character. The latter is formed, as the French say, " a froid," that is, without inflammatory action; the deposit takes place in the absence of all the symptoms of inflammation, "pain, heat, redness, and swelling;" and so silently, so insidiously, that the patient is often ignorant of its presence, or discovers it only by accident. No event is more common than for a surgeon to be consulted by a man who states that he had a sore a few weeks ago, "which did not amount to much;" he "burnt it with caustic and it healed up;" but he has recently found that it left a "lump" behind it. This "lump" is specific induration and denotes that the constitution is infected. A gentleman recently applied to me for phymosis—neither congenital nor inflammatory—which occasioned no inconvenience except an inability to retract the prepuce. He was not aware that he had had any venereal trouble, but, on examination of the parts, a mass of induration as large as an almond was perceptible to the touch and almost to the sight—so great were its dimensions—situated about the furrow at the base of the glans. The phymosis was simply due to the mechanical obstruction presented by the induration to the retraction of the prepuce, and this difficulty alone induced him to seek advice. Frequently, also, patients apply to a surgeon for treat- ment for constitutional syphilis, and honestly declare that they have never had a chancre, though the previous existence of such, and even its very site, are unmistakably indicated by the remaining in- duration. Again, specific induration and inflammatory engorgement differ in their objective symptoms. The boundaries of the former are clearly defined, while the extent of the latter cannot be limited with 1 L'Art de Guenr les Maladies Veneriennes, etc., Paris, 1673. 2 Ricord and Hunter on Venereal, 2d Am. edition, Phil. 1859, p. 286. 5 Treatise on Gonorrhoea Virulenta and Lues Venerea, London, 1793, vol. ii. p. 19. 376 CHANCRES. nicety; the one terminates abruptly, the other shades gradually into the normal suppleness of the part; the first is freely movable upon, the second adherent to, the tissues beneath. The difference in the sensations they impart to the fingers is still greater; specific indu- ration is so firm, hard, and resistent, that it is often compared to a "split-pea"1 or mass of cartilage; the softer and doughy feel of common inflammatory engorgement requires no description. It is hardly necessary to say that there is no incompatibility between these two pathological conditions which can prevent their co-exist- ence, and hence arises, in some few cases, a difficulty of diagnosis. The effect of simple inflammation, however, subsides in a few days, or in a week or two at farthest, and lays bare the specific indura- tion, which may, for a time, have been buried beneath it; and under all circumstances reference may be made to the neighboring ganglia, the induration of which is equally constant and significative with that of the chancre. In the masses of induration of considerable size to which the above description chiefly refers, the adventitious deposit occupies the skin or mucous membrane bordering upon the edges of the sore, and also the cellular tissue beneath it. There is another, but less com- mon form of induration, in which the deposit is confined to the mucous membrane alone, and does not involve the cellular tissue beneath. It most frequently occurs in connection with the super- ficial chancre, and is called the "parchment-induration" because it imparts to the fingers a sensation as if the erosion rested upon a thin layer of that material. Eeadily perceived in most cases, in others it may escape notice, especially to one not familiar with it. The situation of the chancre influences to a certain extent the degree of development of the induration; which, for instance, is generally but slightly marked and of the parchment variety upon the walls of the vagina and the margin of the anus; while, on the contrary, it is fully developed in the furrow at the base of the glans and upon the lips. Some authorities have gone so far as to maintain that induration is entirely dependent upon the seat of the sore, and have instanced the uniformity with which all chancres upon the ' Benjamin Bell usually has the credit of the comparison of induration to a split-pea, but reference to his work shows that he uses the term as indicative of the size of a chancre, and not of the consistency of its base. He says : " A real venereal chancre is seldom so large as the base of a split-pea, and the edges of the sore are elevated, somewhat hard, and painful." Op. cit., vol. i. p. 19. INFECTING CHANCRE. 377 lips are indurated in proof; but, as before stated in this chapter, this objection to the duality of the chancrous virus has been effectu- ally exploded by recent experimental inoculations, in which chan- cres with a perfectly soft base have been developed upon the region in question. Eicord believes that the development of induration corresponds with the supply of lymphatic vessels; that the former is most marked where the latter are most abundant; and that the indura- tion, in fact, consists in an inflammation of the capillary absorbents with effusion into the intervening tissue.1 The tendency of indura- tion to invade the lymphatic system favors this opinion, which, however, has not been corroborated, to my knowledge, by the necessary anatomical investigations. Those microscopists2 who have examined the histology of induration concur in stating that it is composed of fibro-plastic elements—fusiform bodies, nucleated cells, free nuclei, and amorphous matter—infiltrating the layers of the derma and subcutaneous tissue, without any special characters to distinguish it from similar products of non-specific origin. These elements are not found in the secretion of the sore. Eicord, to whose careful investigations I am indebted for a large part of the present section, has endeavored to determine the limits of time within which induration may take place. He states that it occurs most frequently during the first or second week after con- tagion ; never before the third day, nor after the third week; that, consequently, if a chancre is to be indurated at all, it will be so by the twenty-first day after the sexual act in which it originated. It is with great reluctance and hesitation that I dissent from so accu- rate an observer, but believing as I do in the incubation of the infecting chancre, I cannot but think that this subject requires renewed investigation with the additional light we now possess. I believe it would be nearer the truth to substitute the words " after the appearance of the chancre" in place of " after contagion." Taking the former as the starting point, there can be no question that in- duration occurs within a very few days; I have almost invariably met with it during the first week, and should not hesitate to regard its absence, at the termination of three weeks, both in the sore 1 Lemons sur le Chancre, p. 86. * Robin et Marchal de Calvi, Elements caracteristiques du tissu fibro-plastique et sur la presence de ce tissu dans l'induration du chaucre. Seance de l'Academie des Sciences, Nov. '2, 1846. Lebert, Traite d'Anatomie Pathologique, vol. ii. 378 CHANCRES. itself and in the neighboring ganglia, as indicative that the patient was safe from constitutional infection. Sigmund,1 of Vienna, gives the following table of the dates after contagion at which induration was first detected in 261 infecting chancres. On the 9th day in " 10th " " 14th " " 17th " " 19th " " 21st " Mr. Babington, the English editor of Hunter on Venereal, ad- vanced an opinion which has been adopted by a few authors, that induration may take place before the appearance of the chancre; but experience does not confirm this statement. After all, if it be admitted that all possible mischief is accomplished long before the chancre first appears, the exact date of the evolution of the indu- ration possesses less practical importance than it assumed under the supposition that it marked the boundary line between local and constitutional syphilis. Specific induration usually remains for a long time after the cicatrization of the chancre, and, unless dissipated by treatment, may, in most cases, be felt for at least two or three months, and often longer. Some statistics collected by M. Puche show that its persistency becomes rarer after the third month, and is quite excep- tional after the eighth, though this surgeon reports thirteen cases in which it was perceptible from 390 to 2062 days after contagion; in nine of the thirteen, the induration occupied the furrow at the base of the glans, a favorite seat for its full development and long persistency. M. Puche met with still another instance in which induration persisted for nine years. I have met with several cases of two and three years' duration, and Eicord with one of thirty years. It follows from the above data that induration is an early symptom of constitutional syphilis, and that the time within which its presence or absence is of diagnostic value is limited, though variable in different cases. Induration is sometimes much shorter lived; the parchment form especially, according to Eicord, may entirely disappear before the ' British and For. Med.-Chir. Rev., J.in. 1857, p. 206 ; from the Wien Wochen- schrift, No. 18. 71 cases. 84 11 76 11 15 11 12 K 3 II INFECTING CHANCRE. 379 chancre heals, and the cicatrix present as soft a base as the chan- croid. This form of induration is, however, in many instances, as durable as any other. As the process of absorption goes on, the indurated mass becomes less firm and resistent, and gradually softens until it can finally no longer be detected. Occasionally a relapse takes place in which it resumes its original characters. I have seen such accompany a renewed outbreak of a syphilitic eruption; while, in other instances, the exciting cause has appeared to be some local irritation, as a soft chancre, vegetation, etc. Unlike the chancroid, the chancre is rarely met with in groups of two or more upon the same subject. Of 456 patients, under the observation of Fournier at the Hopital du Midi, 226 had but one and 115 several chancres; of the latter 86 had two, 20 had three, 5 had four, 2 had five, 1 had six, and 1 had nineteen. Debauge col- lected 60 cases at the Antiquaille Hospital, at Lyons, in 41 of which there was a single chancre, and in 19 several.1 These statis- tics would show that the infecting chancre is solitary in three cases to one in which it is multiple. The ratio is still greater in M. Clerc's observations, in which the chancre was single in 224 out of 267 cases. If multiple at all, infecting chancres are so as the imme- diate effect of contagion, and because several rents or abrasions were inoculated together in the sexual act. If solitary at first, they con- tinue to be so; since successive chancres never spring up in the neighborhood, as in the case of the chancroid, owing to the fact that the virus ceases to act upon the system as soon as it is once infected. This explanation is alone sufficient, without calling in the aid, as Eicord does, of the paucity of the secretion, which is copious enough to inoculate sound persons. The insidious manner in which induration takes place character- izes the whole development of the infecting chancre, and it is not surprising that it often exists for some time before it is perceived by the patient, or escapes notice entirely. The explanation of many "buboes d'embleV and supposed cases of constitutional syphilis without chancre is evident. Unfortunately the profession has been too prone to go to extremes in taking the testimony of venereal patients: by some their statements are received implicitly; by others they are as constantly disbelieved; while few draw the dis- 1 Op. cit., p. 6. 380 CHANCRES. tinction between honesty, and ignorance necessarily arising from want of experience and the absence of medical knowledge. The secretion from an infecting chancre is much less copious than that from the chancroid. This difference is especially evident in the superficial erosion, but is also perceptible in the excavated forms, the discharge from which is less free and purulent than in the simple chancre. Numerous experiments show that the immunity conferred by one attack of constitutional syphilis extends in most cases, and perhaps in all, even to the initiatory sore. Fournier inoculated the dis- charge of ninety-nine hard chancres upon the patients themselves, and succeeded in but one, in whom the experiment was performed within a very short period after contagion. M. Puche states as the result of his own experiments that auto-inoculation of the infecting chancre is successful in only two per cent. Poisson obtained like results in fifty-two cases,1 and Laroyenne was unsuccessful in every one of nineteen.2 Do not these facts tend to show that the hard chancre is from the very first a constitutional lesion ? Their bear- ing upon the use of artificial inoculation as a means of diagnosis is evident; failure favoring the supposition that the sore is an in- fecting chancre. The great rarity of successful inoculations of the hard chancre strongly favors a supposition recently advanced, that such exceptional cases are really mixed chancres and not uncomplicated infecting ulcers; if this be so, auto-inoculability may be regarded as belonging exclusively to the chancroid and mixed chancre. It should be observed that Mr. Henry Lee, of London, as early as 1856, and prior to the publication of the French experiments, called attention to the difficulty of inoculating indurated chancres, or " syphilitic sores affected with specific adhesive inflammation," upon the persons bearing them.3 This surgeon has since maintained that if an indurated chancre—the discharge from which, under ordinary circumstances, he believes to be destitute of pus-globules —be irritated, as by the application of a blister or ung. sabinae, until its secretion becomes purulent, it is susceptible of inoculation.4 Mr. Lee's experiments require confirmation before coming to any 1 Le?ons sur le Chancre, p. 274. 1 Annuaire de la Syphilis, annee 1858, p. 241. 3 British and For. Med.-Chir. Rev., Oct. 1856. 4 Ibid, for April, 1859. INFECTING CHANCRE. 381 conclusion regarding them. It is difficult to believe that in the numerous French observations the sores had always escaped irrita- tion and that the discharge was invariably serous. The difficulty of inoculating the virus of an infecting chancre is equally as great upon a person who has arrived at any stage of secondary or tertiary syphilis as upon one who has but recently been infected. The infecting chancre, as a general rule, is of somewhat shorter duration than the chancroid, but often remains until after the appearance of secondary symptoms—a remark which I should not think it necessary to make had I not met with persons who supposed that primary syphilis must terminate before secondary commenced ! Of 97 cases observed by Bassereau, in which no treatment had been employed, syphilitic erythema, one of the earliest general symptoms, occurred in 58 before, in 18 during, and in 21 after the cicatrization of the chancre.1 Phagedena generally spares the infecting chancre or limits its ravages to the destruction of the surrounding induration. In rare instances, however, an extensive phagedenic ulcer has been the door of entrance of the syphilitic virus into the economy. An infecting chancre situated upon the external integument, as the sheath of the penis, often leaves a peculiar discoloration of the skin of a sombre brown or brownish-red color, which is never seen after the chancroid; in time its dark hue fades into a white. An instance of this kind is figured by Eicord in his Iconographie des Maladies Veneriennes, pi. 18. Eicord first called attention to the fact, which has since been verified by many observers, that an infecting chancre during the reparative period may be transformed into a mucous patch, and thus a .primary be changed into a secondary lesion. This transformation may take place upon any part of the body whether of skin or mucous mem- brane, but is more frequent upon the latter, especially when habitu- ally in contact with an opposed surface, whereby heat and moisture are maintained; as, for instance, upon the internal surface of the pre- puce and labia majora, and upon the lips and tongue. Davasse and Deville have carefully studied the progressive changes by which this process is accomplished.2 The surface of the chancre loses its ' Op. cit., p. 180. 2 Etudes Cliniques des Maladies Veneriennes; des plaques muqueuses. Arch. GCn. de Med., -le serie, vol. ix. p. 182. 382 CHANCRES. grayish aspect and fills up with florid granulations, commencing at the circumference, as in the ordinary period of repair; but just as these changes are reaching the centre of the sore, a narrow white border of plastic material appears around its margin, and extending towards the centre, finally covers it with the membranous pellicle which is characteristic of a mucous patch. If the patient does not come under observation until these changes have been effected, the origin of his constitutional disease may be ascribed to a mucous patch instead of to the chancre to which it belongs. We have already seen that most simple chancres are free from ganglionic reaction, and that when this occurs it is always inflamma- tory and involves but one ganglion, which tends to suppuration and often furnishes inoculable pus. The infecting chancre, on the con- trary, gives rise to changes in the neighboring lymphatic ganglia, which, by their constancy and the peculiarity of their symptoms, are of the highest value in diagnosis. A number of these bodies become enlarged and indurated in a similar manner to the base of the chancre, without inflammatory action; they do not suppurate except in rare instances, and the pus is never inoculable. The induration of the neighboring ganglia, or the indurated bubo at- tendant upon an infecting chancre, will be more fully described in the next chapter. Mixed Chancre—a combination of the soft and hard chancre.— " A fact, or an ingenious fiction to obviate the difficulties of a too systematic classification?" In reply to this question, no one can doubt that a hard and soft chancre may occupy different situations upon the same person at the same time. Universal experience de- monstrates that constitutional infection presents no barrier to simple chancres. The two species of primary sore may, therefore, coexist upon the same person. But suppose that in consequence of the nearness of their sites, the virus of one comes in contact with the other, what will be the effect ? Will either poison be neutralized or destroyed, or will each maintain its peculiar properties and the resultant sore combine those of both ? The latter supposition, which, moreover, does not conflict with any established principles of pa- thology, is shown to be correct, both by clinical observation and direct experiment. The following case is related by Fournier:— Alphonse N., aged IT, contracted a chancre in the latter part of Sept., 1857. He became an out-patient of the Hopital du Midi, Oct. 3, when MIXED CHANCRE. 383 a chancre, surrounded by cartilaginous induration, was found in the fossa behind the corona glandis, and the glands in both groins were enlarged, hard, and indolent. A dressing with aromatic wine was ordered for the sore, and mercury internally. Oct. 14. The chancre has entered upon the period of repair; it is less excavated, and its edges less prominent. Oct. 24. There has been a change for the worse. The original chancre has increased in surface and in depth; its base is still very much indurated. Moreover, upon the skin of the penis'is found another large chancre; its base cedematous, but without true induration. There are also several small chancres with soft bases upon the external surface of the prepuce. The patient declares most positively that he has had no sexual connection since he contracted his first chancre. Are the recent sores to be attributed to accidental inoculation from the first ? N. is this day admitted as an in-patient. In the early part of Nov. one of the lymphatic ganglia in the left groin became acutely inflamed, and presented all the characters of a bubo dependent upou a simple chancre. It suppurated, and its pus was inocu- lated with success. In the right groin, the enlargement and induration of the ganglia characteristic of an infecting chancre remained as before. In Dec. secondary symptoms appeared: roseola and multiple mucous patches. In spite of the patient's denial, Ricord attributed the more recent chancres to a second exposure and fresh contagion; and a few days after his entrance into the hospital, the patient privately confessed to M. Fournier, the Interne, that on Oct. 15th he had connection with a woman whose name and address he gave. He also stated that on the following day his first chancre began to enlarge, and the others appeared two days after. Fournier immediately visited the woman indicated by N., and found that she had three large chancres with perfectly soft bases, situated upon the internal surface of the left labium, on the fourchette and upon the folds at the entrance of the vagina, and of about three weeks' duration. The inguinal ganglia were in a normal condition. This woman also confessed to M. Fournier that she had infected her lover, Charles V., who, by a singular coincidence, was at that moment a patient in the Hopital du Midi, and who likewise had several simple chancres with soft bases upon the prepuce and an acute bubo in the left groin. To sum up this history: a man with an infecting chancre in the period of repair and an indolent indurated bubo has connection with a woman affected with simple chancres. He contracts fresh 384 CHANCRES. chancres which are simple, and one of which is seated upon the surface of the infecting chancre. An inflammatory bubo appears, which suppurates and furnishes inoculable pus. Finally, symptoms of constitutional syphilis are developed.1 Eollet relates a similar case:— G. Francois, aged 20, entered the Antiquaille Hospital, at Lyons, with a chancre situated upon the meatus which was slightly indurated and presented the usual aspect of an infecting chancre. The fossa at the base of the glans was studded with several chancrous ulcers which were as soft as possible. The ganglia in the groin were indurated. In six weeks after exposure, the patient was attacked with headache, syphilitic roseola, and rheumatic pains. In order to confirm the diagnosis as to the nature of the sores, Rollet inoculated matter from the one which was indurated upon the left thigh, and the secretion of the others upon the right. The result was positive in both. It was then thought that pus from the simple sores might have been deposited upon the indurated one, and thence taken up upon the lancet. Rollet therefore waited until the chancres in the fossa behind the corona had completely healed, and then, after repeatedly cauterizing the indurated sore with solid nitrate of silver, inoculated its secretion a second time. This inoculation produced the characteristic pustule of a chancre as before; thereby showing that the success of the first was not owing to the presence of matter which had been simply deposited and again taken up, but to the inherent properties in the secretion of the sore itself.3 M. Rollet and his Interne, M. Laroyenne, were led by this case to try the effect of inoculating indurated chancres with matter from a chancroid. Their experiments are briefly related as follows:— Case 1. Pieri M.; indurated chancre of the meatus; duration three weeks; indurated ganglia; inoculation of the secretion of the chancre, negative. Sept. 14, the pus of a simple chancre was deposited upon the sore. Sept. 15, application of the solid nitrate of silver ; lotions; dress- ing with aromatic wine. Sept. 19, second inoculation; chancrous pus- tule. Case 2. John L.; indurated ulcer almost healed; indurated ganglia; general treatment and local application of aromatic wine; inoculation 1 Lecons sur le Chancre, p. 119. 2 Laroyenne, Etudes Experimental sur le Chancre, Annuaire de la Syphilis, annee 1858, p. 248. MIXED CHANCRE. 385 negative. Nov. 18, pus from a simple chancre is applied to the ulcer; treatment continued. Nov. 23, second inoculation; this time positive. Case 3. Robert M.; parchment variety of chancre upon the skin of the penis ; duration five days. Dec. 11, inoculation without result; dress with opiated cerate and calomel. Dec. 16, application of the virus of a simple chancre. Dec. IT, same dressing. Dec. 22, inoculation positive. Case 4. Peter M.; infecting chancre of six weeks' duration, occupying three-fourths of the circumference of the fossa glandis. Dec. 11, inocu- lation unsuccessful. Dec. 16, application of the virus of a simple chancre. Dec. IT, dress with opiated cerate with addition of calomel. Dec. 22, inoculation successful. • According to Rollet, two or three days after the application of the virus of a chancroid to a chancre, the sore assumes a grayish aspect like the soft chancre, but is less excavated than the latter; its edges become jagged, and its purulent secretion more copious and sanious; it may give rise to successive chancres in the neighborhood or to a virulent bubo. It preserves, however, the essential charac- ters of an infecting chancre, and, among others, induration of its base, which is always pathognomonic; the ganglia of both groins are indurated as usual, unless a virulent bubo supervenes, when those of the opposite side still indicate the nature of the disease. The constitutional effects of the true chancre are not modified by this inoculation, and secondary symptoms appear at the same time and in the same manner as under ordinary circumstances. The more copious secretion of the chancroid renders this species more liable to be ingrafted upon the infecting chancre than the latter upon the former. Thus far we have supposed the inoculation of one species of virus to succeed that of the other, but both sometimes, though rarely, occur during the same act of coitus. In this case the chancroid, which has no period of incubation, is first developed in its usual form, with abrupt edges, grayish floor, and soft base; subsequently the infecting chancre appears, when the base of the sore and the neighboring lymphatic ganglia become indurated. If, as is probably true, those infecting chancres which are auto-inoculable belong to the mixed variety, we may obtain some idea of the frequency of this form from the inoculations of Eicord, Fournier, Puche, and others; about two per cent, of which have been successful. Eollet's observations make the ratio about five per cent. Eollet is inclined to believe that the ulcer which has been described by Carmichael, 25 386 CHANCRES. Eicord, and Eoyer as the " ulcus elevatum," is a mixed chancre, which generally shows a tendency to become elevated above the surrounding surface.1 The union of the two species of virus in this variety of chancre is analogous to the mixture which takes place when gonorrhoea is complicated with urethral chancre, constituting the only true "gon- orrhoea virulenta;" and also to the union of either chancrous virus with that of vaccinia, of which a number of examples are recorded. Complications of Chancres.—These are chiefly two: excessive in- flammation and phagedena. Inflammatory or Gangrenous Chancre.—The inflammation attendant upon a chancre is sometimes so excessive as to terminate in gangrene, and produce a slough of the surrounding tissues, like that caused by the application of a powerful caustic. This compli- cation is most liable to occur in cases of congenital or accidental phymosis, in which the primary sore is imprisoned beneath the prepuce. The extremity of the penis is very much swollen and cedematous, and often of a livid red color; a dark spot of commenc- ing gangrene soon appears, generally upon the dorsal surface, and involves the prepuce to a greater or less extent; the constricted portion, or glans, commonly suffers less than its covering; if the slough include the whole neighborhood of the chancre, the latter, when the eschar is detached, presents the appearance of a simple wound, and—it is important to recollect—no longer secretes inocu- lable pus. The inflammation attendant upon chancres complicated with paraphymosis may result in a similar manner. It is evident that the excessive inflammation, which is generally induced by mechanical constriction, violence, want of cleanliness, or the abuse of alcoholic stimulants, is to be regarded merely as a complication of the original sore, and does not change its nature, whether it be of the simple or infecting species, nor does it affect the liability of constitutional infection. The chancroid is more' exposed to this complication than the infecting chancre. When occurring in the latter, induration may for a time disappear with the eschar, but often reappears in the subsequent cicatrix, and secondary symptoms follow in the usual time and manner. In- 1 Rollet, De la Plurality des Maladies Veneriennes ; Gaz. Med. de Lyon, No. 7, 1860. PHAGEDENIC CHANCRES. 387 flammatory or gangrenous chancres are included by most English writers among the phagedenic, but there would appear to be suffi- cient reason to follow the classification adopted by the French, and consider them as distinct. Buboes are rare in connection with this variety of chancre. Phagedenic Chancres.—In the chancroid and in the infecting chancre, when the latter assumes the form of an ulcer, the process of ulceration is generally slow and limited in extent, and advances with nearly equal rapidity in all directions; whence the sore maintains a rounded form, and does not involve the tissues to any great extent or depth. Phagedenic chancres, on the contrary, are characterized by their more rapid, extensive, and irregular prog- ress; though these characters vary greatly in degree in different cases. In the mildest and most frequent form of phagedena, the sore extends in surface and in depth beyond its ordinary bounds; this is sometimes observed at all parts of the circumference, but generally at one part more than another, so that the circular form is lost, and the outline becomes irregular; still ulcerative action is not exces- sive, and, in the case of the infecting chancre, is often limited to the destruction of the induration. Phagedena may stop here, or go on to form a serpiginous chancre, to the extent and duration of which there is no limit. The edges of the sore in this variety are thin, livid, and cedematous, and so extensively undermined that they fall upon the ulcerated surface, or may be turned back like a flap upon the sound skin; they are often perforated at various points, and are very irregular in their outline, resembling a festoon. The surface of the sore is uneven, and co- vered with a thick pultaceous and grayish secretion, through which florid granulations at times protrude, and bleed copiously upon the slightest touch. Serpiginous chancres are not attended by much constitutional reaction. They exhibit a predilection for the super- ficial cellular tissue, and are inclined to extend in surface rather than in depth. They sometimes undermine the whole skin of the penis as far as the pubes, or make their way down the thigh nearly to the knee, or upwards upon the abdomen, or follow the course of the crest of the ilium. They often advance on one side, while they are healing upon the opposite. Their progress may appear to be arrested, and the sore nearly cicatrized, when rapid ulceration again 388 CHANCRES. sets in and destroys the newly-formed tissue. Their secretion is copious, thin and sanious, and preserves its contagious properties through the many years that the ulcer may persist. They leave behind them a whitish and indelible cicatrix, resembling that pro- duced by a deep burn. This primary sore may be mistaken for the serpiginous ulceration of tertiary syphilis. It is distinguished from it by the fact that it commences with a chancre—usually seated upon the genitals—or with a suppurating bubo in the groin; that from this point of origin it extends by a continuous process of ulceration, the course of which is evident by the foul cicatrix which it leaves behind it; and that it never overleaps sound portions of the integument. Moreover, the fluidity of its secretion does not favor the formation of scabs, and its contagious properties are manifest if inoculated upon the person bearing it.1 A third variety is called the sloughing phagedenic chancre, and is characterized by the greater acuteness of the destructive action. Its symptoms closely resemble those of hospital gangrene. There is considerable constitutional disturbance, a full and hard pulse, furred tongue, and other symptoms of inflammatory fever. The pain is often excessive, and almost insupportable. The ulcer ex- tends chiefly to dependent parts in the neighborhood, which are infiltrated by its copious and foul secretion. It respects no tissue whatever, and its ravages are sometimes terrible; the glans, penis, or labia may be wholly destroyed, and the testicles entirely laid bare. The sloughing phagedenic chancre is most common among the intemperate and lowest class of prostitutes, and also among persons visiting hot climates and exposed to various hardships. It was this variety which decimated the English troops in the Penin- sular war, although syphilis was a comparatively mild disease among the natives. Phagedenic chancres are not unfrequently attended by buboes, which generally take on the same destructive action as the primary sore. Fournier's confrontations, already referred to, prove that the phagedenic chancre is not always transmitted in its kind, and that hence it cannot depend -upon a distinct species of virus. It does not, however, conflict with this statement to admit that contagious 1 Bassereau, op. cit., p. 475. PHAGEDENIC CHANCRES. 389 matter may possess noxious properties independent of the contained virus, but capable of exciting a severe form of ulcerative action. This appears not improbable when we consider that vaccine lymph which is derived from unhealthy tissues or allowed to stand in solution until it becomes putrid, may develop such a degree of inflammation as to prove fatal. Witness the mortality in the town of Westford, Mass., in the spring of 1860, following vaccination with scabs originally pure, but which were dissolved in water and exposed to air and heat until they were decomposed.1 In most cases, however, phagedena is doubtless dependent upon some form of constitutional cachexia, the exact nature of which is not always apparent. The abuse of mercury in the treatment of primary sores is another cause, which was more frequent a few years since than now; and the improved practice of the present day may account in a measure for the partial disappearance of this variety of chancre. Phagedena is a complication common to both species of primary sore, but much more frequently of the simple than infecting chan- cre ; no certain inference can, therefore, be drawn from its presence relative to constitutional symptoms, but merely a probability that they will not occur. When they do supervene, they are generally of an aggravated character. Babington says: "The secondary symptoms which follow the phagedenic sore are peculiarly severe and intractable. They commonly consist of rupia, sloughing of the throat, ulceration of the nose, severe and obstinate muscular pains, and afterwards inflammation of the periosteum and bones. Similar complaints will follow the ordinary chancre; but when they follow a phagedenic sore they are very difficult to be cured; and it is not uncommon that the constitution of the patient should at length give way under them, and that the case should terminate fatally."2 Bassereau also found a correspondence between the severity of the primary sore and that of the syphilitic eruption. Thus, of 68 chancres which preceded a pustular syphilide, 20 were phagedenic and 4 others serpiginous;3 and 18 of 50 chancres followed by a tubercular eruption produced destruction of the tissues to a greater or less extent. It will be recollected, on the contrary, that 143 of 170 chancres followed by syphilitic erythema were mere erosions, and that 10 only exhibited a very slight tendency to phagedena. 1 Boston Med. and Surg. Journal, May, 1860. 2 Ricokd and Hunter on Venereal, 2d ed., p. 351. » Op. cit., p. 442. 390 CHANCRES. Bassereau states that a similar relation exists between the primary sore and other constitutional lesions, and lays down the rule that "mild syphilitic eruptions and, in general, those constitutional symp- toms which exhibit but little tendency to suppurate, follow the mild forms of indurated chancre; while pustular eruptions, and, at a later period, ulcerative affections of the skin, exostoses terminating in suppuration, necroses, and caries, follow phagedenic indurated chancres." Admitting the general truth of this rule, it does not prove that the phagedenic chancre possesses any peculiar powers of infection, but simply that the primary sore may be taken as an index of the state of the system, which determines, in a great mea- sure, both the severity of the chancre and that of the succeeding constitutional symptoms. DIAGNOSIS. When a sore can be watched through the stages of its evolution and decline, it is rare that we are not able to decide whether it be a chancre or not; and if so, to what species it belongs. The case is quite different when we are called upon to express an opinion from a single examination as to the nature of an erosion or ulcer, especially if the knowledge of its history be imperfect either through the patient's ignorance or deceit; the diagnosis may be comparatively easy in most cases, but in many it is difficult, and in some impossible. Much will depend upon the time at which the sore is seen. The chancroid and especially the infecting chancre, when fully developed, present symptoms which are almost unmis- takable to one at all conversant with syphilis; but at an earlier period, particularly if they occupy a previous solution of con- tinuity, no human eye can see and no human means detect, at once and without delay, the presence of a specific virus. These remarks are not unimportant, since most patients suppose that a competent surgeon can "tell a chancre at first sight;" and I have known young practitioners make the same mistake and feel much chagrined at meeting with cases in which they were at fault. To such it may be a consolation to know that experience, though doubtless adding very much to the facility of diagnosis, cannot, however great it may be, invariably enable the possessor to say from a single examination, "such a sore is a chancre," and "such a one is not." It is not so many years since I was myself a student DIAGNOSIS. 391 of venereal, that I have forgotten the difficulties in the way of the learner, and the embarrassment which is felt in not knowing exactly how far diagnosis is possible. On referring to the sections upon diagnosis in works upon syphilis, many of them are found to be ob- scure, and others diffuse and filled with minutiae which cannot be verified in practice; and the impossibility in any case of arriving at a diagnosis is seldom or never hinted at. In short, the student feels the want of a few plain and practical rules, such as almost every one after a little experience frames for himself in his own mind, and upon which he relies to determine the nature of any suspicious sore following sexual intercourse. This want I shall endeavor to supply to the best of my ability. Suppose, in the first place, that a patient makes his appearance a day or two after connection with a woman of the town, and exhibits one or more raw surfaces upon the penis, which were occasioned by violence at the time of coitus. It is clearly impossible at this early period to determine whether they have been inoculated with the virus either of the chancroid or true syphilis. If they be kept clean and protected by the interposition of lint, their nature will be ap- parent in a day or two; by which time a simple abrasion will generally make some progress towards cicatrization, while a chancre will assume the characters of a specific ulcer. Again, three or four days after exposure, a man seeks advice for one or more small ulcers upon the glans or prepuce, which first appeared within twenty-four or forty-eight hours after coitus. Their early development does not favor the diagnosis of an infecting chancre which possesses a period of incubation. A multiplicity of the sores points in the same direction. If not infecting chancres, they may be ulcers succeeding herpes-vesicles, or chancroids. The former supposition is probable if the patient has been subject to herpetic eruptions; if there are several sores arranged in a circular group, some of them, perhaps, still preserving the form of vesicles or vesico-pustules; and if the ulcerations are superficial. The latter supposition is the more probable, if the ulcers be irregularly situated, and if they perforate the whole thickness of the mucous membrane and present the sharply-cut edges and grayish floor of the chancroid. The diagnosis may, if thought desirable, be confirmed by inoculat- ing the secretion upon the arm or thigh; if herpes, the result will be negative; if a chancroid, positive. Moreover, the former, in most cases, rapidly improves or entirely disappears in three or four 392 CHANCRES. days under simple applications alone; a chancroid grows larger or remains stationary, and its characters become more strongly marked. Subsequent to the fourth or fifth day the symptoms of both species of chancre are generally recognizable without much difficulty; but there are several points which require attention. Irritant applications—as, for instance, cauterization by the patient himself before seeking advice—may so obscure the symptoms as to render a diagnosis impossible until the effect of the application shall have subsided. Chancres are most liable to be overlooked or mistaken when situated at a distance from the genital organs; the infecting chancre less so, perhaps, than the chancroid, owing to the prominent character of the induration of the base and neighboring ganglia in the former. The superficial form of infecting chancre does not differ materially in appearance from a common excoriation, or from the superficial ulcerations of balanitis; it may be distinguished by its late appear- ance after exposure, its induration and greater persistenc}?-. No suspicion of a chancre, however, may be awakened if the erosion be surrounded by simple inflammation of the mucous membrane, unless the induration of the inguinal ganglia be discovered, and hence the condition of these bodies should always be examined in apparent cases of balanitis. No opportunity should be neglected of examining the person from whom the disease was derived. Since there is never an inter- change between the chancroid and true syphilis, the symptoms presented by the giver of a primary sore will throw light upon the nature of the disease in the recipient. The absence of induration, the presence of a suppurating bubo, or, provided no general treat- ment has been administered, the non-appearance of general symp- toms within three months after contagion in the former, will indicate that the latter has a simple chancre. On the contrary, if a person with an indurated specific ulcer or with constitutional syphilis, communicate a sore to another, the latter, without doubt, has an infecting chancre. This method of arriving at a diagnosis is of special value in married life. In several instances, when informed by husbands affected with syphilis that they had communicated their disease to their wives, I have been able to treat the latter by means of specific remedies without making an examination, and have thus avoided a disclosure which could accomplish no possible good, and would surely have been productive of much misery. DIAGNOSIS. 393 Inoculation of the secretion of a sore upon the person bearing it is an unfailing test of a chancroid, but of no value in infecting chancres. Induration of the base of a sore and of the neighboring lym- phatic ganglia are the two most important symptoms of an infecting chancre. Both together are very rarely, if ever, wanting. Of the two, I am inclined to regard the latter as most invariably present. Absence of induration of the base cannot always be depended upon, even according to Eicord's showing, who says that this symptom sometimes disappears after a few days' duration, and it may, there- fore, have passed away before the patient comes under the care of the surgeon. Cases are reported by competent observers of chan- cres with a perfectly soft base, which have yet been followed by constitutional syphilis; such instances, however, are extremely rare. If a caustic or astringent has recently been applied to a sore, indu- ration of its base should be admitted with caution: examine the condition of the neighboring ganglia; direct simple applications only for a week or two, and see if the hardness persists. In- flammation of the surrounding tissues may counterfeit or mask specific induration: here, again, refer to the ganglia, or defer the diagnosis until the inflammatory products shall have time to undergo absorption. Even admitting that cases may possibly occur in which indura- tion of the base and of the ganglia are both absent, yet these two prominent symptoms of an infecting chancre are as constant and as valuable as any others in the whole range of pathology: more than this we can neither ask nor expect. If it be true that absorption of the syphilitic virus takes place instantaneously so soon as it has penetrated beneath the epidermis, and that there is, therefore, no opportunity of preventing constitutional infection by abortive treat- ment, there is less necessity for an early diagnosis than was formerly supposed; and, in obscure cases, we may wait, if necessary, until after the time within which, if ever, secondary symptoms invariably appear. The presence of a mixed chancre is indicated by one or more chancroids springing up in the neighborhood of a primary sore presenting the usual symptoms of an infecting chancre; also by the existence of indurated ganglia in one groin and a suppurating bubo in the opposite, especially if the pus be inoculable. In the absence of these symptoms (since successive ulceration and sup- 394 CHANCRES. purating buboes do not attend every chancroid), an infecting chancre may still be of the mixed variety, and its nature can only be deter- mined by artificial inoculation. DIAGNOSTIC CHARACTERS OF THE SIMPLE AND INFECTING CHANCRES. THE SIMPLE CHANCRE. Origin. Always derived from a simple chancre, or virulent bubo. Anatomical characters. Generally multiple, either from the first or by successive inoculation. An excavated ulcer, perforating the whole thickness of the skin or mucous membrane. Edgesabrupt and well-defined, as if cut with a punch, not adhering closely to subjacent tissues. Surface flat but uneven, "worm eaten," wholly covered with grayish secretion. No induration of base unless caused by caustic or other irritant, or by simple in- flammation ; in which case the engorge- ment is not circumscribed, shades off into surrounding tissues, and is of temporary duration. Pathological tendencies. Secretion copious and purulent, inoculable. Slow in healing. Often spreads and takes on phagedenic action. May affect the same person an indefinite number of times. Cliaracteristic gland affection. Ganglionic reaction absent in the majority of cases. When present, one gland acutely inflamed and generally suppurates. Pus often inoculable, producing a soft chancre. Prognosis. Always a local affection, and cannot infect the system. "Specific" treatment by mercury and iodine always useless, and, in most cases, injurious. THE INFECTING CHANCRE. Oris Always derived from an infecting chancre or secondary lesion. Anatomical characters. Generally single; multiple, if at all, from the first; rarely, if ever, by successive inoculation. Frequently a superficial erosion ; not involv- ing the whole thickness of the skin or mucous membrane, of a red color and nearly on a level with the surrounding surface. Sometimes an ulcer, when its Edges are sloping, hard, often elevated, and adhere closely to subjacent tissues. Surface hollowed or scooped out, smooth, sometimes grayish at centre. Induration firm, cartilaginous,, circum- scribed, movable upon tissues beneath. Sometimes resembles a layer of parchment lining the sore. Generally persistent for a long period. Pathological tendencies. Secretion scanty, chiefly serous ; inoculable with great difficulty, if at all, upon the patient or upon any person under the syphilitic diathesis. Less indolent than the chancroid. Pha- gedena rarely supervenes and is generally limited. One attack affords complete or partial pro- tection against a second. Cliaracteristic gland affection. All the superficial inguinal ganglia, on one or both sides, enlarged and indurated; distinct from each other, freely movable ; painless, and rarely suppurate. Pus never inoculable. Prognosis. A constitutional affection. Secondary symp- toms, unless prevented or retarded by treatment, declare themselves in about six weeks from the appearance of the sore, and very rarely delay longer than three months. TREATMENT. It would be well if the physician or surgeon, before undertaking the treatment of any disease, could always know how far nature is able to dispense with his services. As regards primary sores, there can be no question at the present day that they are capable of spon- taneous cicatrization without the assistance of art. No statement GENERAL TREATMENT. 395 could be more at variance than this with the opinion, generally received not many years ago, that mercury was the touchstone of a chancre, and that the sore that healed without it could not be a chancre. This error is now, however, so nearly abandoned that its repetition, as in the recent work of a distinguished obstetrician, must excite a smile in any one at all conversant with syphilis. I do not think it necessary, therefore, to refute it here, but would simply call attention to the truth of the converse proposition, as important to be borne in mind throughout the treatment of primary- sores. To repeat in a more definite manner the statement above made in its application both to local and general treatment:— Although general treatment by mercury doubtless facilitates the cica- trization of some chancres (the infecting), yet it is necessary for the accomplishment of this process in none, and in the majority (taking chancres in the aggregate) is positively injurious. All primary sores, except perhaps the phagedenic, will heal sponta- neously without local treatment other than cleanliness, generally within a period of a few months, and often within a few weeks, but not always with as little detriment, or the same comfort to the patient, as if art intervened. The office of the surgeon, therefore, is to limit destructive action, and thereby preserve important parts; to hasten cicatrization, that the patient's comfort may be promoted, and the danger of the com- munication of the disease to others lessened. Another object which has generally been regarded as of paramount importance, is the prevention of constitutional infection; we shall presently inquire how far this can be accomplished in practice. I shall consider the treatment of chancres under three heads: 1. General treatment; 2. Abortive or destructive treatment; 3. Local applications. General Treatment.—The most important question under the head of general treatment relates to the employment of mercury. I have already remarked that this agent is not essential to the cica- trization of either species of primary sore, but its effect is much greater upon one than upon the other; indeed, if farther proof were wanting of their distinct nature, it might be found in the obstinacy with which the simple chancre persists, and the readiness with which the infecting chancre heals, under the influence of mercury. Judg- ing from my own experience, no fact is more patent than this. I 396 CHANCRES. am so fully convinced of its truth that, in undertaking the treat- ment of an indurated chancre, I regard the general treatment given to combat the constitutional infection as all-sufficient, and the local sore as scarce worthy of attention. So soon as the slightest tender- ness of the gums appears from the use of mercury—and generally before that time—the chancre, without local treatment other than cleanliness, begins to improve, and rapidly heals in the course of a few days. Even in cases in which the local symptoms are unusu- ally aggravated, as, for instance, when phymosis is present, causing considerable distress to the patient, but not requiring immediate inter- ference from threatening gangrene, if specific induration can be felt beneath the prepuce, the surgeon may rely wholly upon the inter- nal use of mercury as a speedy means of relief. In infecting chancres, however, which exhibit a tendency to phagedenic action, mercury should be dispensed with, or employed with caution, com- bined with a tonic, as iron or quinine, and never be pushed to sali- vation. On the other hand, I am equally certain that mercury has no beneficial influence whatever upon the chancroid, which continues in a state of stubborn persistency, or even progresses, after the sys- tem is fully under its influence. This statement is not a mere infer- ence from the duality of the chancrous virus, but is founded upon experience. I was fully convinced of the fact by personal observa- tion, and ceased to employ mercury for soft chancres, several years before the distinction between the two species was recognized. Since abandoning it in my own practice, I have had numerous opportunities of observing other surgeons administer mercurials for the chancroid, and my former opinion has only been confirmed. A few years since, during three weeks' absence from the city, I com- mitted five patients with soft chancres to the care of a medical friend, and, on my return, found them all salivated, and in every one the sore was aggravated. I could relate many similar instances, in which patients with simple sores have passed from other practition- ers under my care, after going through a course of mercury without the slightest benefit. Phagedena, unless in the mild form which sometimes complicates the infecting chancre, contraindicates the use of mercury. The effect of this agent upon the destructive action of phagedena is most disastrous, imparting to it increased power and more rapid progress. It is a rule expressed in a few words, but one of great importance GENERAL TREATMENT. 397 to be remembered: " Never give mercury in acute cases of phage- dena." As regards the use of mercury in primary syphilis, practitioners may be divided into three classes: 1. Those who administer it in- discriminately in all cases of chancre; 2, those who limit its use to indurated chancres; and 3, those who do not employ it at all in the treatment of primary sores. The course adopted by the first class is one which has come down to us from a time when the utmost confusion reigned in matters of venereal; when gonorrhoea, the simple and the infecting chancre were regarded as essentially one; when each was looked upon as a source of constitutional infection; and instances of escape were attributed to the happy influence of mercury. The medical pro- gress of the present century has done away with the use of mercu- rials in gonorrhoea, but has not been so generally successful as regards the chancroid. Yet it is difficult to say on what grounds the indiscriminate employment of this mineral in all cases of pri- mary sores is still maintained by some practitioners. No fact can be better established than that a large proportion of chancres—at least three out of every four — are never followed by secondary symptoms, even if no treatment at all be employed. Can mercury " hinder a syphilitic disposition from forming," as Hunter supposed, in the small minority who are really liable to it ? This assumption, which arose from ignorance of the natural course of primary sores, is now known to be entirely destitute of proof. Is it because it is thought to be impossible to distinguish between those chancres which will and those which will not terminate in constitutional infection? Admitting that this is so, mercury is given to three patients unnecessarily in order that it may reach a fourth who needs it; and, on the same supposition, treatment should be deferred till secondary symptoms are developed, since there is a complete absence of proof that mercury has any less power over the diathesis then, than shortly after contagion. I suspect, however, that the in- discriminate use of mercury still retains a foothold among the pro- fession more from the reputation which it acquired in former years and from the force of early teaching and example, than from any well-grounded reasons in its favor. The objections to this course are conclusive, and may be briefly stated. In the first place, it unnecessarily subjects a large number of persons to the influence of a powerful agent, which must do 398 CHANCRES. harm if it does no good. Sir Astley Cooper said of the use of mercury in gonorrhoea at Guy's Hospital: " To compel an unfor- tunate patient to undergo a course of mercury for a disease which does not require it, is a proceeding which reflects dishonor and dis- grace on the character of a medical institution;" and this remark is no less true of a chancre which will never be followed by consti- tutional infection than of gonorrhoea, nor less applicable to private than public practice. In the second place, the duration of treatment adopted by those who administer mercury without discrimination is almost neces- sarily insufficient to prevent secondary symptoms after a truly infecting chancre, but merely delays their appearance, and, mean- while, gives the patient a false sense of security. I have endeavored to ascertain from surgeons who make no distinction between the soft and hard chancre, and from patients who have been under their care, for how long a time they usually continue a mercurial course. I find, by such inquiry, that some are in the habit of giving mercury until the gums are tender—which usually occurs within a fortnight—and no longer; while few persevere beyond a month or six weeks, during which time they are satisfied with rendering the mouth sore two or possibly three times. The general results of their practice justify these limits. Suppose twenty patients are thus treated; fifteen escape and five incur secondary syphilis: several of the latter are probably never seen again in consequence of passing into the hands of other surgeons ; and thus the sufficiency of the treatment in an overwhelming majority is apparently estab- lished; unfortunately for this reasoning, fifteen of the twenty would have been equally exempt if they had taken no mercury at all. That a mercurial course faithfully continued for a month or six weeks, or even for two months, is not sufficient to prevent the occurrence of secondary symptoms in any except a few rare in- stances of the infecting chancre, is a truth deduced from my own experience, and for the confirmation of which I am willing to refer to that of any surgeon who has treated a dozen cases of primary sore attended by well-marked induration, and who has kept watch of the patients for two years afterwards. Now and then a fortunate individual escapes farther trouble, but nearly all present some constitutional symptom within a year. Hence, when a patient in relating his previous history tells me that he had "syphilis" several GENERAL TREATMENT. 399 years ago, and I learn on inquiry that he had only a chancre for which he took mercury for two, four, or six weeks, and that he has had no subsequent symptoms, I do not hesitate to infer that his sore was in all probability a chancroid, and that his system was not infected with syphilis. But to return to our subject: this short treatment by mercurials, when the chancre is of the infecting species, serves but to retard the outbreak of secondary symptoms beyond the usual time of their appearance. Unless by the persistence of the induration—the value of which those who pursue this course for the most part ignore—no one can tell whether the patient had a simple or infecting chancre; whether his continued health at the end of six months is due to the nature of the virus or to the effect of treatment; whether he is safe for the future or not. The patient believes himself secure, and may marry, suddenly to break out with a syphilide on his wedding journey, or to infect an ovum and through it his wife. On the other hand, when the original sore was a chancroid, the surgeon has the credit of a cure which he never effected, or the patient's history adds to the confusion prevailing in syphilis, if ever he or his off- spring incur the suspicion of syphilitic taint, and is perhaps recorded in some work on hereditary diseases in connection with other mar- vellous cases in which gonorrhoea in one of the parents gave rise to syphilis in the children twenty years afterwards without interven- ing symptoms. In short, the past, present, and future condition of every patient who is subjected to this unphilosophical method of treatment, based upon no accurate diagnosis of his disease, and calculated to obscure its subsequent history, is liable to remain open to doubt and conjecture. It is an exceedingly difficult and embarrassing question to decide, when a person who had a primary sore several months ago, the remaining traces of which are obscure and for which he took mercurials under the care of another surgeon, comes to inquire whether he may marry with safety. His own account of his case may be too indefinite to found an opinion upon. More than three months may have passed since the appearance of the chancre, and there is no persistent induration of its site, but the inguinal glands are suspiciously large without marked induration. Under these circumstances it is almost an impossibility to determine whether he had a chancroid and has nothing farther to fear; or whether he had a chancre, the traces of which have disappeared and the 400 CHANCRES. natural effects of which have failed to be developed in consequence of treatment, but which may yet give him trouble. Unless the usual mode of practice of the surgeon who treated him be known, no definite answer can be returned to his inquiry, and he must be told to await the developments of time. The second of the three classes into which I have divided prac- titioners, as regards their use of mercury, employ this agent only in cases of primary sore attended by specific induration. This class is already very numerous, and is rapidly increasing; it embraces many of our older men who have kept pace with the advance of science, and probably all, with but few exceptions, who have de- rived their ideas of syphilis from the knowledge of the present, and not from that of the past. It is not hazardous to predict that the extensive and radical change which has been going on during the last ten years in the treatment of primary syphilis, will, in the next generation, become universal. It is hardly necessary to say that the limitation of mercurials to indurated sores is in accordance with the doctrine of the duality of the chancrous virus; but it should be distinctly understood that a belief in this doctrine is not essen- tial to the adoption of this practice, which originated long before the absolute distinction between the two species of primary sore was recognized. Many, doubtless, who pursue this treatment, would say: Expe- rience teaches us that indurated chancres are certainly followed by secondary symptoms; with regard to other chancres, we cannot tell whether they will be or not; we therefore administer mercury for the former, and, in cases of the latter, wait and see whether it will be required. This is the mode of reasoning of the surgeons of the various London hospitals, where, on the authority of the Medical Times and Gazette, " the rule of practice, which is almost universally agreed in, is never to give mercury except for the indurated sore or its results."1 The same journal states the grounds upon which this practice is based as follows: " In a large majority of sores not attended by induration, no constitutional phenomena will follow; and to discriminate between those likely to be so followed and the harmless class is impossible. There is, therefore, no alternative, except we would give mercury very often unnecessarily, but to wait in these cases until the real nature of the affection shall have 1 Medical Times and Gazette, Aug. 28, 1858, p. 221. GENERAL TREATMENT. 401 been made manifest."1 "We find, therefore, that the same treatment may be adopted by those who attribute to induration a merely secondary value, and by those who recognize in it an expression of a distinct species of virus. There is still a third class of practitioners who abstain from mer- cury in all cases of primary sore, whether soft or indurated, until secondary symptoms make their appearance. This class is probably not very large. The most prominent member of it, so far as I am aware, is the distinguished surgeon of Lyons, M. Diday, author of the excellent treatise on infantile syphilis. Another is Dr. Thaddeus M. Halsted, Surgeon to the New York Hospital, whose name adds great weight to this practice. It would naturally be supposed that surgeons of this class abstain from mercury in consequence of distrust in the prognostic value of induration. This is by no means so, however. No one is a firmer believer in the distinct nature and symptoms of the two species of chancre than M. Diday; and he abstains from specific treatment in hard chancres not from any doubts as to the certainty of constitutional infection, but because he believes that the patient will ultimately be better off, if the disease is left to follow its natural course; even in the secondary stage he does not employ mercury unless the severity of the symptoms compels him to do it. Whatever may be thought of this mode of practice, we cannot but be grateful for the valuable information relative to the natural history of syphilis which it has enabled Diday to give us. Dr. Halsted gives me the following history of his adoption of this practice. He had already been convinced by experience of the injurious effect of mercury upon tubercular subjects, having ob- served several cases in which treatment administered for syphilis had apparently hastened the development of phthisis in persons of this diathesis, when a gentleman belonging to a consumptive family applied to him with an apparently well-marked indurated chancre. Dr. H. resolved to abstain from mercury until secondary symptoms should appear, and directed a course of iodide of potas- sium ; and though several years have since elapsed the patient has experienced no farther trouble.2 The success of this case induced 1 Med. Times and Gaz., " Hospital Notes," Jan. 16, p. 62. 2 I cannot admit that this was a true indurated chancre, the natural sequences of which were averted by iodide of potassium. 26 402 CHANCRES. Dr. H. to temporize in all cases of primary sore, at the same time warning patients of their danger and directing them to report them- selves from time to time; and an experience of many years has now convinced him that the effect of a mercurial course in syphilis is certainly no less, and is perhaps even more satisfactory when treatment is deferred until the appearance of constitutional symp- toms, than when administered at an earlier period. My own views have already been inferred by the reader. I believe that the indiscriminate use of mercury in primary sores is unnecessary, unscientific, and reprehensible; that a chancre which will not be followed by secondary symptoms may almost always be distinguished from one that will; that mercury should be adminis- tered only when the diagnosis of an infecting chancre is clear and unmistakable; and that in exceptional cases of a doubtful character, the patient should be kept under observation without treatment until after the usual period of incubation of secondary manifesta- tions has passed. I prefer this course to the one adopted by Drs. Diday and Halsted, because it generally saves the patient from being exposed by the sudden outbreak of a syphilitic eruption, loss of his hair and eyebrows, or other symptoms likely to attract the attention of his associates; if these occur after the administration of mercury, they are generally somewhat modified and less promi- nent; also because mercury is the best means of hastening the cicatrization of the infecting chancre, which it is desirable to get rid of as soon as possible, in order to diminish the chances of con- tagion, as well as to promote the comfort of the patient if the sore be excavated—the superficial variety occasioning but little incon- venience ; moreover, I have seen no reason to believe that treatment is more effectual if deferred until after the appearance of secondary symptoms, and hence nothing is gained by delay. At the same time, I know of no decided objection to the course pursued by Diday and others, since the cicatrization of the chancre will take place spontaneously, or may be hastened by destructive cauteriza- tion ; which, however, is also rejected by Diday in this species of primary sore. Full directions for the administration of mercury will be given in the chapter upon the treatment of general syphilis. With regard to the general treatment of uncomplicated cases of the chancroid and infecting chancres, little remains to be said in GENERAL TREATMENT. 403 addition to the above remarks on the use of mercurials. It is im- portant, however, that the surgeon should exercise supervision over the patient's mode of life, regulate his secretions, and so direct his diet, exercise, etc., as to maintain his general health at a normal standard; on the one hand forbidding stimulants and excess of every kind that inflammatory action may be averted; and, on the other, avoiding depression of the system which would favor the progress of ulceration or aggravate subsequent secondary manifes- tations. It is not generally necessary to confine the patient to the house or to prevent his engaging in his daily avocations, unless they be attended by an unusual amount of exercise and fatigue. The supervention of inflammation, as in the inflammatory chancre, demands antiphlogistic regimen and treatment, proportioned to the severity of the symptoms. On the contrary, when gangrene has taken place, and in all chancres in weak and broken-down consti- tutions, a nourishing diet should be given, and frequently tonics and stimulants. The general treatment of phagedenic chancres should be based upon a knowledge of the cause of the destructive action when this can be ascertained. Phagedena most frequently occurs in persons debilitated by various causes, as intemperance, irregularity of life, want, or a residence in damp, unhealthy apartments; in these cases, nourishing food, the ordinary comforts of life, and the mineral or vegetable tonics are required. Scrofula is another fruitful source of phagedena, and calls for preparations of iodine and other anti- strumous remedies. Moderate doses of opium repeated at short intervals, so as to keep the patient gently under its influence, are often of essential service in allaying pain, and in controlling the progress of the disease. Numerous observers have called attention to the beneficial effect of this agent upon ulcerative action, and have ascribed to it a decidedly tonic influence. Rodet reports several cases of serpiginous chancres which resisted a great variety of means, but which yielded to opium. This surgeon commences with about one grain of the gummy extract of opium morning and night, and gradually but rapidly increases the dose so that the system may not become habituated to it before its therapeutic effect takes place. He prefers two large doses in the twenty-four hours to smaller ones more frequently repeated, in order that diges- tion may go on unimpeded in the intervals. Light wines are 404 CHANCRES. largely administered at the same time, and are said to correct any tendency to constipation.1 In many cases it is impossible to discover the cause of phage- dena. The general condition of the patient is good; all his func- tions are duly performed; and yet his primary sore continues to extend. In such cases our chief reliance must be placed upon deep cauterization, and the general treatment must be more or less experimental. The potassio-tartrate of iron is a remedy of great value in phage- denic chancres, and in all primary sores in which a tonic is required. Ricord calls this preparation the " born enemy" of phagedena, and attributes to it an almost specific influence upon ulcerative action. I can add my own testimony to that of Ricord and many other surgeons in its favor, and would strongly recommend a trial of it in the class of cases under consideration. R. Ferri et potassae tartratis §ss. Aquae §iij. Syrupi §iij. M. From two teaspoonfuls to a tablespoonful of this solution may be taken three times a day, within an hour after meals, and a lotion containing the same salt be applied to the ulcer. An attack of erysipelas has been known to arrest the progress of phagedena and to induce cicatrization of serpiginous ulcers which had proved intractable under almost every form of medication. An instance of this kind is contributed by M. Buzenet to Ricord's Lecons sur le Chancre,2 and several are reported by other surgeons. Abortive and Destructive Treatment. — Many surgeons believe that the infecting chancre is at first a mere local affection, and that the general circulation does not become contaminated until some days after the appearance of the ulcer, hence that the early and complete destruction of the sore is capable of averting infection of the constitution. We are therefore advised to cauterize a chancre as soon as it appears, and are told that if the caustic be sufficiently powerful to kill the tissues to an extent exceeding the sphere of specific influence, a simple wound will be left after the 1 Am. Journal of the Med. Sci., Oct. 1856, from the Bull, de Thgrap., xlix. * Page 278. ABORTIVE AND DESTRUCTIVE TREATMENT. 405 fall of the eschar, and our patient will be preserved from constitu- tional infection. The " abortive method," as this treatment is called, is said to be identical with that adopted in other poisonous wounds, as the bites of venomous snakes and rabid dogs, and to be as reasonable in the one case as in the other. It is an old practice, which, as shown by Fournier, was recommended by John de Vigo in 1508; and in more modern times it has received the sanction of Hunter. One of its chief advocates at the present day is Ricord, whose extensive experience and keen powers of observation are of themselves sufficient to create confidence in any treatment recommended by him. In his Notes to Hunter on Venereal,1 Ricord states that the abortive treatment is always successful when applied not later than the fifth or sixth day after contagion; and that a chancre destroyed within this period has never been known to be followed by constitutional infection. In his Lecons sur le Chancre,2 however, he places the limit at the end of the fourth day, and it would appear from his own statements that it ought to be still more nearly approximated to the time of contagion, for he admits that induration is sometimes developed as early as the third day, and that this is an evidence that constitutional infection has already taken place. Prof. Sigmund, of Vienna, whose field of observation is scarcely less extensive than Ricord's, is also a firm believer in the efficacy of this method, and says that in eleven years' practice, and in more than one thousand cases to which he has applied the abortive treatment, he has never seen secondary symptoms follow a chancre which was completely destroyed within four days; and that he has met with only two doubtful cases in which cauterization as late as the fifth day was ineffectual; and even after this time he thinks it will often be successful. I have adduced this testimony in favor of the abortive treatment before stating my objections to it, in order that the reader may be better enabled to judge for himself, and that I may not lead any one causelessly to adopt a wrong conclusion. It would certainly be assuming a fearful responsibility to arouse unjust suspicions of a mode of practice which, if based upon correct principles, may save thousands of persons every year from the terrible curse of constitutional syphilis. And yet, in spite of this strong testimony, 1 2d edition, p. 320. 2 P. 206. 406 CHANCRES. I cannot think that the abortive treatment of infecting chancres is of any practical value. I believe that however early the patient applies to the surgeon after the development of an infecting sore the mischief is already done. The existence of a period of incuba- tion, which I have before endeavored to establish, is one argument in favor of this position. If the inoculated point remains in a state of quiescence for several days and exhibits no traces of inflammatory action, the subsequent appearance of the chancre can only be ascribed to changes which have already taken place in the general circulation; and, if this be true, cauterization of the sore will be as ineffectual in arresting the action of the virus, as when applied to the vaccine pustule, or to the bite of a mad dog which has become tumefied or reopened as the earliest symptom of hydrophobia. And here we see how defective is the analogy drawn from venomous wounds by which it is attempted to sustain the abortive treatment of chancres. If a person be bitten by a rabid animal, and the part at once excised and cauterized, there is some hope of averting farther trouble; but no one would expect immunity when treatment was deferred from one to four days. So with the infect- ing chancre, the time to apply abortive treatment with success would, if possible, be directly after coitus; the delay of an hour, and probably of a few moments will render it useless. Experiments with other morbid poisons prove that absorption is almost instanta- neous. Bousquet inoculated the vaccine virus, and immediately applied cups and washed the part with chlorinated water without preventing the evolution of a pustule.1 Renault, Surgeon of the Veterinary School at Alfort, inoculated horses with acute glanders, excised the part and applied the actual cautery one hour afterwards, yet the animals died of the disease.2 Similar experiments with the sheep-pox virus proved that its absorption does not require more than five minutes. In many instances of infecting chancre, the conditions under which contagion takes place are precisely similar to those in the above experiments; a specific virus is applied to a raw surface, produced in the one case by violence in coitus, in the other by a lancet. Nor will the course of events be materially changed in those instances in which the poison is deposited upon the sound integument or mucous membrane, and, at first acting as a simple 1 Traite de la Vaccine. * Academie des Sciences, 1849. ABORTIVE AND DESTRUCTIVE TREATMENT. 407 irritant, gains access beneath the surface through ulceration of the epithelium; since the moment a sore is produced, the virus is in the same condition as when originally applied to a rent or abrasion. We may fairly conclude, therefore, that so far as we are justified in reasoning from the analogy of one specific poison to another, there is no ground whatever for supposing that the syphilitic virus can remain in contact with a solution of continuity for several days without absorption taking place. But although this argument is of very considerable weight, it must be confessed that it is not in itself conclusive; since, although it is highly improbable, it is by no means impossible that the phenomena of absorption of the syphilitic are different from those of any other known specific poi- son ; and the question must after all be finally settled by an appeal to facts. The value of Ricord's and Sigmund's experience is very much weakened, if not entirely annulled, by several considerations. In the first place, the diagnostic symptoms between the two species of chancre are never manifest within four days after contagion, so that it is clearly impossible for either of these surgeons to indicate a single one of their numerous cases as an undoubted instance of the prevention of constitutional infection by the abortive treatment. The nature of the ulcer might have been determined by reference to the sore from which it was derived, but this means of diagnosis was unknown at the time their observations were made and was consequently never resorted to. In any future investigation of this question, it should not be neglected. Again, infecting chancres constitute but a small proportion of the aggregate of primary sores, so that the " more than a thousand cases" adduced by Sigmund are far more imposing in appearance than in reality. But a still stronger argument against the admis- sion of this testimony is found in the recently discovered period of incubation of the infecting chancre, which places the usual time of its development beyond the limit assigned by these surgeons to the efficacy of the abortive treatment, and thereby renders it extremely doubtful whether, in any of the cases upon which they rest their assertions, general syphilis would have ensued, even if no treatment whatsoever had been instituted.1 Reference has already been made 1 It does not appear incredible, nor even improbable that Ricord, for more than twenty years, should mistake the effect of the abortive treatment, when we recol- 408 CHANCRES. to Diday's investigation of 29 cases of infecting chancre, from which it appeared that the average period of incubation was 14 days. In 28 cases observed by M. Ponset the average was 8 days ; and in 11 cases collected by Fournier the interval between coitus and the appearance of the chancre was 3, 4, 5, 5, 5, 5, 6, 6, 6, 7, and 9 days respectively. The average deduced from the aggregate of these 68 cases is nine days} This period of incubation of an infecting chancre, which is a strong reason for distrusting the statement of Ricord and Sigmund, also renders it difficult positively to disprove their assertion by facts complying to the very letter with the conditions which they require; but a number of cases are recorded in which destructive cauterization within a few days and even a few hours after the de- velopment of the chancre, has failed to avert constitutional infection, and which are sufficient, at least, to show that the abortive method is unreliable. Diday has thoroughly cauterized chancres four days and a half and others five days after coitus, and secondary symp- toms have still appeared. In another case, occurring in a patient who had watched himself with the greatest care from day to day and almost from hour to hour, the chancre was not developed until a month after the sexual act, but the abortive treatment was ap- plied within six hours of its first appearance; the sore healed in the course of three days, but secondary symptoms appeared three weeks afterwards.2 More recently,3 Diday has reported several additional cases as follows:— Case 1. A man, aged 45, somewhat of a syphilophobist, and conse- quently very attentive to the condition of his genital organs, consulted Diday, Sept. 24th, 1858, for a chancre which he had first observed three days before. The sore was at once cauterized with the paste of vegetable carbon and sulphuric acid, in use at the Hopital du Midi. The patient was seen again Oct. 3, when the chancre was found to have healed and to have left a healthy-looking cicatrix. Slight induration of a few ganglia in the groins inspired, however, some doubts as to the future. lect that, although habitually inoculating, during the same period, the secretion of primary sores upon the persons bearing them, he never discovered until recently that the infectiug chancre is not auto-inoculable. 1 Gaz. Med. de Lyon, 1859, p. 570. 2 Ibid., March 1, 1858. 3 Annuaire de la Syphilis, annee 1858, p. 134. ABORTIVE AND DESTRUCTIVE TREATMENT. 409 Nov. 8. The cicatrix presented a well-marked mass of induration, and the glands of both groins were also evidently indurated; and the patient complained of scabs in his hair. Nov. 19. A papular eruption of a decided copper color appeared over the whole body. Case 2. A youug man who had been subject to herpes preputialis, and who had been in the habit of consulting his physician for each re- newed attack, presented himself, Sept. 21, 1858, with a small chancre upon the integument of the penis, which had existed but two days only. Canquoin's paste was at once applied and left on the ulcer for two hours. A week after, he was apparently well, but a slight hardness, like a grain of millet seed, felt when the cicatrix was pressed between the fingers, ren- dered the prognosis somewhat doubtful. Oct. 27. Syphilitic roseola began to appear upon the abdomen, and by Nov. 4, became general and unmistakable. The patient also had acne capitis, engorgement of the cervical ganglia, headache, etc. Case 3. A young man, who, from former experience, was familiar with the appearance of chancres, sought advice Oct. 14, 1858, for a small abrasion, which, as he stated, appeared only twenty-four hours before. It was immediately burnt with the carbo-sulphuric paste. Oct. 28. The sore had cicatrized but had left well-marked induration, which also involved the inguinal ganglia. Nov. 26. He presented a papular syphilitic eruption, and scabs upon the hairy scalp. The following case is reported by M. Langlebert.1 Case 4. A student of medicine, who was thoroughly informed upon all subjects connected with syphilis, consulted Langlebert for a small ulcer behind the corona glandis which he was certain had appeared only two days before. The sore was very superficial, scarcely larger than the head of a pin, was not indurated, nor accompanied by engorgement of the inguinal ganglia. It was cauterized the same day with nitrate of silver, and healed in less than a week. No induration appeared in the groins, but two months after constitutional syphilis declared itself. The above cases are sufficient to show that the early destruction of an infecting chancre is incapable of averting general syphilis. Indeed, as I have previously stated, the existence of a period of in- cubation, during which the inoculated point remains in a state of 1 Moniteur des Hopitaux, Dec. 21,1858. 410 CHANCRES. quiescence, proves that the chancre itself must be looked upon as the effect of changes which have already taken place in the general circulation. We can, at this time, no more hope to arrest the action of the virus by the abortive treatment, than we could expect, by destroying a vaccine pustule, to restore the system to the same con- dition as before vaccination. I have thus endeavored to show that destructive cauterization is ineffectual for the purpose for which it is often employed, viz., the prevention of constitutional syphilis; and I believe it should be abandoned as useless, and as subjecting the patient to unnecessary pain, whenever there is reason to suppose that the chancre is of the infecting species. In doubtful cases, however, we may still resort to it, for fear the sore may be a chancroid, which can be much more readily destroyed at an early than at a late period of its existence.1 Several surgeons have endeavored to discover some single sub- stance or compound capable of neutralizing the chancrous virus, and yet not so powerful as ordinary caustics, so that it might be used with safety by any one after exposure to bathe the genital organs; but such attempts have not been very successful. Rodet2 hag experimented with the following mixture and found that when applied to the puncture of an artificial inoculation, it undoubtedly prevents the development of a soft chancre, provided that a drop of the fluid remains in contact with the part for fifteen or twenty min- utes ; but it would be impossible to induce men generally to adopt any prophylactic measure requiring so long an application. R. Aquae destillatae §j. Ferri perchloridi, Acidi citrici, Acidi hydrochlorici, aa 3j. M. Destructive Method.—Though the abortive and destructive methods of treatment involve the use of the same means, yet the object of 1 A number of surgeons have expressed their disbelief in the efficacy of the abortive treatment as a means of preventing constitutional infection, among whom may be mentioned Diday, Rollet, Clerc, Dron (Annuaire de la Syphilis, 1858, p. 202), Erichsen (Science and Art of Surgery, 2d London ed., p. 447), Vidal (Treatise on Venereal Diseases, 1st Am. ed., p. 198), Langston Parker (Modern Treatment of Syphilitic Diseases, Am. ed., 1854, p. 107), Harrison (Pathology and Treatment of Venereal Diseases, 1860, p. 129), and Dr. Wm. H. Van Buren, of this city. 2 Compte Rendu du Service Chirurgical de l'Antiquaille, 1855, p. 74. DESTRUCTIVE METHOD. 411 each is different. The abortive treatment regards a chancre as the precursory symptom of syphilis, and endeavors by its removal to prevent constitutional infection. The destructive method has refer- ence only to the local sore and its immediate neighborhood, and aims to limit the duration and extent of the ulcer, and to prevent successive inoculations, the formation of virulent buboes, and the supervention of phagedena. Destructive cauterization as a means of hastening the cicatriza- tion of chancres, and not for the purpose of preventing constitu- tional infection, was first employed by Richond des Brus in 1826. This surgeon limited its use to the commencement of primary sores, but it has since been extended by Ricord to every stage in the existence of these ulcers, with the exception of the reparative period. The destructive method may be applied either to the chancre or to the chancroid, but is not generally required in the former, which, as already stated, readily cicatrizes under the use of mercury given to combat the constitutional infection. In applying it to cases of a doubtful character, in which some prove to be infecting chancres, the effect of the treatment is found to be the same as in the chan- croid : the specific is transformed into a simple sore which rapidly heals, though induration supervenes either before or after complete cicatrization. But this simple method finds its chief application in the simple chancre or chancroid, in which the influence of the virus is con- fined to the ulcer and the tissues immediately surrounding it; and if these be all included in the eschar produced by the caustic, the whole disease will be removed. Destructive cauterization is the only means which can be depended upon to effect a speedy cure of the chancroid. Astringent and disinfecting lotions, and cleanliness may prevent inoculation of neighboring parts, but have little, if any, power to control the duration or extent of the ulcer itself, which pursues its natural course unchecked and cicatrizes only after several weeks' or months' duration, unless eradicated by caustic. Hence destruction of the primary sore is the most valuable means that we possess of averting phagedenic ulceration, and of arresting its progress when once it has supervened. The destructive method, if applied sufficiently early, prevents the occurrence of virulent buboes by removing the source from which the virus enters the lymphatics; but if deferred until a bubo has 412 CHANCRES. commenced, the latter goes on to suppuration unchecked, and may furnish inoculable pus in the same manner as if the chancroid had been allowed to remain. Even the sympathetic bubo is often benefited by destruction of the primary sore and undergoes resolu- tion.1 Destructive cauterization is impracticable when the chancroid cannot be fully exposed, as in consequence of phymosis, conceal- ment within the urethra, os uteri, etc. It is inadmissible in ulcers situated directly over the urethra either in the male or female on account of the danger of opening this passage; for similar reasons, in chancroids of the deeper portions of the vagina, the walls of which are in contact with the bladder, rectum, and peritoneum; in those upon the margin of the meatus, from the fear of the cicatrix occasioning stricture; and finally in all cases in which the presence of other chancres in the neighborhood, which cannot be subjected to the same treatment, would expose the wound after the fall of the eschar to a second inoculation.2 An attempt to remove chancres by the knife is rarely successful, since, however carefully the secretion of the sore may first be re- moved, enough usually remains to inoculate the fresh wound. For this reason, excision should be employed only when a cutting operation is rendered necessary, as by the presence of phymosis and threatening gangrene; and the knife should be carried as wide as possible from the specific sore, and the bleeding surface be freely cauterized with nitrate of silver or nitric acid. On the contrary, the application of caustic leaves the tissues for a time protected by an eschar, and is, therefore, almost always to be preferred to the knife. Nitrate of silver is too feeble a caustic to be employed except at the commencement of a chancroid, or in wounds and abrasions im- mediately after a suspicious connection, before the surrounding tissues have become infiltrated with the virus. It is chiefly used for the purpose of destroying the pustule which appears on the second or third day after a successful inoculation. A fragment of the solid crayon corresponding in size to the excavated ulcer which is exposed by the removal of the epidermis, is pressed into it and 1 Rollet, Gaz. Med. de Lyon, March 1, 1858. 2 De la Methode Destructive des Chancres, par M. Dron; Annuaire de la Syphi- lis, annee 1858, p. 202. DESTRUCTIVE METHOD. 413 allowed to remain until it comes away with the small eschar which is formed. The simple wound which is left speedily cicatrizes. For the fully developed chancroid a stronger caustic is required, as nitric or sulphuric acid, potassa cum calce, the pernitrate of mercury, chloride of zinc, or the actual cautery. Of these, strong nitric acid and Vienna paste, from the convenience of their appli- cation, have deservedly come into the most general use. Nitric acid is preferably applied by means of a glass rod with a rounded extremity; a " drop bottle," with a tapering glass stopper, the point of which extends nearly to the bottom of the flask, is still more convenient; but a simple piece of wood, as an ordinary lucifer match, will answer. Brushes of fine glass are objectionable, since the filaments are liable to break off' upon the surface of the sore and excite irritation. The pain is for an instant very severe when the acid first touches the ulcer, but becomes much less acute on subsequent applications, of which there should be several in order to render the destruction complete. I usually employ several minutes in making these applications, watching the effect produced, and judging by the changes which take place in the tissues when enough has been applied. Any residue should be carefully removed or neutralized by an alkali, and the neighboring surfaces be protected from contact by the interposition of dry lint. A water-dressing may be substituted as soon as suppuration takes place. After the fall of the eschar, the surface is still covered for a short time with a slimy secretion, but this soon clears off, and any in- flammatory engorgement produced by the caustic subsides, leaving a healthy looking wound, which should be protected from the urine and leucorrhceal discharges in order to insure its speedy cicatriza- tion. If any symptoms of a chancroid remain, the cauterization should be repeated. I am convinced that nitric acid is far superior to the nitrate of silver which is so commonly employed in the cauterization of chan- cres, and that the latter should never, as a general rule, be applied for this purpose except at the very commencement of the ulcer. Any one may convince himself of this truth by a comparative trial of the two agents. The same sore which continues to extend under the application of the nitrate of silver, will speedily cicatrize under the use of nitric acid repeated, if necessary, every second or third day. Any fears which might be entertained that the frequent 414 CHANCRES. application of so powerful a caustic would do mischief appear to be groundless. The liquor hydrargyri pernitratis may be applied in a similar manner; I am not aware, however, that it possesses any advantages over nitric acid, and it is attended with some danger of producing salivation. Potassa cum calce made into a paste and spread upon the chan- croid, where it is allowed to remain from five to fifteen minutes, is another convenient mode of applying the destructive method. Ricord has of late years employed a paste composed of vegetable carbon mixed with strong sulphuric acid. Its advantages are said to be that it forms a crust which closely adheres to the tissues, and does not fall off until the sixth or eighth day, when cicatrization is far advanced. I have used the carbo-sulphuric paste in a few in- stances, but not in a sufficient number to speak decidedly of its merits. Thus far, it has not appeared to me to be superior to other caustics, nor so convenient; and it is, I think, little used elsewhere than at the Hopital du Midi. A valuable caustic, judging from the high encomiums bestowed upon it by many French surgeons, especially of the Lyons school, is to be found in " Canquoin's paste," composed of equal parts of chloride of zinc and flour, which was first recommended for the destruction of the chancroid by MM. Rollet and Diday. The only serious objection to it is the difficulty of preserving it, owing to the deliquescent properties of the chloride. If carefully prepared, however, and protected from moisture, it may be kept indefinitely. Some, which I have repeatedly used with very satisfactory results, was made by an expert druggist over a year ago from Squibb's chloride of zinc, and, surrounded by tinfoil, has been kept in a drawer without becoming soft. Debauge recommends that fresh chloride of zinc should be pre- pared for the purpose by dissolving laminae of the pure metal in hydrochloric acid, filtering the solution through carded cotton and evaporating it by a gentle heat; I believe, however, that chloride of zinc obtained at the druggists' and thoroughly dried over a spirit lamp, is equally as good. The finely-powdered chloride should be intimately mixed with an equal quantity of flour, which has also been dried by heat, and alcohol added drop by drop until a paste is formed, which is to be spread in a thin layer upon cloth, and again subjected to gentle DESTRUCTIVE METHOD. 415 heat. Should deliquescence subsequently take place, the paste may readily be dried again without losing its caustic power.1 When required for use, a disk, corresponding in shape to the chancroid, and slightly exceeding it in .size, is cut out and retained upon the surface, previously cleansed of matter, from one to three hours, and in large or phagedenic ulcers for five or six hours. Two hours is the average duration required for ordinary cases. The patient should keep his bed until the paste is removed; and, since only one surface of the plaster is covered with caustic, the prepuce may be drawn forwards, when the sore is situated upon its internal surface, or upon the glans, without danger of injury to the sound tissues. The advantages of Canquoin's paste are its facility of application and freedom from the danger to which all liquid caustics are liable of involving the sound tissues; the small amount of pain which it excites; and the possibility of graduating the depth of its destructive action, which is directly proportioned to the length of the applica- tion. Diday has especially insisted upon the absence of pain, and says that he has frequently been told by patients that they felt only a slight pricking sensation; Rollet states that it is not painful, ex- cept when applied to sores involving the frsenum. Some oedema is observed after the cauterization, and also inflam- matory hardness of the base of the sore, which must not be mis- taken for specific induration. The eschar usually falls off about the fourth or fifth day; and of forty-one cases of which a record was kept by Rollet, the shortest time required for complete cicatri- zation was eleven days and the longest fifteen days.2 Canquoin's paste has also been employed for the destruction of chancres suc- ceeding the opening of virulent buboes. Rollet has recently applied the actual cautery to serpiginous chancres, and although he reports but two cases,3 yet the results were so satisfactory as to encourage us to hope that an effectual mode has at length been found of treating these ulcers, which have long been the opprobrium of surgery. In one case, the ulcer, of ten months' duration, extended from ' Debauge, Traitement des Chancres Simples et des Bubons Chancreux par la Cauterisation au Chlorure de Zinc; These de Paris, 1858, p. 12. 2 Gaz. Med. de Lyon, Dec. 15, 1857. » Note sur la Destruction du Chancre PhagMenique Serpigineux par la Cauteri- sation Actuelle ; Annuaire de la Syphilis, 1858, p. 116. 416 CHANCRES. the root of the penis to the spine of the ilium and encroached upon the integument of the abdomen, thigh, and scrotum: various con- stitutional remedies had been tried without effect, but complete cicatrization took place in one month after the application of the cautery. In another case, which had persisted for eight months and which had been ineffectually treated by general remedies and local cauterization with Canquoin's paste, the success attending the use of the hot iron was no less remarkable. Although constitutional cachexia is the chief cause of phage- dena, yet the abundant secretion from a serpiginous ulcer and the excessive pain attending it, often more than counterbalance the effect of tonics, nourishing diet and other hygienic measures. By destroying the specific ulcer, these causes of debility are in a great degree removed, and the system rapidly yields to the influence of constitutional remedies. The caustics above mentioned are not sufficiently powerful or rapid in their action effectually to destroy the whole extent of phage- denic chancres. If the smallest loophole be left from which virulent pus can proceed, it will inoculate the wound remaining after the fall of the eschar, and the only effect of the treatment will be to increase the size of the ulcer. It is evident, therefore, that the destruction of the ulcer, in order to be a benefit and not an injury, must be thorough and complete. Some hesitation may be felt in applying the actual cautery to so extensive a surface, but when the gravity and obstinacy of the disease are considered, it must be confessed that almost any means is justifiable which holds out a fair promise of cure. The patient should be rendered insensible by means of an anses- thetic, and cauterizing irons of different shapes and sizes be raised to a white heat. Rollet directs that the ulcer should first be cleansed by washing it copiously with water, removing all adherent matter and then drying it. Every portion of the secreting surface should now be deeply cauterized, carrying the hot iron into every nook and sinus, and paying special attention to the parts overlapped by the skin of the edges. These flaps of integument should be cauterized not only upon the under, but also upon the outer surface, so as to be for the most part destroyed. A cold water-dressing is afterwards applied, and the patient, on waking, does not suffer much more than he did before the operation. When suppuration commences, Goulard's extract or aromatic wine may be added to the lotion. TOPICAL APPLICATIONS. 417 Topical Applications. — We now proceed to consider the local treatment of chancres by other means than destructive cau- terization. I have already stated that little dependence can be placed upon any therapeutic effect from the ingredients of the lotion or dress- ing applied to a primary sore. I do not mean to imply, how- ever, by this remark that the local treatment of chancres is unim- portant. Neglect in this direction may result in decided injury; while proper attention will put the ulcer in the most favorable condition for cicatrization to take place. If the secretion be allowed to accumulate and stagnate—if scabs be permitted to form under which matter may burrow, ulcerative action will be favored, and also (in case of the chancroid) successive inoculations in the neigh- borhood. These evils may be obviated by cleanliness, and by such form of dressing as will absorb or remove the pus as fast as it is secreted, assisted by astringents or disinfectants for the purpose either of hardening the surrounding surface or neutralizing the virus. But this, I think, is about all that local applications can accomplish. To attribute to them specific virtues, as, for instance, to suppose that mercurial applications possess any power over the sore because it is a chancre, is to my mind absurd. In short, topical remedies have the same influence upon a chancre as upon simple ulcers, and do not affect its specific character. It is highly desirable to aim at simplicity in the local treatment of primary sores; though applications must be varied somewhat to correspond with the situation and species of the ulcer, and the copiousness of the discharge. Chancres situated beneath the prepuce, when this fold of integu- ment habitually covers the glans, may be dressed with dry lint, which will be sufficiently moistened by the natural secretion of the part. Indurated chancres are not liable to give rise to successive sores in the neighborhood, and hence astringents and disinfectants are rarely required. In the superficial variety upon the internal surface of the prepuce, the interposition of a small piece of dry linen between the glans and prepuce is all-sufficient. In the more exca- vated form which is commonly met with in the furrow at the base of the glans, scraped lint is preferable, since it is a better absorbent. Lotions are necessary when the sore is situated upon the external integument, in order to keep it moist and prevent the dressing from 27 418 CHANCRES. adhering to the surface, and this object may be still farther pro- moted by covering the dressing with oiled silk. In most cases, the lotion may consist of simple water or glycerine; when medicated, such ingredients should, as a general rule, be added as will not leave a deposit or change the aspect of the sore, and thus render its condition obscure. The following formulae are among the best:— R. Liquoris sodae chlorinatse 5j- Aquae purae §ij. M. R. Acidi nitrici diluti 3,i- Aquae purae §viij. M. R. Vini aromatici Jj. Aquae 3 iij. M. A formula for a convenient substitute for the French aromatic wine may be found on page 167. The strength of these lotions must be adapted to the sensibility of the part, which varies in different cases. They should never be so strong as to excite pain or produce irritation. The black wash, composed of from one to three scruples of calo- mel to four ounces of lime-water, is a favorite application with many surgeons. The dark-colored sediment in this mixture is an oxide of mercury, and is inert unless it affords mechanical protec- tion to the sore. In my opinion, black wash is a less cleanly and less desirable lotion than those before mentioned. A solution of the potassio-tartrate of iron, in the proportion of from two to eight drachms of the salt to six ounces of water, is much employed by Ricord, especially in the treatment of phage- denic chancres. In many cases this application acts very favorably; while in others, I have found that the sore became covered with a dingy coating of coagulated master, which obscured its condition, and required to be removed by a water dressing. I have only observed this unpleasant effect when the application has been made to chancres beneath the prepuce, and have been inclined to attribute it to a combination of the iron with the smegma prseputii. The dressing of primary sores, and especially of phagedenic chan- cres, most recently adopted by Ricord, is the stearate of iron, which may be prepared in the following manner. Dissolve castile soap TOPICAL APPLICATIONS. 419 in a sufficient quantity of water, and gradually add a salt of the peroxide of iron, as the liquor ferri perchloridi or liquor ferri per- sulphatis, until it ceases to form a precipitate, which collects in a tenacious mass upon the surface. This mass, which is a stearate and oleate of the peroxide of iron, should be freed from impurities by being washed or melted in fresh water, and, either pure or mixed with lard, is to be spread upon lint and applied to the sur- face of the chancre. Some of this pomade has been kindly pre- pared for me by Mr. Ferdinand F. Mayer, a skilful chemist of this city, but I have not as yet experimented with it. Lotions of acetate of lead are objectionable, since this salt is decomposed when brought in contact with the animal secretions, and an insoluble albuminate of lead, which is with difficulty re- moved, is deposited upon and incrusted in the tissues. Unguents are less desirable applications than lotions, and should only be employed when, from the position of the sore, or from the necessarily long interval between the dressings—as at night or during a journey—the evaporation of a water dressing cannot be prevented, even with the assistance of oiled silk and glycerine. Mercurial ointment, which, as procured in the shops, is generally rancid or rapidly becomes so, is irritating and especially objection- able. One of the following formulae may be employed when an unctuous dressing is required. The first is much used in French hospitals. R. Cerati simplicis ^j. Tincturae opii 5j- Calomelanos gr. xxxvj. M. R. Balsami Peruviani, Olei ricini, aa §j. M. R. Ung. zinci oxidi §j. Pulv. opii 5j. M. The frequency with which local applications are to be changed must be determined by the copiousness of the secretion, which should not be allowed to collect and stagnate, or (especially in case of the chancroid) extend to surrounding parts. Before one dressing is soaked with the discharge, another should be substituted. If the first adhere to the surface, it should be care- 420 CHANCRES. fully moistened before attempting its removal, in order to avoid any abrasion, which, by subsequent inoculation, would increase the size of the sore. The patient should also be directed not to cleanse the ulcer itself, but simply to remove the discharge from the neighboring parts by touching them gently (without friction) with a soft piece of linen. The dressing of most uncomplicated chancres need be renewed only two or three times a day, but phagedenic ulcers re- quire a much greater frequency. During the process of cicatrization, exuberant granulations may spring up and require repression by pencilling with a crayon of nitrate of silver. A superficial application of this agent is also beneficial in relieving the irritability and pain of some chancres in the progressive and stationary periods. Other applications than those now mentioned may be required in the treatment of primary sores. For instance, in chancres attended by much inflammation, leeches to the groins or perineum, and poul- tices or sedative lotions, are of service. Pain should be relieved by the exhibition of opium in large doses internally, and by its application externally. The detached edges of phagedenic chancres should be removed by destructive cauterization with Vienna paste, nitric acid, or the actual cautery. The above remarks on the treatment of chancres may be summed up as follows:— 1. In the treatment of all primary sores, the general health is to be maintained as nearly as possible at the normal standard; avoid- ing both a depressed and stimulated condition of the system. Local applications should be simple and unirritating. Cleanliness should be carefully observed. 2. Simple chancres do not require the administration of mercu- rials, either as a preventive of constitutional infection or to promote cicatrization of the ulcer. The most effectual treatment is deep cauterization with a powerful caustic, as fuming nitric acid, repeated as often as may be found necessary. 3. The internal use of mercury is justifiable only in undoubted cases of infecting chancre; and, in nearly every case of this species of primary sore, is the only treatment required. The abortive treatment at the earliest period at which the sore can be detected, is ineffectual in preventing constitutional infection. 4. When in doubt as to the nature of a chancre, treat it as be- CHANCRES OF THE FR2ENUM. 421 longing to the simple species, and keep the patient under observa- tion until the period of incubation of secondary symptoms has been passed in safety. 5. Inflammatory chancres are to be treated by rest, low diet, and other antiphlogistic measures, so long as the acute symptoms con- tinue; if gangrene occur, tonics and stimulants will be required. 6. The treatment of phagedenic chancres consists in attention to the hygienic condition of the patient, nourishing diet, tonics, stimu- lants, opium, and deep cauterization by means of nitric acid, Vienna or Canquoin's paste, or the actual cautery, followed by appropriate lotions, as the potassio-tartrate of iron. Mercurials are highly detrimental in acute phagedena, and are rarely of benefit in any case in which this complication is present. Special Indications from the Seat of Chancres.—The seat of chancres often modifies their symptoms and necessitates changes in the treatment. Chancres of the Frsenum.—Chancres of the fraenum are espe- cially painful, persistent, and exposed to hemorrhage. They may commence either upon the free margin or upon the base of the bridle. In the former case a rent or fissure, the result of violence during coitus, has probably been inoculated; and the resultant chancre gradually eats away the whole bridle, and hollows out a narrow longitudinal groove upon the under surface of the glans, giving great annoyance, persisting indefinitely, and resisting ordi- nary modes of treatment. Again, chancres of the fraenum may proceed from primary sores in the neighborhood, which exhibit a remarkable tendency to involve the bridle, if situated near it. In this case the base of the fraenum is first attacked, and often becomes perforated from side to side; the chancrous opening gradually en- larges, extends to the free margin, and, as in the former case, pro- bably destroys the whole bridle. The fraenum is copiously supplied with blood, and exceedingly sensitive; hence chancres of this part are very liable to bleed and give rise to much suffering. Their persistency and destructive tendency are due to the frequent rupture of the longitudinal fibres of the fraenum, occasioned by the constant motion to which it is exposed, in walking, handling the penis during micturition, in erections, etc. Minute rents are thus caused in the sore which become inoculated and increase its depth; and ulcerative action goes on until the whole bridle is destroyed, 422 CHANCRES. including the portion buried in the under surface of the glans; and hence the fossa already referred to. In the treatment of these chancres, the patient should be directed to avoid all motions of the part which will stretch the fraenum; the glans should not be uncovered except to dress the sore, and even then no farther than is absolutely necessary to insert the dressing. If the chancre threaten to destroy the whole bridle, time will be gained by accomplishing the same at once by means of caustic. When perforation has taken place, the remaining portion of the bridle should be divided with scissors, and the raw surfaces freely cauterized. The flow of blood in this operation is often troublesome, and may be avoided by previously passing a double ligature through the opening and tying each thread at either extremity of the fraenum, all of which should be removed. Diday heats one blade of a dull pair of scissors over a spirit lamp, and passing the opposite blade through the opening to serve as a support, divides the fraenum by the actual cautery.1 Urethral Chancre.—" Gonorrhoea virulenta" either proceeds from a urethral chancre alone, or consists of the discharge of ordinary gonorrhoea, which has acquired specific properties, from being mingled with the secretion of a chancre or secondary lesion. There is no other " gonorrhoea virulenta" than this; and as the name has usually a very different and erroneous interpretation, it should be banished from our nomenclature. Terms like this are clogs upon the feet of science. By referring to the table of the seat of chancres on page 356, it is seen that of 814 chancres observed at the Hopital du Midi, 41 involved the meatus, and 20 were situated within the urethra, at a greater distance than was visible on forced separation of the lips. Attempts have been made to determine the frequency of urethral chancres by artificial inoculation of gonorrhceal discharges, but this test, as we shall presently see, may be fallacious. As might be supposed, urethral chancres are most frequently found near the meatus; but they may be seated in any portion of the canal, and, in rare instances, even in the bladder. Ricord presented to the Academy of Med. of Paris2 two specimens of phagedenic chancre involving the deeper portions of the urethra ' Du Chancre Primitif du Frein de la Verge; Gazette Hebdomadaire, Oct. 19, 1855, p. 749. 2 Bull, de l'Acad. de Med., 1838, t. ii. p. 506. URETHRAL CHANCRE. 423 and bladder, in each of which the disease had been recognized during life by the successful inoculation of the urethral discharge.1 Vidal, with strange inconsistency, denies the possibility of these cases, and then reports a similar one of his own !2 Many chancres of the fossa navicularis are visible on forced separation of the lips of the meatus. For the purpose of exploring this portion of the urethra, I am in the habit of using Toynbee's ear-speculum, the uniform calibre of the extremity of which permits its introduction for about an inch, and if the patient be placed in direct sunlight, an excellent view of the lining membrane for this distance may be obtained. When situated beyond the field of vision, urethral chancres are recognized with greater difficulty. Successful inoculation of the discharge will determine the presence of a chancroid, which, if the surrounding parts be much inflamed, may sometimes be felt on external palpation. Auto-inoculation, as already seen, is not a test of the true syphilitic or infecting chancre, and hence cannot be relied on; but this species may be recognized in most cases by other symptoms.' The specific induration which surrounds it is often perceptible to the touch; the glands of the groin present their characteristic changes; and hard, indurated cords (specific lymphangitis) may sometimes be felt extending from the seat of the chancre towards the root of the penis. It is evident, however, that unless the surgeon be on his guard, these symptoms may escape notice; there are certain phenomena in an apparent case of gonor- rhoea which should lead him to suspect and search for a urethral chancre; these are the small quantity and dark color of the discharge, its mixture with blood, and the location of the pain, especially during the passage of the urine, at a fixed point. It is unnecessary to insist upon the fact that urethral chancres sometimes give rise to constitutional infection, the origin of which is unknown to the patient, who may honestly declare that he has never had a chancre. Urethral chancres, so near the meatus as to be visible, are to be treated like other primary sores; the dressing, with a thread attached to facilitate its withdrawal, being inserted by means of a probe after each act of micturition. Deep urethral chancres are not 1 These cases are figured in Ricord's Notes to Hunter. 2 Treatise on Venereal Diseases, 1st Am. ed., N. Y., 1854, p. 209. 424 CHANCRES. susceptible of much local medication. Injections of a solution of nitrate of silver have been recommended, but neither in this form, nor when the solid crayon is applied by means of Lallemand's instrument, can this agent destroy the specific sore, and it only serves to irritate, as when applied to external chancres. Topical applications must therefore be limited to injections containing opium, glycerine, or some mild astringent. If the chancre be indurated, give mercurials; if simple, abstain from specific treatment; relieve inflammation, if necessary, by leeches to the groin; if abscesses form, open them early; and, in all cases, guard against erections which tear and irritate the sore. Chancres of the Vagina and Os Uteri.—Chancres of the deeper portions of the vagina cannot be treated by destructive cauterization, owing to the proximity of important parts—an objection which does not apply to those of the os uteri. The local applications employed in external chancres may be made through a speculum. It is important to recollect that induration is not so constant a symptom of the infecting chancre in women as in men; hence in establishing the diagnosis, we are often obliged to rely almost exclusively upon the condition of the inguinal ganglia, or even wait until the normal period for the appearance of secondary symptoms has passed. According to Gosselin, hypertrophy of the labia majora, whether accompanied or not by that of the labia minora and some of the carunculae myrtiformes, is so exclusively an effect of chancres in the neighborhood of the vulva, that its presence is sufficient to justify the conclusion that a woman has at some previous time had primary syphilis.1 Chancres of the Anus and Rectum.—Chancres of the margin of the anus are liable to be mistaken for fissures. They are attended by much pain, especially during the passage of the feces, which should always be rendered liquid by a mucilaginous injection. It is sometimes advisable after clearing out the bowels, to thoroughly cauterize the chancre, and to confine the patient to bed and a low diet, and administer opiates for the purpose of preventing any farther stools until cicatrization has taken place. It is a fact worth remembering that an infecting chancre of the anus or rectum causes induration of the more external inguinal 1 Arch. Gen. de Med., Dec. 1854, p. 684. CHANCRE OF THE MOUTH. 425 ganglia, which are situated near the anterior and superior spine of the ilium. Chancres about the Mouth.—Chancres of the lips are generally superficial, and very rarely excavated unless subjected to irritation. Their outline is ovoid, the longer axis parallel to the buccal fissure, and their general aspect is the same as that of the superficial infecting chancre, to which variety they belong. When they involve the labial commissure they are divided into two portions, separated by a deep ulcerated fissure at the angle of the mouth. Chancres upon the tongue are most frequent near its extremity. They are generally of small size, and are more deeply excavated than those upon the lips. Chancres have also been observed upon the gums, internal surface of the cheeks, palate, and tonsils. Induration is nowhere more fully developed than upon the lips, except, perhaps, in the balano-preputial furrow; and is often so massive as to cause the lip to protrude and disfigure the countenance. It is less marked at the angle of the mouth, upon the tongue, etc., though it may usually be detected without difficulty. The parch- ment form of induration is also met with upon this region in some instances. The ganglia connected with the seat of the chancre by means of the lymphatic vessels take on induration, as in infecting primary sores upon other parts of the body; and, in most cases, they belong either to the anterior or posterior sub-maxillary groups. Phagedena is a rare complication of the buccal chancre. A single instance was observed at Cullerier's clinique, in which irri- tant applications had caused the ulcer to extend until it involved one-half of the lower lip and the inferior half of the cheek.1 All undoubted cases of primary sore which have as yet been met with upon the head or face, have belonged to the infecting species; there can be but little doubt, therefore, that any chancre observed upon this region will be followed by secondary manifestations. If, however, there be any question as to the nature of the ulcer, the administration of mercury should be deferred until its necessity becomes apparent. i Buzexet, Du Chancre de la Bouche, etc., These de Paris, 1858. 426 LYMPHATIC VESSELS AND GANGLIA. CHAPTER III. AFFECTIONS OF THE LYMPHATIC VESSELS AND GANGLIA ATTENDANT UPON PRIMARY SORES. Bubo, derived from the Greek "ftovPav, the groin," etymologically signifies any tumor of the inguinal glands; and the term is also commonly applied to glandular swellings of other parts of the body, as the axilla, neck, etc. Many affections, distinct in their nature and origin, are thus confounded under a common name, which, unless limited by some qualifying epithet, conveys but a very vague meaning. It would doubtless be desirable, as proposed by Mon- tannier and Maisonneuve,1 to limit the name to acute inflammation of the lymphatic ganglia in the neighborhood of a primary sore, and thus exclude glandular enlargement dependent upon scrofula, and the specific induration symptomatic of an infecting chancre; but until generally adopted by the profession, this change must be regarded in the light of an innovation; and I shall therefore retain the ordinary signification, but so qualify the term, wherever it is used, as to render its meaning unmistakable. The influence of the virus of a soft chancre upon the ganglia is confined to those which are nearest to it in the course of the lymphatic circulation; as, for instance, to the inguinal glands when the chancre is situated upon the genital organs, and to those of the armpit or axilla when it is seated upon the upper extremity.2 In like manner the immediate effect of the virus of the infecting chancre is also confined to the neighboring ganglia. At a later period, to be sure, those of the back of the neck and other parts of the body often become enlarged, but this change is separated from the former by a period of incubation, and belongs to the secondary and not to the primary manifestations of syphilis. ' Traite Pratique des Mai. Veneriennes, p. 164. 2 See Hunter's remarks upon this point, Ricord and Hunter on Venereal, 2d ed., p. 366. SIMPLE BUBO—VIRULENT BUBO. 427 Buboes are always seated in the superficial and never in the deep ganglia. They are of three kinds: the simple, virulent, and indurated. I shall also inquire into the nature of the so-called " bubon d'emblee" (" non-consecutive or primary bubo"). Simple Bubo.—The simple, sympathetic, or inflammatory bubo, as it is variously called, is due to common inflammation, and, when terminating in suppuration, secretes pus destitute of specific properties. It is, therefore, identical in its nature with the frequent form of adenitis, which appears in the axilla in consequence of a wound upon the finger, and which is supposed to be occasioned by extension of the inflammation along the course of a lymphatic vessel. That this is the case in some instances is shown by a red line upon the surface, extending from the source of irritation to the inflamed ganglion. A simple bubo-may attend a chancroid or gonorrhoea of the urethra in the two sexes, and, in rare instances, vaginitis; but has never been known to accompany uncomplicated balanitis. Its occur- rence is favored by irritant applications to the seat of the original disease, by exercise, coitus, alcoholic stimulants, and especially by the strumous diathesis. The symptoms of simple adenitis are well known. The patient first notices a hard swelling of the gland attended with pain and tenderness, which impede and are aggravated by motion. When suppuration occurs—which does not necessarily ensue—it is often ushered in by a chill followed by more or less fever; the presence of matter is indicated by a soft spot in the midst of the general hardness of the tumor, and by fluctuation; the cellular tissue in the neighborhood of the ganglion frequently participates in the inflam- mation, and may also be the seat of purulent deposit; the skin becomes adherent, thin, and of a livid red color, and opens by a pro- cess of ulceration; after the contents of the abscess are discharged, the pain gradually subsides, the power of locomotion returns, and the simple wound, under favorable circumstances, speedily heals by granulation; but if the opening be not free, or the patient be affected with the strumous diathesis or general cachexia, the pus may burrow in various directions and give rise to tedious and trouble- some sinuses, extending for several inches beneath the surface. Virulent Bubo.—The virulent bubo receives its name from the fact that the pus which it contains is contagious, and will, upon 428 LYMPHATIC VESSELS AND GANGLIA. artificial inoculation, give rise to a soft chancre. It is sometimes called " the syphilitic bubo," but this term, if used at all, properly belongs to the induration of the ganglia accompanying an infecting cnancre, and is entirely inapplicable to the bubo under consideration, which can only arise from a chancroid. If it be allowable to invent an adjective for the occasion, it may appropriately be called the chancroidal bubo. A virulent bubo may form either at an early or late period of the existence of a chancroid. M. Puche reports a case in which it first made its appearance three years after the commencement of a soft, serpiginous chancre.1 A virulent bubo is due to the absorption of virus from the sur- face of a chancroid, and its conveyance by means of the lymphatics to the ganglion; here its farther progress is arrested in the intricate meshes and minute ramifications of this body, and its presence gives rise to inflammation which assumes the specific character of the exciting cause. The same power of reproduction is manifested which gives to virulent pus its contagious qualities, and the abscess which necessarily ensues is filled with inoculable matter. Resolu- tion is as impossible and suppuration as inevitable as if the secre- tion of the chancroid had been deposited within the ganglion upon the point of a lancet. Virulent adenitis is usually situated upon the same side as the chancroid, but sometimes upon the opposite, owing to the interlace- ment of the lymphatic vessels upon the dorsum of the penis. Sometimes both groins are affected, especially when the primary sore is situated upon any part in the median line, as the fraenum. It is very rare for more than a single gland on one or both sides to suppurate specifically; and hence the virulent bubo is said to be "mono-ganglial." Other ganglia in the neighborhood may, how- ever, be secondarily affected through sympathy or extension of the inflammatory process, but should they suppurate, the pus is not inoculable like that of the first ganglion. Prior to its spontaneous or artificial opening, the course of a virulent is the same as that of a simple bubo, and the student should understand that the early symptoms of the two are identical; though the distinction between them is fully justified by the inevitable sup- puration and specific properties of the one, and the possible resolu- tion and simple character of the other. 1 Ricord, Lecons sur le Chancre, p. 40. VIRULENT BUBO. 429 The virulent pus is at first confined to the interior of the affected ganglion, and does not communicate with the abscess which often forms in the surrounding cellular tissue. In this case the pus which issues when the integument alone is divided by the knife, is innocuous, but if the incision be made to include the ganglion, the contents of the latter may be proved to be contagious by artificial inoculation.1 The specific matter from the gland speedily inocu- lates the whole surface of the wound and transforms it into an inguinal chancroid, presenting the everted and sharply-cut edo-es, and grayish aspect of this species of primary sore, and capable of giving rise to other ulcers in the neighborhood by successive inoculation. If the chancroid upon the genitals be complicated with phagedena, the open bubo generally follows the same course • and hence arise those extensive and foul ulcerations of the groin which are occasionally seen in hospitals, and which are depicted in nearly all illustrations of venereal diseases. As a general rule, morbid products which undergo absorption do not manifest their presence in the lymphatics themselves, probably in consequence of the rapidity of their passage, and the changes which take place in the ganglia where their progress is impeded, are the only indications that this system of vessels is affected. In conformity with this law, the lymphatics which convey the pus from the chancroid to the ganglion generally escape, but in some in- stances inoculation takes place and virulent lymphangitis is set up. This should be carefully distinguished from the induration of the lymphatics observed in cases of the infecting chancre. In both a thickened cord may be felt running along the upper surface of the penis; but in the former it presents the characters of ordinary in- flammatory engorgement, usually includes the dorsal vein and artery which are united to it by inflammation of the surrounding cellular tissue, is attended by considerable heat and pain in the part, and the skin over it is swollen and red; while in the latter, there are no 1 " Equally instructive examples (that the glands collect hurtful ingredients and therehy afford protection to the body) are afforded by the history of syphilis in which a bubo may for a time become the depository of the poison, so that the rest of the economy is affected in a comparatively trifling degree. As Ricord has shown, it is precisely in the interior of the real substance of the gland that the virulent matter is found, whilst the pus at the circumference of the bubo is free from it; only so far as the parts come into contact with the lymph conveyed from the diseased part, do they absorb the virulent matter." (Virchow, Cellular Pathol- ogy, p. 187.) 430 LYMPHATIC VESSELS AND GANGLIA/ symptoms of acute inflammation, and the indurated lymphatic may readily be isolated from the neighboring bloodvessels.1 Virulent lymphangitis, like a virulent bubo, necessarily terminates in sup- puration ; abscesses form in the course of the vessel either upon the penis or pubes, and, when open, are in reality chancroids. Indurated Bubo.—This affection is only met with in connection with an infecting chancre, of which it is as necessary an attendant,' and affords as valuable an indication as the induration of the base of the sore. Of 120 cases of syphilitic erythema, Bassereau found that in 116 indurated buboes had accompanied the chancre, only one of which had suppurated; in three alone had there been no appreciable changes in the inguinal ganglia. The indurated bubo, unlike either of the preceding, is always developed at an early period—usually during the first week, and invariably within the first three weeks of the existence of the ulcer—and is contemporaneous with the induration of its base, or follows it almost immediately. The simple and virulent buboes are mono-ganglial, the indu- rated poly-ganglial. All the superficial ganglia in one, and gen- erally in both groins, become enlarged, and attain the size of a filbert or almond. One is frequently found to be more devel- oped than the others, which surround it like satellites. This change takes place without any symptoms of acute inflammation, and so insidiously that the patient may be entirely ignorant of it, and deny its existence; but the surgeon, whose suspicion has already been excited by the induration of the primary sore, on examining the groin, finds a "pleiad" of small tumors, of a cartilag- inous hardness, and freely movable upon each other and the sur- rounding tissues. When firm pressure is made upon them, the patient sometimes complains of slight tenderness but not of severe pain. They preserve their indolent character throughout their whole course, and do not become inflamed or suppurate unless under the influence of some aggravating cause, as violence, a stru- mous diathesis, general cachexia, or the coexistence of a chancroid or urethritis; and, except in the case of a chancroid, the pus is never inoculable. Induration of the ganglia and induration of the base of an infect- Bassereau, op. cit., p. 160. INDURATED bubo. 431 ing chancre are in their nature and signification one; but, as else- where remarked, the first is perhaps the more constant and per- sistent, and, therefore, the more valuable symptom. When the latter is imperfectly developed or obscured by common inflam- mation, reference may be made to the former, which will rarely fail to afford the desired information; after the latter has disap- peared, the former often persists for months, as an index, that upon some part of the superficies the lymphatics of which rendezvous at these ganglia, there has been a primary sore which has infected the constitution; and thus ifr determines not only the existence but the approximate seat of a chancre, and may afford invaluable aid in unravelling the history of venereal cases. For instance, induration of the inguinal ganglia points to the genital organs, including the internal surface of the urethra, and to the hypogastric region; that of the external group near the anterior superior spine of the ilium to the anus; that of the submaxillary glands to the lips, mou,th, and tongue; that of the axillary ganglia or those about the elbow to the hand or arm; that of the praeauricular ganglion to the eye- lid and its neighborhood; and so each region has its recording index. From induration of the inguinal ganglia, I have repeatedly been able to satisfy myself of the previous existence of a chancre in op- position to the asseverations of patients, and even when no cicatrix or specific induration could be found upon the genital organs. For instance, in the spring and summer of last year, a young man had two attacks of what was apparently simple gonorrhoea. In the autumn he applied to me with syphilitic iritis, alopecia, acne capitis, and post-cervical engorgement, and there could be no doubt that he had had a chancre upon the genitals, although he was quite unconscious of the fact, since each groin presented the charac- teristic indurated pleiad. One of his attacks of gonorrhoea was probably complicated with a urethral chancre. Ricord relates the following case:!— " Two or three years ago, one of our most prominent young physicians came with a fright.ened air to my office, when the following conversation ensued: ' Until now I had faith in your doctrines, but I find them at fault, and in my own person. It is too bad. What is this V (removing his clothes and showing me his breast and back). I examine him and reply :— 1 Lettres sur la Syphilis, 2d ed., p. 45. 432 LYMPHATIC VESSELS AND GANGLIA. " ' A fine syphilitic roseola.' " ' Syphilitic, did you say ? Are you sure V " 'Perfectly so.' " ' Very well! You condemn yourself. I have never in my life had any venereal symptom but a gonorrhoea, and that was twelve years ago.' " I examine him from head to foot, and say to him :— "' My friend, you have recently had a chancre on your right hand, which was situated neither upon the thumb nor index, but upon one of the remaining fingers.' " ' You are joking.' " ' Not at all; you have a bubo at the present moment;' and I place his finger upon a ganglion still engorged near the elbow-joint. After thinking a moment, he then told me that a few months before, while treat- ing a woman with chancre, an ulcer appeared on the middle finger of his right hand, to which he paid but little attention, and which had soon healed. ' This,' said I, ' is the source of your roseola; act accordingly.' " I do not recollect a single instance in my own practice, which ultimately proved to be one of the infecting chancre, in which induration of the neighboring ganglia was wanting; yet Bassereau's statistics above referred to would appear to show that this may occasionally happen; though it should be observed that many of this surgeon's patients were not seen until a month or two after contagion, by which time this symptom may possibly have disap- peared. Yet I think that the absence of induration of the base of an infecting chancre and of its attendant bubo may, in rare instances, be admitted, without materially detracting from the value set upon their diagnostic and prognostic indications; for why should abso- lute constancy be expected in syphilitic symptoms any more than in those of other diseases, and in the whole range of pathology it would be difficult to find two which are more uniformly present than these. Induration does not constitute the essence of syphilis, which lies in the virus; neither the base of the sore nor the ganglia are indurated when an infecting chancre is implanted upon a sys- tem already contaminated with syphilis, yet the poison remains the same.1 The only affection liable to be confounded with an indurated bubo is strumous enlargement of the ganglia, and I have met with a number of cases, in which the diagnosis remained for a while in 1 Vide p. 342. INDURATED BUBO. 433 doubt, owing to ignorance of the condition of the glands before contagion. In persons of a strumous diathesis who can give no reliable account of their previous history, this difficulty must some- times arise. It is perhaps unnecessary to remind the reader that an indurated bubo is not to be looked for in old cases of syphilis of several years' duration. Like the induration of the chancre, it disappears, even without treatment, after a variable period, although somewhat more persistent than the latter. The value of suppuration in a bubo as an element of diagnosis is a question of considerable practical importance. A patient with general symptoms of a doubtful character seeks advice of a sur- geon, who learns that several years ago he had a primary sore, but can obtain no accurate description of its symptoms. On farther inquiry he also ascertains* that there was tumefaction of the glands in the groin, and the patient rarely fails to remember whether they suppurated or not—a fact which may also be determined in most cases by the presence or absence of a cicatrix. What light will this investigation throw upon the nature of the chancre ? If the description above given of the different kinds of bubo be correct, the fact that suppuration took place will favor but will not absolutely prove the supposition that the sore was a chancroid. It is a general but not invariable rule that constitutional syphilis does not follow an open bubo. Indolence is one of the chief characteristics of an indurated bubo, but to deny that suppuration ever takes place, as some authors have done, is to assert that induration protects the ganglia from every cause of acute inflammation, which is evidently absurd. If the primary sore be of the mixed variety, or if a chancroid and a chancre coexist upon the genitals, a virulent bubo and constitu- tional infection may both follow. A remarkable instance of this kind has already been related upon page 382. Again, irritant applications to the chancre, external violence, alcoholic stimulants, excessive coitus, gonorrhoea, or fatigue, may excite common inflammation, terminating in an abscess, of ganglia, indurated in consequence of constitutional infection; but the most fruitful source is the strumous diathesis or general debility. The following case will illustrate the fact that suppuration may be due to several causes combined, and cannot always be ascribed to the influence of the virus alone upon the ganglia. 28 434 LYMPHATIC VESSELS AND GANGLIA. B. belonged to a strumons family. His sister, aged 17, had been afflicted with an aggravated form of chronic eczema since early infancy. Uis brother, after hardship and exposure upon a wreck, was confined to his bed for six months with suppuration of the inguinal glands. B who had alwavs enjoyed good health, contracted a chancre in June 1859, fol- lowed byan indurated bubo. Syphilitic erythema appeared in September, when the bnbo, which until then had been indolent, became inflamed, suppurated, and remained open six weeks. The constitutional disease proved to be very obstinate, and he was still under treatment in July, 1860, when, after violent exercise at leap-frog, another abscess formed in the same groin. It will be noticed in this case, that the inguinal glands remained in a quiescent state for nearly three months after the healing of the chancre, and their suppuration at the end of this time can only be ascribed to the strumous diathesis of the patient, and also, in a measure, to the febrile excitement preceding the syphilitic eruption. Statistics collected by various observers concur in showing the rarity, but yet the possibility of a suppurating bubo attending a chancre followed by secondary symptoms. The following table which I have compiled from Bassereau, exhibits: 1st. The number of cases of constitutional syphilis under observation, which were preceded by buboes; 2d. The number of buboes which suppurated, and 3d. The form of eruption which subsequently appeared:— WnoLK Number. Suppurated. Form of Eruption. 117 . . 1 Erythematous. 42 . . 5 Papular. 108 . . 1 Mucous patches 12 . . 1 Vesicular. 54 . . 4 Pustular. 50 . . 4 Tubercular. Total 383 16 Thus in 383 cases of infecting chancre attended by an affection of the ganglia and followed by secondary symptoms, there were only sixteen suppurating buboes. Fournier states that in the large number of indurated chancres treated by Ricord, at the Hopital du Midi, in the year 1856, there were only three which were accompanied by suppurating buboes. Mr. Henry Lee, in an analysis of 1409 cases of venereal disease, "excluding simple gonorrhoea," recorded in the books of Lock Hospital, London, found ninety-eight cases of secondary symptoms. complicated with suppurating bubo, but in all, with the exception INDURATED BUBO. 435 of six, there was reason to believe that the latter affection was due to a different contagion from the one which produced the former, or to causes independent of the syphilitic virus.1 Bassereau reviews this subject in so clear a light, that I shall quote his remarks: "There is a fact which is not recognized In- most writers on syphilis, and of which many practitioners are igno- rant; I refer to the rarity of suppurating buboes attending those chancres which precede general syphilis. The inverse proposition, viz., that general syphilis is rare after chancres attended by suppu- rating buboes, is equally true, and as generally unknown, although of great practical importance. It is not to be inferred, however, that every person who has a chancre and indolent ganglionary engorge- ment must necessarily have general syphilis; nor that the appear- ance of suppuration in a bubo is a guarantee that the patient will be free from all constitutional manifestations; since very many in- flamed ganglia, which do not suppurate, are never followed by infection of the system, and a few suppurating buboes are succeeded by general syphilis. But though suppuration and indolence are not symptoms of absolute value, they at least furnish a strong pre- sumption as to the future, and hence afford diagnostic and thera- peutic indications of great importance. Even many years after contagion, data with regard to the course pursued by any glandular engorgement which accompanied the primary sore, will assist us in determining the character of symptoms, the nature of which appears doubtful. Suppose, for instance, that we wish to know whether a cutaneous eruption or ostitis is syphilitic; if we find as antecedents a chancre and a suppurating bubo, there is little probability of its specific origin; and though mercury is not absolutely contra-indi- cated, prudence will lead us not to employ it longer than is neces- sary to test its effect. "The early writers on syphilis did not include suppurating buboes among the symptoms which preceded those general erup- tions which then bore the name of ' the French disease;' and when the efficacy of mercury in the treatment of the new disease was recognized, they did not administer it indiscriminately to all per- sons affected with ulcers upon the genital organs and with buboes, without distinguishing between the different forms of these symp- 1 On the Non-mercurial Treatment of Certain Forms of Syphilitic Disease ; Analysis of 14)0 cases. Association Med. Journal, Dec. 7, 1>55. 436 LYMPHATIC VESSELS AND GANGLIA. toms. This fact may be established by reading their writings. The first half of the sixteenth century had not, however, passed, before they began to depart from these sound doctrines; but sup- purating buboes had no sooner been confounded with the symptoms of 'the French disease,' than physicians noticed that they appar- ently afforded protection against general manifestations. Consult with regard to this point Nicholas Massa, Mathiolus, Antonius Lecoq, and Botal; they all call attention to this fact, and William Rondelet comes still nearer to the truth when he says that buboes which undergo resolution, and those which are indurated and show no tendency to suppurate, are certain indications that constitutional syphilis is imminent: 'Si qui dolores patiantur, praecesseritque ex- ulceratio in mentula intra vel extra et bubones venerei qui non profluxerint sed retrocesserint vel indurati sint, eos morbo gallico laborare certo et intrepide, etiamsi negent, afnrmare possumus.'" Induration of the Lymphatics.—As both the simple and virulent bubo have their occasional attendants in simple and virulent lym- phangitis, so has the indurated bubo its accompanying induration of the lymphatics, a more constant attendant, though not invariably present, than either of the former. Specific engorgement of the lymphatics is dependent upon changes in the walls of these vessels identical with those which occasion induration of the base of the chancre and of the ganglia, and is characterized by the same three important symptoms, viz., induration, absence of inflammation, and persistency. The indurated vessel feels like a hard cord running from the neighborhood of the chancre towards the pubes along the upper surface of the penis in the course of the dorsal vein and artery, or, in a few instances, occupies the side of this organ. It is generally single, but sometimes multiple; of the size of a crow or goose- quill; in some cases of uniform diameter, when it communicates to the fingers a sensation like that of the vas deferens, while in others it is swollen at regular intervals like a necklace, or is, as botanists would say, moniliform. The distal extremity arises in the induration surrounding the chancre, and the cord can generally be traced for two or three inches towards the pubes, sometimes to the base of this prominence, but rarely as far as the indurated ganglia in the groin. Induration of the lymphatics is most frequently observed upon the penis, but is not limited to this organ. Bassereau relates a NON-CONSECUTIVE BUBO. 437 case of infecting chancre upon the cheek, in which a hard cord could be traced from the indurated base of the sore to an indurated bubo beneath the angle of the jaw. Induration of the lymphatics appears about the same time and in the same manner as that of the base of the chancre, and the two generally correspond in degree of development. As already stated, the former is less constant than the latter, but if sought for may be found in a large proportion of cases. Induration of the lymphatics usually undergoes resolution about the same time as that of the base of the sore; but in a few rare instances it becomes inflamed and terminates in suppuration, when fistulous openings may form along the course of the vessel. Bas- sereau met with three cases in which the induration of the chancre took on inflammatory action and was transformed into a phlegmo- nous tumor, the cavity of which was found to communicate with the interior of an hypertrophied lymphatic, through which a probe could be passed up to the pubes. In one instance he was able to make a post-mortem examination, the patient having died of an intercurrent acute disease. The dorsal vein and artery were found to be intact, and the fistulous canal evidently consisted of an hyper- trophied lymphatic with hard and thickened walls, which could be traced from the induration of the chancre to the right inguinal ganglia. Induration of the lymphatics may readily be distinguished with care from the dorsal vein and artery. It is more liable to be con- founded with simple or virulent lymphangitis. The diagnostic symptoms have already been given when describing the latter. This symptom of an infecting chancre has the same prognostic signification as the induration of the base of the sore and the in- guinal ganglia, and denotes that the constitution is already infected and that general syphilis will soon make its appearance. "Non-consecutive Bubo," or " Bubon d'Emblee."—These terms are applied to a class of cases in which the inguinal ganglia become inflamed and suppurate after coitus, without our being able to detect the presence of a chancre, and with regard to the character of which a great diversity of opinion has been expressed. The only surgeon, so far as I am aware, who has investigated the symptoms and nature of this affection, with the light afforded by 438 LYMPHATIC VESSELS AND GANGLIA. the more recent discoveries in venereal, is Diday, who describes the symptoms of the bubon d'emblee as follows:'— 1. A long period of incubation, which is usually of about three weeks' duration. 2. A few days before the appearance of the bubo, the patient suffers from general disturbance of the system, inability to sleep, heat and dryness of the skin, irregular chills, lassitude, loss of appetite, and pain in the lumbar region. These symptoms pre- cede rather than follow the evolution of the bubo, do not correspond with it in intensity, and diminish as it progresses. 3. The inflammation is always subacute. The tumor is slow in forming; the pain and sensibility are slight; and if suppuration take place, the skin does not become reddened nor matter form in the surrounding cellular tissue, as almost invariably occurs in virulent adenitis. 4. It is of long duration, and under the most favorable circum- stances generally persists for at least a month. 5. It suppurates in about one case out of every four; but the opening of the abscess is never transformed into a chancre, and the pus can never be artificially inoculated. 6. Constitutional syphilis never follows when this has been the only venereal symptom. Diday states that clinical observation compels him to admit the existence of a bubo not preceded by a chancre and presenting the above characters; that so far he is sustained by facts, the explana- tion of which is, however, quite another matter, and one which he approaches with much hesitation. He yet ventures to suggest a theory to account for their origin by supposing that the virus of the chancroid may, under certain conditions, reach the ganglia through the absorbents without giving rise to an ulcer at its point of entrance, but that it is so modified by imbibition that it loses its specific properties, acts only as a common irritant, and does not occasion a virulent bubo. Ricord explains the same cases on the ground, either that " their appearance after coitus is a mere coincidence and that they are due to other causes, or that they are occasioned by sympathetic reac- tion consequent upon irritation of the extremities of the absorbents during coitus, as may occur after any non-specific excitation of the 1 Nouvelles Doctrines sur la Syphilis, p. 18(3. NON-CONSECUTIVE BUBO. 439 part." To this Diday objects, that buboes do not follow a much greater degree of irritation than is produced by sexual intercourse; that, for instance, they are not observed after excision or cauteriza- tion of vegetations and haemorrhoids, operations for phymosis, am- putation of the penis, etc.; and hence that it is unreasonable to suppose that they may arise from mere coitus without contagion. I can say for my own part that I have met with several cases of bubo presenting in the main the same combination of symptoms as described by Diday, and in which, upon the most careful examina- tion, no chancre could be discovered. I have particularly noticed the subacute character and the slow development of the tumor, and the absence of subsequent symptoms of constitutional syphilis. Private practice has not afforded me the opportunity to test the nature of the contained pus by artificial inoculation, but the open- ing of the abscess has never assumed a chancrous appearance ; and the freedom from constitutional infection has been confirmed by long-continued observation. But I have seen no reason whatever to believe that these cases were in any way connected with either species of chancrous virus, and I regard Diday's theory to account for their origin as fanciful and untenable. I believe that they are the effect of irritation or excessive exercise of the genital organs during coitus, aided frequently by a strumous diathesis, or other accessory causes. The influence of muscular fatigue and local irritation upon distant organs is difficult of explanation but is often observed in other parts of the body. Diday's objection to this view is readily answered by propounding two questions, viz: Which is the more likely to excite axillary adenitis, amputation of the arm, or a scratch upon the finger; and will an operation for phymosis probably ag- gravate an inguinal bubo more than a long walk or repeated acts of coitus? Eegarding this affection, therefore, as entirely inde- pendent of contagion, I deem it unfortunate that it has received the name of bubo, which is commonly applied to diseases of the ganglia dependent upon the virus either of the chancroid or true chancre, and which, therefore, in the present instance, is apt to lead to an erroneous conclusion. The existence of a bubon d'emblee, secreting inoculable pus and capable of infecting the constitution, is entirely inconsistent with our present knowledge of venereal diseases, and cannot now, as formerly, be admitted. The reported cases of this character are very far from being conclusive. 440 LYMPHATIC VESSELS AND GANGLIA. Treatment of Buboes.—In respect to treatment, buboes may be divided into two classes-1. Acute inflammation of the ganglia prone to terminate in suppuration, and requiring local treatment; 2. Indurated buboes, free from inflammation, and demanding only general treatment. The first-mentioned division includes both the simple and viru- lent bubo, and also those exceptional cases of indurated buboes in which inflammation is set up by some cause independent of the syphilitic virus. In all these, inflammation, though varying greatly in intensity in different cases, is the prominent symptom requiring attention; and to subdue this, if possible, and avert suppuration, and to hasten cicatrization when an abscess forms, are the objects of treatment. When the bubo is virulent and specific pus is imprisoned within the ganglion, all attempts to effect resolution will certainly fail; but as this species cannot, at an early period, be distinguished from a simple bubo—although the presence of a chancroid upon the genitals may lead us to suspect it—we cannot in practice discrimi- nate these cases, and must treat all inflammatory buboes as if dispersion were possible. This happy result is not, indeed, attained in the majority of cases, but inaction will never satisfy the patient, and the success of remedies in a few instances will amply compen- sate for their employment in all; since a suppurating bubo is a source of considerable pain and great annoyance, generally necessi- tates confinement in bed for several days at least, exposes the patient to detection, and leaves an indelible cicatrix. The idea formerly entertained that danger would result from the " repulse of matter" if buboes were dispersed, is now known to be without foundation. The means employed to effect resolution are an antiphlogistic regimen (rest and low diet), cathartics, local depletion, counter- irritants, and compression. General Treatment.—General remedies are not always required. When the inflammation is subacute, local applications may be relied upon from the first. Rest is of course of the first importance; and the more absolute, the better. It would appear that common sense would suggest this to every one with a commencing bubo, but if the surgeon rely upon the patient's intelligence alone, he will in most cases be disappointed, and will find that the swelling has been aggravated by a long walk, COUNTER-IRRITANTS. 441 or by what is equally detrimental, the standing posture. Rest upon the back should in all cases be secured, if possible. An active cathartic at the outset will rarely be amiss, and an evacuation from the bowels should be obtained daily. If the patient be of full habit, his diet should be low; but when the system is already depressed or cachectic, strict abstinence will favor suppuration, and should be avoided. Similar rules should govern the use of local depletion, the benefit from which, however, is so uncertain as scarcely to compensate for its inconvenience; yet when the patient is plethoric, and the local symptoms acute, from six to a dozen leeches may be applied near (not upon) the tumor, and the bleeding be promoted by immersion in a hot bath; but leeches should never be used when an abscess has formed and is upon the point of opening, lest their bites be inoculated and transformed into chancroids. The administration of a solution of Epsom salts and tartar emetic may often be advan- tageously substituted for abstraction of blood in any manner. No benefit can at this period be expected from specific remedies. Mercury is uncalled for, since the inflammation is not dependent upon the action of the virus of true syphilis. I have frequently employed iodide of potassium, but never with perceptible effect unless in strumous subjects. The large number of local applications recommended in the early treatment of buboes proves how little dependence can be placed upon any of them. Nearly all of them act as counter-irri- tants, or aim to produce absorption and resolution by compression. To this remark ice- is an exception, which if applied to a bubo at its very commencement before acute inflammation is set up will sometimes discuss it. Counter-irritants.—One of the best counter-irritants is the strong tincture of iodine. I do not attribute its beneficial action to any special power of inducing absorption, but rather to the inflamma- tion of the skin which it excites. The same may be said of the following ointment, which I am also in the habit of using:— R. Potassii iodidi £)j. Iodinii gr. v. Unguenti hydrargyri §j. M. Either of these preparations may be applied twice a day until as much inflammation is induced as the patient can well bear, when the application must be less frequent. 442 LYMPHATIC VESSELS AND GANGLIA. A strong solution or the solid crayon of nitrate of silver is another excellent counter-irritant highly recommended by Mr. Henry Thompson,1 whose paper on the subject first induced me to try it. The strength of the solution is three drachms of the nitrate of silver to the ounce of water with the addition of twenty min- ims of strong nitric acid. This should be freely applied to the whole surface of the tumor and be repeated as soon as the eschar comes away; or the solid nitrate of silver may be employed by first moistening the part with water and then rubbing the crayon for a few minutes upon it. A blister may be employed for the same purpose and the vesi- cated surface be dressed with various irritant or resolvent oint- ments. When the acute symptoms have somewhat subsided, or at the outset of virulent buboes, Ricord recommends that the blister should be dressed twice a day with half a drachm of strong mer- curial ointment, and be covered with a rye-meal poultice which should be changed three or four times in the twenty-four hours. A caustic solution of the bichloride of mercury, proposed by MM. Malapert and Reynaud for the treatment of buboes after suppura- tion has taken place, has also been employed by some surgeons for the purpose of inducing resolution. A few years since a favorite mode of treatment of subacute buboes in the French hospitals was by means of "cauterisation ponctue'e," or the rapid application of a pointed iron heated to a white heat to numerous points over the tumor. This method was tried at my suggestion at Bellevue Hospital in this city with very satisfactory results. The dread rather than the pain of the appli- cation, which does not exceed that produced by many caustics, interferes with its adoption in private practice. Compression.—Compression is another means employed to induce resolution of buboes, and is said to have been suggested by the observation that these tumors do not occur wherever a truss is worn. The most ready method of applying pressure is by means of compressed sponge and a spica bandage, and the application of hot water to cause the sponge to swell. An Interne of the Hopital du Midi has invented a truss or pad for the same purpose, consist- ing of a rounded piece of wood covered with leather, and provided with straps to pass round the waist and thigh. This may be ob 1 London Lancet, Am. ed., June, 1855, p. 536. METHODS OF OPENING BUBOES. 443 tained at most instrument makers, and is very convenient and serviceable. It is generally called "Ricord's pad for buboes." Reynaud1 combines heat and pressure by heating the half of a common brick, the edges of which have been chipped offj wrapping it in a napkin, laying it upon the bubo, and changing it at the end of three or four hours, by which time it becomes cool. The application of collodion, which, by its power of contraction, exerts pressure upon the tumor, has been recommended by Dr. J. II. Clairborne and others. Methods of Opening Buboes.—So soon as matter can be detected, and it is evident that resolution is impossible, the abscess should at once be opened. Delay will allow the pus to collect and under- mine the skin, which, becoming thin and deprived of its vascular supply, will be destroyed to a greater or less extent, thereby in- creasing the difficulty of cicatrization and adding to the dimensions of the unsightly scar. The knife is in most cases preferable to caustic for this pur- pose. The extent and number of incisions to be made have been the subject of much discussion, and have called forth a great diver- sity of opinions. The chief question has been between a single free opening and a number of small punctures. The object pro- posed in these two methods is different. In the first, it is intended to transform the abscess into an open wound which will heal by granulation from the bottom; in the second, which is the less pain- ful method, the design is to simply evacuate the contents of the swelling and secure adhesion of its walls, and thus expedite the cure and avoid the formation of a cicatrix. These results are indeed highly desirable provided they can be attained, but my own expe- rience has led me in most cases to give a decided preference to the former course; since in numerous trials with multiple punctures, the matter, not finding free exit, has burrowed in various directions, and it has become necessary to resort to a free incision before cica- trization would take place. My manner of proceeding is as follows. The hair should be thoroughly shaved from the surrounding parts to facilitate the after-dressing and promote cleanliness. If the patient be nervous, I administer ether so as thoroughly to explore the abscess without interruption. Entering the point of the knife at the most dependent 1 Traite des Maladies Veneriennes, p. 76. 444 LYMPHATIC VESSELS AND GANGLIA. part of the tumor, I carry the incision upwards parallel with the median line of the body to the full extent of the cavity. An in- cision in this direction is preferable to one in the course of the inguinal fold, since its edges are separated while those of the latter are approximated, by flexure of the thigh. Exposure to the air generally arrests the hemorrhage in a few moments, when I care- fully examine the walls of the cavity for sinuses, and if any are found extending more than half an inch beneath the surface, I slit them up with a probe-pointed bistoury. Glands nearly isolated by the suppuration of the surrounding cellular tissue, and attached only by a small base or pedicle, are often found projecting into the cavity; and having been taught by experience that the wound does not commonly heal until these are cast off by a slow process of ulceration, I remove them with scissors or tear them out with the fingers when this can be done without much violence. If left, their dark sloughy surface is perceptible for a long time, and they doubtless prolong the process of cicatrization. The hemorrhage from this operation is seldom so severe that it may not be arrested by exposure to the air, ice, or pressure; but should it be profuse, or continued even in a small quantity, the bleeding vessel must be secured. I once saw a patient in whom a bubo had been opened, and who was completely blanched by a slight oozing of blood which had been allowed to go on for a number of days, beneath the coagulum which formed upon the surface. Scraped lint, either dry or moistened in a mixture of laudanum and water, is now introduced into every recess of the cavity, paying particular attention to any short sinuses which it was not thought necessary to lay open with the knife, and a poultice or water- dressing applied. The pain and difficulty of motion which proba- bly diminished on the first formation of matter, again increase for a few days, but are not severe if the patient keep quiet on his back. The first dressing, which becomes glued to the wound by coagu- lated blood, is loosened about the third day by the free secretion of matter, and should be removed, having first applied a hot poultice for a few hours. The subsequent dressings may consist of lint smeared with simple or medicated cerate, or moistened with any of the lotions recommended in the treatment of chancres (as nitric acid and water, aromatic wine, Labarraque's solution, or the potas- sio-tartrate of iron), and will require to be changed twice a day. METHODS OF OPENING BUBOES. 445 The cavity should from time to time be examined, and any bur- rowing sinuses that may be found be slit up with the knife; those of small extent, however, may be made to close by filling them carefully with lint at each dressing. The rapidity with which the wound contracts by granulations from the bottom and the approxi- mation of its sides, is often astonishing, and but from two to four weeks are generally required for complete cicatrization to take place, during which time it is desirable that the patient should be confined to his room. But though I cannot subscribe to the high encomiums bestowed upon multiple incisions, and think that they are inapplicable to the treatment of most buboes, yet I believe that they may be used with advantage in a few cases in which the abscess is superficial, and the skin over a considerable surface so thin and of such low vitalitv that a free incision would probably result in its total disorganization. In such instances, a number of punctures with a bistoury or a grooved needle may be made around the margin of the tumor (as recommended by Vidal) rather than towards its centre, and the contents be allowed to drain away. Continued pressure should be applied after the lapse of twenty-four hours by means of compresses and a spica bandage, in order to prevent any farther collection of matter and secure adhesion of the walls. Even when these objects are not attained, the abscess will have time to contract, and a subse- quent free incision may, if necessary, be made with less destruction of the integument. Langston Parker's favorite treatment is as follows: "When a bubo is ready to be opened, we should not suffer the skin to become too thin, but make several very small punctures over its thinnest part with a grooved needle, perhaps six, eight, or ten; through these the matter will ooze out till the cavity of the abscess is emptv. Through one of the punctures the point of a very small glass syringe may be introduced, and a very weak solution of the sulphate of zinc injected, in the proportion of two or three grains to the half-pint of water. When the abscess is quite empty, place over it a large compress of lint, and use moderately tight pressure by means of a roller. In many instances, if we can keep the patient quiet for twenty-four hours, we get either partial or total adhesion of the sides of the bubo, and a speedy cure will be the result; in other instances this may not be the case, but by the daily use of the injection through one of the punctures, which should be kept open 446 LYMPHATIC VESSELS AND GANGLIA. for that purpose, we succeed in a few days, in almost every case, in effecting a cure."1 I wish that I were able to confirm the above praise of this method to its full extent. Roux (de Toulon) and Marchal (de Calvi) have proposed to inject buboes immediately after opening them with a mixture of one part of tincture of iodine to three or four of water. Langston Parker sometimes employs a solution of iodine and iodide of potassium, as follows:— R. Iodinii gr. iv. Potassii iodidi gr. viij. Aquae ^viij. M. A filiform seton recommended by Bonnafont, and also by Mr. Parker, was reported against by a committee of the Soc. de Med. de Paris, in 1859. The use of caustics in opening buboes has been advised by several authors, but finds few advocates at the present day. The method of MM. Malapert2 and Reynaud,3 which acquired some notoriety for a time, and was extensively used at the Emi- grants' Hospital, Deer Island, Boston, when I was a student of medicine, consists in the application of a blister over the tumor, and of a pledget of lint soaked in a solution of corrosive sublimate (gr. xv to 3j of water) to the vesicated surface previously freed from all secretion of serum. The caustic is allowed to remain for two hours, or until a superficial eschar is formed, when a large poultice is applied. The authors of this method claim that as the eschar is detached, the contents of the abscess ooze out through minute openings in the integument, the whole substance of which is not destroyed, and that the walls of the cavity are so stimulated and modified by the caustic that they rapidly contract and adhere. As stated upon a previous page, this method, although designed by its authors solely for the treatment of buboes after suppuration has taken place, has been applied by others for the purpose of effecting resolution. The excessive pain attending the application is not counterbalanced by any advantage over milder methods Treatment of Difficult fe-Unfortunately all buboes do not heal so readily as the reader might infer from the preceding remarks, • The Modern Treatment of Syphilitic Diseases, Phil., 1854, p. 148. Arch. Gen. de Med., March, 1832. 3 Traite des Maladies Veneriennes, p. 70. TREATMENT OF DIFFICULT CASES. 447 which are intended to apply to the more favorable cases consti- tuting doubtless the majority. Persistent buboes may be divided into two classes: 1st. Virulent buboes which take on phagedenic action and pursue a similar course to phagedenic chancres upon the genitals, and which may extend to a considerable distance beyond the inguinal region, giving rise to large open sores; and, 2d. Those which are maintained, not by the presence of the chan- croidal virus as in the former class, but by some morbid diathesis or general cachexia, and which are generally limited to the groin, where they burrow in various directions beneath the surface, with- out causing extensive ulceration of ftie integument. The treatment of buboes belonging to the first class is the same as that of phagedenic chancres, for which I would refer the reader to the preceding chapter. At present I would simply recall to mind the danger of the internal use of mercury or its topical application to the sore in the form of ointment, etc., and to the benefit to be derived from nourishing diet, fresh air, tonics (es- pecially the potassio-tartrate of iron), and opium internally; and locally from cleanliness, deep cauterization with nitric acid, Vienna paste, or the actual cautery, and suitable lotions and dressings. Cases belonging to the second class are met with in persons in whom the glandular swelling has been allowed to go on unchecked, or whose general condition or neglect to comply with the surgeon's directions has rendered treatment of no avail; and they are es- pecially frequent in patients of a strumous habit and in those who have been debilitated by intemperance, an irregular course of life, antecedent diseases, want, or other causes. To this class belong most of the so-called "constitutional buboes," occurring in persons who are really laboring under the syphilitic diathesis, but which are not, strictly speaking, to be regarded as syphilitic symptoms, since syphilis has merely acted like any other depressing influence in predisposing to a low form of inflammation and suppuration. Instances of this kind are frequent; advice is sought by a patient who evidently has constitutional syphilis and who has perhaps arrived at the tertiary stage; his general condition is very low; he complains of nocturnal pains, and exhibits a patch of rupia upon the arm, and also a large, oval, firm and projecting tumor in one or both groins; its longer diameter corresponding to the inguinal fold, its surface studded here and there with fistu- lous openings, and presenting at some distance soft or fluctuating 448 LYMPHATIC VESSELS AND GANGLIA. points, pressure upon which forces from the mouths of the connect- ing sinuses a small quantity of thin, sero-purulent fluid; the surgeon is at first disposed to look upon the case as one of the exceptions to the rule that general syphilis does not follow an open bubo, but he finds on inquiry that the glandular tumor is of a much later date than the constitutional disease; that it followed a chancroid or ex- cessive sexual indulgence, or arose without any apparent exciting cause, and that it has clearly no direct connection with the original infecting chancre. Has the reader never observed a very similar condition in the axillae of poor, half-starved, and over-worked washerwomen, in whom there could be no suspicion of syphilis ? AVhatever the depressing cause may be, it should if possible be removed and the system be brought into a better condition before benefit can be expected from local treatment. Favorable hygienic influences, a simple but nourishing diet, and tonics are required in all cases; and, in strumous subjects, iodine, the iodides of potassium and iron, and cod-liver oil. Recollect that the presence of a bubo by no means proves that the patient has constitutional syphilis, the existence of which should not be admitted until after the most careful and thorough examination. Should this fact be clearly established, specific remedies will sooner or later be required. If the constitutional disease be in the tertiary stage, iodide of potas- sium may be freely given and will prove the best tonic that can be found; but mercury should be administered with great caution and combined with quinine or iron, or be altogether deferred until the general health has been improved by the means above indicated. No course of treatment which adds to the existing depression of the system will benefit the local affection. As the patient's health improves, the bubo generally assumes a more favorable aspect, and if it does not entirely heal will yield to remedies which were before powerless. When the sinuses are not too deep or extensive, they should be slit up and dressed from the bottom with lint, or their walls be pencilled with a crayon of nitrate of silver. When this course is inadmissible, I believe that the best results are obtained from injecting them with diluted tincture of iodine every few days, and applying pressure over the tumor by means of compressed sponge and a roller, or with Ricord's pad. Under one or the other of these methods they will rarely fail to cicatrize. In desperate cases, Ricord resorts to the destruction of the diseased ganglia by Vienna paste, in the following manner: TREATMENT OF INDURATED BUBOES. 449 "This caustic is applied over an extent of two-thirds of the tumor, so as to destroy the cutaneous surface, then on the fall of the eschar, which is hastened by basilicon ointment and other digestives, the ganglia are attacked layer by layer; increasing our caution as we proceed in depth, and stopping within accessible limits, or when we approach the neighborhood of vital parts. This method is generally very rapid, and the deep ganglia undergo resolution as the superficial ones are destroyed."1 Treatment of Indurated Buboes.—Uncomplicated cases of indurated buboes require absolutely no local treatment whatever. When, therefore, an otherwise healthy patient with an indurated chancre and induration of the neighboring ganglia anxiously inquires whether he is likely to be laid up with a suppurating bubo, he may be assured that there is no danger unless he commit some great imprudence. Under the mercurial treatment required by the constitutional infection which has already taken place, the indurated ganglia gradually diminish in size and lose the slight degree of tenderness which they possessed. In the exceptional cases of suppuration the treatment is the same as for inflammatory buboes, though generally less active. 1 Notes to Hunter, 2d ed., p. 390. 29 450 GENERAL SYPHILIS. CHAPTER IV. GEXERAL SYPHILIS. —INTRODUCTORY REMARKS. The earliest manifestation of constitutional infection is the indu- rated chancre situated at the point where the virus entered the system, and the indurated bubo in its immediate neighborhood. These, strictly speaking, constitute primary syphilis.1 Subsequently there is an interval during which the virus gives no evidence of its presence; but immediately following this period of latency the poison resumes its activity and gives rise to various symptoms, the seat of which has no constant relation with that of the primary sore, and which may occupy distant parts of the body. They are there- fore called "General" or "Constitutional" symptoms; the former being the preferable name. The term " Consecutive," used by Vidal and some other authors, has been applied by Ricord to another class of symptoms, and to avoid confusion, should be abandoned as a synonyme of general syphilis. General Syphilis always follows a Chancre.—In the im- mense majority of cases of acquired syphilis (excluding those of hereditary origin), general symptoms can clearly be traced to a preceding chancre. Thus of 826 patients with constitutional syphilis who were treated at the Hopital du Midi in 1856, the pre- vious existence of a chancre in 815 was established beyond a doubt either by examination or by voluntary confession; in 9, there was strong reason to suspect it; and in the remaining 2, the disease was evidently due to hereditary taint. Of 267 cases of secondary syphilis observed by Fournier,2 the same fact was proved in 265. Of 198 cases of syphilitic erythema under the care of Bassereau,3 either a chancre or unquestionable traces of one were seen in 170; in 19, the patients confessed to the fact, although no evidence of ■ De la Contagion Syphilitique, Paris, 1860, p. 15. 1 See p. 353. 3 Op. cit., p. 103. GENERAL SYPHILIS FOLLOWS A CHANCRE. 4'51 it was found upon their persons; 4 acknowledged having had a gonorrhoea; 5 declared that they had had no preceding symptom. Thus we find that in a total of 1291 cases, general syphilis was un- doubtedly preceded by a chancre in all except 22. These statistics agree with the experience of all physicians, that, as an almost invariable rule, constitutional syphilis evidently origi- nates in a primary sore; and the small number of cases in which the previous existence of a chancre cannot be established, renders it extremely probable that there are no exceptions to this law, especially when we take into account the following considera- tions :— Chancres are capable of spontaneous cicatrization, and all traces of them may disappear in time, even without treatment. They may occupy unusual situations, where their presence may readily escape notice, or be almost impossible to detect; among which the interior of the urethra, vagina, cervix uteri, and the buc- cal and rectal cavities deserve special mention.1 Exceptional cases almost invariably rest upon the testimony of patients alone; and are the more frequent, the later the constitu- tional lesion presented in the order of succession of syphilitic symptoms, in other words, the longer the time which must have . elapsed since contagion took place. For instance, cases are rare in which a patient with syphilitic erythema does not confess that he has had a chancre; on the contrary, they are not infrequent when the constitutional symptom is syphilitic rupia, tubercles, orchitis, or periostitis. This fact leads us to suspect that the defective memory of patients will explain some apparent exceptions to the rule. From various motives, patients often conceal facts within their knowledge. With perfect memory and unquestionable honesty, patients are in- competent witnesses upon subjects which involve medical knowledge, which they do not possess. The superficial chancre—the form which most frequently precedes constitutional syphilis—is so indolent and so insignificant a sore, that it may readily pass unnoticed, or, if seen, be mistaken for a mere abrasion. I have met with several -instances in which patients bearing this form of chancre in plain sight upon their persons, were entirely ignorant of its presence, or thought it of no consequence. 1 See p. 356, and also case upon p. 431. 452 GENERAL SYPHILIS. A chancre may be overlooked by the patient because seated else- where than upon the genitals—the exclusive seat of primary sores in the estimation of the public—or may not be discovered, because concealed within the vagina, or beneath the prepuce when phymosis is present, or when the glans is never uncovered. In three in- stances, married men have applied to me with infecting chancres, and within four months their wives have exhibited the initiatory symptoms of constitutional syphilis, without having noticed or sus- pected the presence of a chancre which undoubtedly existed, but which fear of exposing the husbands prevented my searching for. In other cases where an examination has been made, I have found chancres of which patients were entirely ignorant within the vagina. Again, chancres are not unfrequent within the urethra beyond the reach of vision (see table on page 356), where an unprofessional person cannot be expected to be a^ire of their presence from the slight discharge, pain in micturition and induration, which con- stitute their only symptoms, and which may be obscured by a co- existing gonorrhoea. I repeat, therefore, that when we consider in how great a pro- portion of cases constitutional symptoms are known to have been preceded by a chancre, and when we reflect upon the numerous sources of error attending the testimony of patients in apparently exceptional cases, it is infinitely probable that a law which is known to be general, is in fact invariable, and that constitutional syphilis always follows a chancre. I would add that the admission of this truth is not inconsistent with the communicability of secondary symptoms, but, on the con- trary, would favor it, provided that the latter are found by expe- rience to give rise to a chancre by contagion; but of this more hereafter. Period of Incubation.—The smallpox, hooping-cough, measles, scarlet fever, vaccinia, and other contagious diseases, have all a period of incubation preceding the outbreak of general symptoms, and confined within certain and definite limits; so that when, after exposure to one of these diseases, its period of latency passes by and the person exposed remains in perfect health, he may be pronounced beyond danger. Is it probable that syphilis is an exception to this law? Can it be true that, unlike all other con- tagious diseases, "the period of its latency is wholly uncertain and PERIOD OF INCUBATION. 453 indefinite ?" Only to those who refuse to watch the workings of nature untrammelled by art, or who rely upon the statements of unprofessional persons and not upon direct observation. Were it not for the abundant proof to the contrary to be found in many works upon venereal, no one would be likely to suspect the neces- sity of the remark, that the natural history of syphilis can only be learned from cases which are not influenced by treatment. Mercury is given for the very object of preventing or at least retarding con- stitutional symptoms, and if it have any effect at all, its adminis- tration vitiates the case for the purpose of observing the natural course of the disease. When left to itself, syphilis possesses as true, and nearly as definite a period of incubation as any other contagious disease; and the contrary opinion has arisen solely from the causes above stated. In determining the duration*' of this period, we may take as a starting-point either the date of the infecting coitus or that of the appearance of the chancre. We shall presently see that some authors adopt one and some the other. The latter is perhaps pre- ferable, because- it can generally be ascertained by the surgeon with greater precision than the former. It would clearly be inad- missible to take as a starting-point the date of the cicatrization of the chancre, which is dependent upon many extraneous influences, and which is often subsequent to the outbreak of general mani- festations. Again, in order to obtain reliable results, it is essential that the termination as well as the commencement of this period should be ascertained with at least approximate accuracy; and this can rarely be done unless the patient be under the observation of some one who is familiar with the early general manifestations of syphilis, and who knows where to look for them and how to recognize them ; since they are often so obscure as not to attract the attention of the patient himself. For instance, syphilitic erythema, which is one of the earliest secondary symptoms, is generally unattended by itching, and is often confined to the abdomen or perhaps to the flexures of the joints, so that the patient may be unaware of its presence until it is pointed out by the surgeon. The headache and general malaise, the post-cervical engorgement, alopecia, and acne capitis, which also appear at an early date, may likewise escape notice or not be recognized by ignorant persons. Taking these sources of error into account, it cannot be considered unfair to 454 GENERAL SYPHILIS. reject cases which rest solely upon the testimony of patients, when conflicting with the results of direct observation, and to adopt the latter as alone worthy of confidence. The conditions, therefore, which should be required of any case or series of cases brought forward to determine the natural period of incubation of syphilis, are :— 1. That the date of the infecting coitus or of the appearance of the chancre should be known. 2. That the patients have not been subjected to treatment. 3. That they have been under the observation of some one competent to discover the earliest manifestation of general syphilis. If these conditions be fulfilled, the analogy drawn from other' contagious diseases leads us to expect, that although the period of incubation of syphilis may vary somewhat in persons of different constitution, or in those exposed to different hygienic or climatic influences, 3-et that it may be defined with a great degree of accu- racy, and that the extremes of variation will not be far apart. Let us see how far these anticipations can be realized. The first testimony which I shall adduce is that of Diday,1 who has carefully fulfilled each of the above conditions in fifty-two cases. In all, the patients came under observation soon after the development of the chancre, the exact date of which to within a few days was invariably ascertained, and was taken as the commence- ment of the period of incubation. This surgeon never administers mercury for primary syphilis, but, when the chancre is indurated, gives the patient a written statement of the time when constitu- tional symptoms may be expected, of the situation they will pro- bably occupy, the appearances they will present, and the necessity of his return for treatment. In none of these fifty-two cases, therefore, was the natural course of the disease interfered with; and in all, the very earliest indication of the invasion of general syphilis (in most instances, either headache accompanied by general malaise, engorgement of the sub-occipital ganglia, acne capitis, or an eruption upon the abdomen or arms) was observed by the sur- geon himself. The interval between the dates specified, viz., the appearance of the chancre and that of the earliest general symptom, was as follows:— ' Nouvelles Doctrines sur la Syphilis, p. 265. PERIOD OF INCUBATION. 455 No. of Cases. Interval is Days. No. of Cases. Interval in Days. 1 25 4 47 1 28 4 48 1 33 3 50 2 35 1 52 3 36 1 54 1 37 2 56 4 38 1 57 1 39 2 58 1 40 1 60 1 41 1 63 1 42 1 70 1 44 1 105 10 45 — 2 46 Total, 52 It appears from this table that the shortest period of incubation was 25 days, and the longest 105 days, but that the latter was 35 days more than the one immediately preceding it. The extreme limits of variation are not widely separated (certainly not if com- pared with the variation from a few weeks to thirty years, which is given by some authors), and we find on examination that in by far the larger proportion of cases, the periods of incubation terminated within two weeks of each other; thus in 38 of. the 52 cases, or in about four-fifths, this period was from 35 to 50 days. Taking the average of the whole number, it was 46 days. Victor de Meric, Esq., Surgeon to the Royal Free Hospital, London, arrived at very nearly the same result from the observa- tion of nine cases in which no treatment was administered. " In three cases of papules, the eruption in one appeared seven weeks after the primary symptom; in the other, the interval had been six weeks ; and in the last, eight weeks. Two cases of roseola or efflo- rescence appeared, one, twenty-four days after the occurrence of the chancre, and the other, one month. Psoriasis appeared in two sub- jects at the distance of four and eight weeks. So that we may, regardless of the kind of eruption, reckon a mean of six weeks where no treatment has been resorted to."1 Bassereau was able to ascertain the approximate interval between the infecting coitus and the outbreak of syphilitic erythema ("one of the earliest manifestations of general syphilis") in 107 cases in which no treatment was administered, and has given the results in the following table:—2 1 Lettsoinian Lectures, 1858, p. 31. 2 Op. cit., p. 176. 456 GENERAL SYPHILIS. Erythema appeared in from 20 to 30 days in 14 cases « u " 30 to 60 " 66 " u k " 60 to 90 " 23 « k ii " 90 to 120 " 3 " k (i in the course of the fifth month in 1 case. Total, 107 Bassereau adds that the appearance of erythema for the first time as late as the fifth month is a very rare and exceptional occur- rence. It should be observed that these statistics are less reliable than those of Diday, since many of the patients were not seen until some time after the appearance of the erythema, and their histories were obtained from their own statements. Fournier,1 from an examination of 307 cases, concludes that syphilitic erythema most frequently appears, in the absence of preventive treatment, between the fortieth and fiftieth day; and MacCarthy2 states that the average is about seven weeks. I am myself in the habit of giving mercury for indurated chan- cres, and can report but four cases in which patients have been under my care without treatment from the commencement of the primary sore until secondary symptoms appeared. In the following instances, however, which I take from my note-book, various reasons induced me to defer treatment until the outbreak of general syphilis. Case 1. Chancre appeared Nov. 26, 1856, followed by general ma- laise, headache, pains about the joints, and papulae in patches upon the forehead, Jan. 29, 1857. Period of latency, 64 days. Case 2. Chancre appeared April 2, 1857 ; syphilitic roseola May 12. Interval, 40 days. Case 3. Chancre first seen Jan. 1, 1859; mucous patches upon scro- tum and internal surface of cheek, acne capitis, and post-cervical engorge- ment, Feb. 15. Interval, 45 days. Case 4. Chancre developed Feb. 2, 1859; syphilitic roseola appeared March 13. Interval, 40 days. I have also met with frequent instances in which patients who had received no treatment, applied to me with early symptoms of general syphilis without being able to give the exact time of the 1 Notes to Ricord's Le?ons sur le Chancre, 2d ed., p. 466 2 These de Paris, 1844. PERIOD OF INCUBATION. 457 appearance of the chancre, but it has invariably been stated that this occurred within the preceding three months. Ricord, as the result of his extensive experience, enunciates the law that " when no specific treatment is administered for an infect- ing chancre, and the disease is left to itself, six months never pass without the appearance of general symptoms;" and he adds, " in most cases, these supervene from the fourth to the sixth week; frequently during the second or third month; and very rarely as late as the fifth or sixth month." " M. Puche has verified the same fact in hundreds of cases, without meeting with a single excep- tion."1 Prof. Sigmund, of Vienna, in order to determine the duration of the incubation of general syphilis, examined the notes of 1473 cases occurring in his own practice, and from these selected 293 as es- pecially reliable, because copulation had occurred but once or only after a long interval, and because the primary sore had received no specific treatment. In none of these 293 cases did general symp- toms fail to appear within three months. The chancre took on induration (reckoned by Sigmund among general symptoms) in 261; the lymphatic glands were affected in all, the fauces in 248 ; spots appeared on the skin in 204; and papulae, pustules, and con- dylomata, either alone or combined, were present in 134. Sigmund, however, calls attention to the fact that the early symptoms of gen- eral syphilis may occasionally be so slightly marked or so obscure, that they will not be discovered or will not be recognized by in- competent persons; and it is only in such cases, he asserts, that the tardy appearance of late secondary and tertiary manifestations has given any semblance of truth to the assertion that the incubation of syphilis can be indefinitely prolonged. Sigmund lays down the rule, that when a chancre heals without induration, and when, no specific treatment being administered, secondary symptoms do not appear within the first three months, the patient has nothing farther to fear.2 Cazenave is the only author of any eminence whose statistical observations would appear to controvert the position which I have here advocated. This distinguished physician of the Saint Louis Hospital, founding his opinion upon only seven cases, estimates » Ricord, Lettres sur la Syphilis, 2d ed., p. 300. 2 British and For. Med.-Chir. Rev., Jan. 1857, from the Wien Wochenschrift, No. 18. 458 GENERAL SYPHILIS. the average interval between contagion and the development of syphilitic erythema at nearly two years. In one instance, he states that it was ten years, but the syphilitic nature of the disease may well be doubted, since the patient was cured by a few simple vapor baths and barley water; and if this case be eliminated, the average duration will be much diminished. Moreover Cazenave's position at a hospital for skin diseases, where patients are not seen until a long time after contagion, and where consequently the sources of error already referred to cannot well be avoided, detracts from the value of his observations, which cannot compare in number and importance with those of the observers before quoted. Bassereau,1 who served as Interne both at the Hopital des Veneriens and at the Hopital Saint-Louis, states that syphilitic erythema was very common at the former, but that he met with only one case during his year's residence at the latter; and adds that this affection is not even mentioned in the work upon syphilitic eruptions by MM. Martins and Legendre, who collected their cases at the Saint-Louis, where they were internes with him. Thus we have direct proof that the above objection to Cazenave's testimony is not without foundation. Vidal2 avoids expressing an opinion upon this subject, but refers with apparent approval to Cazenave's statement; and also adds, " M. Legendre, un des eleves les plus distingues de l'Hopital Saint- Louis, auteur d'une th&se remarquable sur les syphilides1, dit en propres termes: 'J'ai obtenupour moyenne g£n£rale de l'intervalle de temps qui separe les symptomes primitifs des syphilides (acci- dents secondaires) cinq ans, rdsultat absolument semblable a celui que M. Martins avait deja, consign^ dans son mdmoire.'" Unfortu- nately for the value of this testimony, which alone is quoted in full by Vidal, M. Legendre has since written a letter to Diday,3 in which he states that the words in brackets ("accidents secondaires") are an interpolation; that his meaning has thus been misrepresented and made to support an untenable doctrine ("pour batir un point de doctrine insoutenable"); that his statistics include tertiary as well as secondary syphilitic eruptions; and that he "never intended to assert that my (his) patients had, on an average, passed five years without having syphilitic roseola, which is frequently overlooked, 1 Op. cit., p. 48. 2 Traite des Maladies Veneriennes, p. 261. 3 Nouvelles Doctrines sur la Syph., p. 270. PERIOD OF INCUBATION. 459 but which is none the less an evidence of the existence of the first stage of general infection of the system." I should not have re- ferred to this error, had it not very naturally been reproduced in the American edition of Vidal on Venereal, and been copied into a recent work on "Gonorrhoea and Syphilis;" in both of which the liability of misleading the reader has been increased by interchang- ing the words "syphilides" and "accidents secondaires," and placing the former instead of the latter in brackets. I have dwelt thus at length upon this question, not only on ac- count of its scientific interest, but because it is one of great prac- tical importance both to the patient and surgeon, and because I have desired to leave no doubt as to its correct solution. If it be true that the incubation of syphilis is "wholly uncertain and indef- inite," the unfortunate individual who contracts a chancre, the nature of which is doubtful, can never feel secure for the rest of his . . . . . • days, nor be sure that his posterity will not inherit this great curse; but if, as I believe, it is of certain and definite duration, the lapse of a few months without the appearance of the disease will place the patient beyond danger. To the surgeon the conclusions at which we have arrived furnish the strongest inducement in all chancres of a doubtful character to defer general treatment, and keep the patient under careful observation until secondary symptoms appear, or until the period of latency is passed in safety. To sum up this whole matter :— A chancre which is not subjected to specific treatment (so-called), will generally, if at all, be followed by secondary symptoms within three, and always within six months. It follows as a corollary from this proposition and the one upon page 450, that The earliest symptoms of general syphilis (except in cases of hered- itary origin and of transmission through the foetal circulation) have been preceded by a chancre, probably within three, and certainly within six months. I will merely add that the development of general syphilis is hastened by an elevated temperature, and by those causes which tend to depress the vital powers, as excessive or prolonged exer- tion, or a dissipated course of life; and that it is, on the other hand, retarded by the contrary influences, and also by the supervention of an acute disease, as continued fever, inflammation of the lungs, etc. It also appears to be earlier in women, in whom mucous 460 GENERAL SYPHILIS. patches are developed with great rapidity, sometimes even three weeks after contagion. Classification of General Symptoms.—Ricord's classification of constitutional symptoms into secondary and tertiary, which is generally adopted at the present day, is founded upon Hunter's division of the tissues affected by syphilis into "parts first in order, and parts second in order." Both systems are based upon the con- formity by nature to laws which are more or less fixed as well in disease as in health, and upon the anatomical structure of the parts affected. An important distinction, also, which Ricord claims to exist between the two divisions in this classification, is a difference in the effect of remedies; secondary symptoms being more suscep- tible to mercury, and tertiary to iodine and its compounds. Ricord's classification may best be given in his own words: " Secondary symptoms are the consequence of the absorption of the virus, and are transmissible by hereditary descent, without being inoculable. Tertiary symptoms are not only not inoculable, but cannot be transmitted by hereditary descent under their pecu- liar type, although in consequence of a kind of degeneration or modification of the syphilitic virus, they are probably one of the most fruitful sources of scrofula. " Secondary symptoms rarely occur before the third week follow- ing the appearance of primary symptoms, and more rarely still after the sixth month; whilst tertiary symptoms scarcely ever appear before the sixth month, and may not until after several years. " To secondary symptoms are referred certain affections of the skin (syphilitic eruptions), and of some parts of the mucous mem- branes (mucous patches, condylomata and superficial ulcerations) and their dependencies (alopecia and onyxis); also some peculiar pathological affections of the eyes (iritis), lymphatic ganglia (en- gorgement of the glands in various parts of the body, especially the neck), etc. Tertiary symptoms consist of certain changes which take place in the subcutaneous or submucous cellular tissue (gummy tumors), in the testicles (orchitis), in the fibrous and osseous tissues (periostitis, ostitis, caries, etc.), and in the deeper organs. " Proper treatment of primary symptoms may prevent the de- velopment of secondary symptoms. Very often this treatment cures the primary and arrests only the secondary symptoms; in classification of general symptoms. 461 this way may be explained, for example, the late appearance of diseases of the periosteum and bones, without the secondary link, in persons who have taken mercury. When once the primary ulcer is healed, it cannot be reproduced except by a new contagion; while secondary and tertiary symptoms may appear repeatedly, and at various intervals, within periods which cannot be limited. An apparent inversion in the succession of secondary and tertiary symptoms is observed only in persons who have undergone treat- ment. After the appearance of constitutional symptoms, the syphilitic diathesis may cease spontaneously or in consequence of appropriate treatment, and yet the symptoms persist under the influence of purely local causes, as is observed especially in many cases of diseased bones."1 In another place Ricord says of tertiary symptoms: "They not only differ from primary and secondary symptoms in affecting the deeper tissues, but also in the fact that in them syphilis loses, in part, its peculiar type. Though the skin is often affected at this period with the most severe tubercular eruptions, yet the subcu- taneous and submucous cellular tissues, and the fibrous and osseous systems are far more frequently involved. But, in addition to these parts, where the tardy effects of constitutional syphilis are so common and clearly admitted by all good observers, we may well inquire whether there be any privileged tissues of the body which are invariably exempt from its effects. We would inquire, also, if syphilitic infection, though it may not produce all the evils with which it is reproached, be not in a multitude of cases the cause of the evolution, or 'putting into action'—to use an expression of Hunter's—of diseases which have previously existed in a latent state, and of which it is thus only the exciting cause. Observation replies in the affirmative to these questions, and also teaches us that tertiary symptoms may continue under the influence of the virulent cause, or persist as local effects after this cause has been destroyed or neutralized by treatment; it shows, in a multitude of cases, that the syphilitic virus, after having been the cause of other diseases, may cease to exist or persist as a complication; and these are cir- cumstances which, though real, are unfortunately not always easily appreciated. " Tertiary symptoms rarely occur before the sixth month follow- 1 Notes to Hunter, p. 396. 462 GENERAL SYPHILIS. ing the appearance of the primary ulcer, and the latter seldom re- mains at the time of their development; but they are frequently attended by some secondary symptom. They never furnish in- oculable secretions, nor transmit characteristic constitutional syphilis from parent to child; their only hereditary influence being the fre- quent transmission of a taint as injurious and almost as fearful, viz., a scrofulous diathesis." Ricord's classification may, I think, be resolved into two parts. The first is the chronological system, which, originating with Fer- nel and Hunter, has been freed from many errors by Ricord, and greatly perfected by this surgeon's keen powers of observation, and which is both natural and eminently practical. The second part consists of various additions relative to the inoculability of the dif- ferent orders of symptoms, their transmission by hereditary descent, and the effect of treatment; some of which are open to criticism. I shall speak of each in turn. The general symptoms of syphilis are not drawn at hap-hazard, but make their appearance with a great degree of order and regu- larity. This fact is most apparent in those lesions which follow immediately upon the period of incubation, and which vary but little in different subjects. Allow any patient with an infecting chancre to go without treatment, and it may be predicted with almost absolute certainty, that within three months he or she will be attacked by the following category of symptoms with but little variation, viz., general lassitude, accompanied by headache and fleeting pains in various parts of the body; an eruption of blotches or papulae upon the skin; pustules upon the hairy scalp; engorge- ment of the post-cervical glands; and whitish patches, which may become ulcerated, upon the mucous membrane of the mouth, anus, or vulva. Subsequent to the first outbreak of general syphilis, the same uniformity does not prevail; and certain symptoms are absent in one case and present in another, or they appear to be modified by the constitution of the patient, the hygienic conditions in which he is placed, his habits, and especially by treatment. But if we take a number of cases, some of which supply what is wanting in others, we find that we can, as it were, make up a complete series, in which the symptoms progress by a regular gradation, and may be divided into two classes, distinguishable by the time of their appearance, their character, and their seat. Those of the first class classification of general symptoms. 463 follow immediately upon the earliest constitutional symptoms before mentioned, with which they are evidently identical in character. Those of the second class never occur until after a certain interval which experience enables us to determine with great precision. Again, the order of the two classes is never reversed. For instance, a patient who has been suffering with symptoms belonging to the second, as deep tubercles of the cellular tissue or caries of the bones, is never known to exhibit the premonitory fever, exanthematous eruption, and other early symptoms of the first. The disease pro- gresses with greater rapidity in some cases than in others, yet owing to the general uniformity referred to, simple inspection of a patient will enable any one familiar with its natural course to arrive at an approximate conclusion as to the length of time that has elapsed since contagion, and also as to the character of the preceding symp- toms, unless these have been altogether suppressed by treatment. Apparent exceptions to the regular succession of the general symptoms of syphilis are met with, and may readily deceive an inexperienced observer. One of the most frequent of these is due to treatment. It often happens that a patient had an infecting chancre many years ago, and perhaps early secondary symptoms, for one or both of which he took mercurials; a long period has since passed without further general manifestations; but his system has continued under the syphilitic diathesis, which finally becomes active again and gives rise to tertiary lesions. Evidently the exemption from late secondary symptoms may be ascribed to mercury. Again, the date of the first appearance of any lesion determines its position in the syphilitic scale; while its persistency may be due to many causes, too numerous to mention. It is a very common occurrence for a chancre to remain until secondary symptoms break out; but we do not therefore conclude that both belong to the same order. In the same way, secondary are often present long after tertiary manifestations have supervened. In Ricord's admirable remarks already quoted, allusion has been made to the fact which I have often had occasion to verify, that syphilis may give rise to symptoms, which are continued by various causes and especially by a strumous diathesis, long after the exciting cause has been subdued. Moreover, many syphilitic lesions, and particularly eruptions upon the skin and mucous membranes, may, either with or without treatment, disappear, and again return within a limited period with the same characters as at first. This tendency, how- 464 GENERAL SYPHILIS. ever, ceases with time; and relapses after a considerable interval are in all cases rare. For instance, syphilitic erythema which usually appears about the sixth week after the development of the chancre, may perhaps return as late as the eighth or ninth month, but never several years after the primary sore. Finally, the same name is, in several instances, applied to symp- toms which are in reality distinct, and which are widely separated upon the syphilitic scale. Thus there is a form of alopecia which is one of the earliest general symptoms, and in which the hair is freely shed from the scalp and eyebrows, but may grow again, since the hair-bulbs are not seriously affected; and there is another and rarer form, observed only in the later stages of syphilis, in which the whole integumental surface becomes permanently bald. Two forms of iritis, ecthyma, etc., are also observed at distinct periods; but these constitute no exception to the law of succession of syphi- litic symptoms. "We thus see that a simple chronological division of constitutional symptoms may be maintained; but there are several objections to the additions made to this system by Ricord, as I shall proceed to show. In the first place, Ricord's statement that •" secondary symptoms are not capable of inoculation," is true in the guarded sense in which it was intended, viz., that they are not inoculable upon the persons bearing them; but the inference which was also designed to be conveyed, that they differ in this respect from infecting chancres, is not true, as Ricord himself has since acknowledged. Both are contagious and inoculable upon persons free from syphilitic taint, but neither are auto-inoculable. Again, Ricord's statements relative to tertiary symptoms cannot at the present day be implicitly received. This author maintains that tertiary lesions are not inoculable and cannot be transmitted by hereditary descent under their peculiar type, and hence that the virus in this stage must be entirely changed from its original character. The first of the above assertions is doubtful, the second incorrect. The inoculability of tertiary symptoms has never been tested upon persons free from syphilitic taint, and its possibility, there- fore, may yet be demonstrated, as that of secondary symptoms has been. Their transmission by hereditary descent in many instances, still preserving their peculiar type, is a known fact. The most fre- quent instance of this is the occurrence of syphilitic hepatitis and deep CLASSIFICATION OF GENERAL SYMPTOMS. 465 tubercles of the subcutaneous cellular tissue in infants affected with hereditary syphilis. Dr. Wm. II. Van Buren, Professor of Anatomy at the University Medical College, K Y., has also ob- served nodes upon the forehead and ulna, and syphilitic orchitis in several instances, and has kindly furnished me with notes of the following case occurring at his clinique:— James Hannon, aged 14 months, was brought to the clinique, Oct. 22, 1853. The patient is the fifth child, his mother having had in addition two miscarriages. The first child died five weeks after birth, and had, when born, an erup- tion on the face, arms, and legs, and around the corners of the mouth. The second child, born three years after, had an eruption in much the same localities, appearing about three weeks after birth, and died in nine months. The third child, born three years after the second, had a similar eruption, but lived nearly two years. The mother then had two miscar- riages in succession. The fourth child also had an eruption appearing about three weeks after birth, and lived sixteen months. This child is now fourteen months old. About three weeks after birth, he also had an eruption making its appearance on the face and arms, and, in the course of three months, on the legs and around the anus, which was cured by "a blue powder" (hyd. cum creta?). About three months ago (July, 1853), both of the testicles of this child commenced slowly and painlessly enlarging, and have gradually increased in size up to the present time. Both are extremely hard and irregular to the feel. The child also presents a small node upon the forehead and periosteal thickening over the ulna, and appears to be suffering from great muscular debility, and its appetite is poor. It is unnecessary to enter into the details of the treatment of this case. Suffice it to say that the nodes entirely disappeared under the administra- tion of the iodide of potassium. Both testicles suppurated; one after- wards healed and returned to its normal size; the other was in an indolent condition and still discharging at last record. Two similar cases have recently occurred at the Hospice des EnfantSrSainte-Anne, at Vienna;1 and Virchow2 has found small collections of the deposit peculiar to tertiary syphilis in the cerebral substance of children born of syphilitic mothers. ' Syphilis Tertiaire chez des Enfants, L'Union Medicale, Aug. 11, 1860, from the Wien Medizin Wochenschr. 2 La Syphilis Constitutionnelle, traduit de l'Allemand par le Dr. Picard, Paris, 1860, p. 4. 30 466 GENERAL SYPHILIS. Hunter attributed the difference in the situation of early and late constitutional symptoms to the influence of cold, which, as he sup- posed, rendered the more superficial parts of the body most sus- ceptible to, and earliest affected by the virus. This anatomical distinction, without Hunter's explanation, has been retained in Ricord's classification, in which the skin and mucous membranes on the one hand, and the osseous, fibrous, and cellular tissues on the other, are regarded as the exclusive seat of secondary and tertiary manifestations respectively. But this rule cannot always be main- tained, since one of the earliest symptoms of general syphilis- preceding in many cases the eruption upon the skin—consists of pains resembling rheumatism, some of which are evidently seated in the periosteum (chiefly that of the cranium and in the neighbor- hood of the joints), and this fibrous tissue has been known to take on acute inflammatory action at this time. In order to avoid this difficulty. Bassereau asserts that general syphilis attacks indiffer- ently the integumental, fibrous, and osseous structures in all periods of the disease, but that the more superficial portions of each are affected in the earlier and the deeper in the later stages. Virchow1 would exclude all consideration of situation from the classification of general symptoms, and has proposed a system based upon the nature of the pathological changes in the different lesions, but which is too widely at variance with the ideas at pres- ent received to meet with general adoption. De Baerensprung2 offers a similar classification in which secondary symptoms are made to include those lesions which are characterized by hyperemia and simple exudation; and tertiary symptoms those in which there is tubercular deposit. But it is easier to pull down than it is to build up, and attempts in the latter direction may well be deferred until many preliminary points are settled. Meanwhile, we have every reason to be satisfied with the simple and natural chronological division which forms the basis of Ricord's classification, and which owes its excellence in a great measure to the keen powers of observation of this truly eminent surgeon. The few errors which he introduced are not essential to the system, and may well be forgotten, when we recol- lect his important contributions to our knowledge of the natural history of syphilis. 1 Op. cit. * Annales de la Charite, vi. p. 56, et vii. p. 173. symptoms of syphilis contagious. 467 Some of the Symptoms of General Syphilis are Contagious. —The older writers on syphilis fully believed in the contagiousness not only of secondary symptoms, but also of the sweat, saliva, semen, milk, blood, and even the breath of persons affected with constitu- tional syphilis. Hunter, founding his opinion upon a few unsuc- cessful inoculations of secondary symptoms upon the persons bearing them, declared that the power of contagion was confined to primary sores. Auto-inoculations, similar to those of Hunter, were repeated in thousands of instances by Ricord, and, in imitation of his example, by numerous surgeons in various parts of the world, the results of which were uniformly unsuccessful with scarcely an exception worthy of notice. On the other hand, the chancroid was regarded by Ricord and by the profession generally as the type of primary sores, and its secretion was found to be inoculable with the greatest facility. The inference which was drawn was a natural one, viz., that a radical distinction existed between primary and secondary lesions in the contagiousness of the former and the in- communicable character of the latter; and the zeal, energy, and ability with which this idea was for many years defended are known to the whole medical world. The plausibility of this evidence, the. immense number and uni- form results of the experiments resorted to, the keen powers of observation, ingenious reasoning, attractive manners, and evident sincerity of the Surgeon of the Hopital du Midi, united in adding weight to a doctrine which had already been sanctioned by the great name of Hunter, and which was consequently for a time received as almost beyond dispute. Yet cases in apparent contra- diction to Ricord's "law" were met with by many careful observers, especially in infants affected with hereditary syphilis, whose early age, incapacitating them from sexual intercourse, greatly dimin- ished the chances of error of observation; and although instances of transmission of secondary symptoms from the nursling to the nurse, and vice versa, were explained away with great ingenuity by Ricord and his adherents, yet they gradually came to be admitted by the majority of the profession. At the same time it was felt to be highly desirable to demonstrate this power of con- tagion by experimental inoculation, and thus place it beyond a doubt; and afterwards to study the phenomena of the process and compare them with those attending the evolution of constitutional 468 GENERAL SYPHILIS. syphilis when originating in a chancre. Until this was done, the subject was likely to remain an open question. This test, however, could not readily be applied. Ricord and his school—to their honor be it said—had confined their inocula- tions to persons already infected, and it was generally admitted that further experiments, in order to be decisive, must be made upon those who were free from syphilitic taint—a course which could not be justified in a moral point of view even for the purpose of advancing science. Wallace had already, in 1835, succeeded in inoculating the secretion of condylomata upon healthy individuals, but the want of precision in his observations rendered them of little value. Subsequent inoculations, however, within the last ten years, by Waller of Prague, Rinecker of Wurzburg, a surgeon of the Palatinate who has concealed his name, Gibert and Vidal of Paris, and others, can leave no further doubt that the contagious- ness of secondary symptoms can be demonstrated by the lancet.1 Gibert's experiments, although by no means the most conclusive that have been published, have probably attracted the most atten- tion in this country, since they ostensibly formed the basis of a report in favor of the contagiousness of secondary syphilis, which was adopted by the Academy of Medicine of Paris, at its session of May 31, 1859, and during the discussion of which Ricord gave in his qualified adhesion to the same doctrine. These cases are as follows:— Case 1. Patient No. 1, Saint-Charles ward; an adult affected with lupus of the face, which he had had since infancy. A vesicated surface was produced upon the left arm by aqua ammonia?, and charpie soaked in the purulent secretion of secondary mucous patches situated around the anus was applied to the raw surface. The patient from whom the matter was taken presented around the anus a corona of condylomata (pustules plates) which had already existed for a fortnight, and which were consecutive to a chancre of the prepuce con- tracted fifteen months before, the cicatrix of which was still apparent. Jan. 30, 1859, five days after the inoculation, no trace of the latter was visible except the mark of the blister, which was about the size of a ten- 1 A resume of the inoculations of Wallace and Waller may he found in the Arch. Gen. de Med. for Feb. 1856 ; and of those of Rinecker and the anonymous surgeon of the Palatinate in the same journal for May, 1858. Vidal's experiments are given in his Treatise on Venereal. symptoms of syphilis contagious. 469 cent piece. Nine days later all vestige of the blister had disappeared, but a little redness was seen at the same spot. Feb. 12, the eighteenth day after the inoculation, a prominent copper- colored papule appeared. Feb. 16 (the twenty-second day), a small quantity of serous exudation appeared on the surface of the papule, which in the meanwhile had spread and increased in size generally. This secretion becomes purulent, and forms by concretion a thin scab. Feb. 23 (the twenty-ninth day), an enlarged gland is found in the cor- responding axilla, Feb. 26 (the thirty-second day), the scab is detached by a vapor bath, when a very superficial excoriation is found beneath it. .March 21 (fifty-fifth day), a superficial ulceration, slightly excavated, has formed in the centre of the papule, which has become more and more prominent and indurated, and now constitutes a true tubercle. Moreover, several blotches and reddish papules have appeared upon the body; subsequently they are transformed into pustules resembling acne, and this eruption becomes general upon the anterior surface of the upper extremities, upon the abdomen, internal surface of the thighs, inguinal regions, etc. March 31, the patient is directed to take a mixture of the biniodide of mercury and iodide of potassium in syrup, and baths containing corrosive sublimate. May 16, after six weeks' treatment the ulcerated tubercle upon the arm has disappeared, leaving behind it a white and slightly depressed cicatrix. The enlarged ganglia in the axilla remain. The general syphi- litic eruption is beginning to disappear. Case 2. Patient Xo. 47, Saint-Charles ward. A vigorous adult, affect- ed with an inveterate papulo-tubercular lupus, which covers the whole face. Several inoculations were made in the same manner and with the same matter as in the preceding case. Two of these succeeded and gave rise to the same local changes, but preceded by a longer period of incubation, which was a little less than twenty-five days. Slight redness then showed itself, followed by the development of a papule, which was at first dry, then became moist, excoriated, covered with a scab, indurated, and finally formed a true condyloma (tubercule plat). A ganglion in the axilla at the same time enlarged to the size of a hazel-nut. An eruption of roseola appeared upon the body on the fifth of March; that is to say, on the thirty-seventh day following the inoculation. Specific treatment was commenced a short time after; and on May 17 following, the cure appeared to be complete. 470 GENERAL SYPHILIS. Case 3. This case presents a striking analogy with the two preceding, except that the papule was much smaller, and the tubercular induration was less marked, less extended, and underwent resolution more rapidly, leaving a rounded, superficial, and slightly fungous ulceration. Specific treatment was commenced before the appearance of the roseola. To-day (May 17) the patient is rapidly improving. The inoculation was per- formed Feb. 28,1859. The matter employed was the viscous and plastic secretion from the papular surface of patient Xo. 1, whose local sore was at that time sixteen or seventeen days old. Case 4. This case is more interesting in respect to the source from which the virus was taken (a scaly papule upon the forehead); the appear- ance of the matter itself (there was only bloody serum upon the lancet when withdrawn); the long duration of the incubation (about thirty-five days); and finally the form of the initial lesion, which, during its whole duration, presented no other appearance than that of a scaly papular sur- face, without secretion or excoriation. The patient who furnished the matter for the inoculation had been treated by M. Puche, at the Hopital du Midi, for an indurated chancre upon the external surface of the prepuce. At the time of his entrance into our wards (Feb. 7, 1859), this chancre had left in its place an indurated cica- trix, still a little red, in the form of a condyloma, and lenticular and indo- lent engorgement of the inguinal ganglia. Secondary mucous patches had been developed upon the penis, scrotum, the internal portions of the thighs, and anus, and had thence extended to other portions of the body. Upon the forehead was a large scaly patch, of a coppery red color, entirely dry, and about the size of a ten-cent piece. Feb. 9, the point of a lancet was plunged into the circumference of this patch, and charged with slightly serous blood, which was at once inocu- lated upon the palmar surface of the right forearm of a patient affected, like the preceding, with lupus of the face. As we had no idea that this inoculation would succeed, we allowed the patient, a fortnight after, to leave the hospital. All traces of the puncture had at that time entirely disappeared. r April 1st following, this young man re-entered the hospital under the care of M. Bazin. At this time (fifty days after the inoculation), we were surprised to find that there had been developed at the point of inoculation a reddish papule, which was spread out in an irregular form, entirely dry, and about the size of a ten-cent piece, and which thus resembled the scaly patch upon the forehead from which the virus was taken. The patient reported that this patch appeared about fifteen days before, which was thirty-five days after the inoculation. Above and around it were seen several slightly prominent and coppery spots, the commencement SYMPTOMS OF SYPHILIS CONTAGIOUS. 471 of a squamous syphilitic eruption, which subsequently extended to other parts of the body. A painful ganglion, larger than a hazel-nut, was found in the corresponding axilla. April 23, the patient's condition was as follows: blotches of roseola upon the body; a few scattered scaly papules upon the anterior surface of the upper extremities; an abundant eruption upon the scalp; engorge- ment of the posterior cervical ganglia; commencing mucous patches about the umbilicus and the margin of the anus; no symptoms about the mouth, throat, or genital organs. Specific treatment was soon commenced, and by May 18th all the symp- toms were much improved. Gibert attempts to justify these inoculations on the ground that the patients were all affected with inveterate lupus of the face, which he hoped to benefit " by the double influence of a new con- stitutional disease and the specific remedies administered in its treat- ment ;" and he has since stated that in three of the four cases this hope was realized and the patients entirely cured of their lupus;] this statement, however, requires confirmation, and the author has not escaped severe and just censure for inoculating syphilis upon persons who must have been ignorant of the risk they were incur- ring. Looking at Gibert's cases from a purely scientific point of view, they are deficient in detail and in accuracy of observation, and could not be received in proof of the contagiousness of secondary syphilis, were the latter not sustained by clinical experience and the more reliable experiments of others. A sceptic in this doctrine would naturally say : " These cases prove nothing.—No exploration was made of the rectum ofj the patient from whom the matter was de- rived for the first two inoculations. This cavity may have con- cealed a chancre, the secretion of which was mingled with that of the mucous patch upon the margin of the anus.—Nor is it said that the patient bore any other evidences of constitutional infection. How do we know that the sore which he had upon the penis fifteen months before was not a chancroid, and that his supposed con- dyloma was not a recent infecting chancre, undergoing a process of transformation into a mucous patch or tubercle, as often takes place during the reparative stage ?—Owing to one or the other of these sources of error, which were not guarded against, the secretion of a 1 Gaz. des Hopitaux, No. 144, 1859, from the Gaz. Medicale. 472 GENERAL SYPHILIS. primary instead of a secondary lesion was inoculated. No wonder a chancre was the result, the secretion of which was employed in the third successful inoculation.—The fourth case is vitiated by the absence of the patient from observation during thirty-five clays between the inoculation and the outbreak of constitutional symp- toms ; during which time he may have been exposed to many other sources of contagion." These objections are not without foundation, and it is certainly not unfair to conclude that the Academy of Medicine did not rest its adoption of the report of its committee upon the experimental inoculations which it contained, but rather upon the large amount of evidence drawn from clinical experience which has for years been accumulating, and probably also upon the more reliable ex- periments of others, although the latter were not properly under discussion at the time. The conclusions of the report of the com- mittee were as follows:— 1. Some secondary or constitutional symptoms of syphilis are manifestly contagious. The mucous patch or tubercle holds the first rank in this respect. 2. This truth is applicable both to the nurse and nursling and also to persons in general; and there is no reason to suppose that the secretion of secondary symptoms in infants at the breast pos- sesses different properties from those which are known to belong to secondary symptoms in adults.1 The objections which I have brought against Gibert's inocula- tions, as recorded in his report, are well founded, and would justify a medical jury in pronouncing t*he verdict, "not proven;" but at the same time, considering the standing of their author and the concordance of the results with those of other observers, I have no doubt, in my own mind, that the matter employed was derived from the sources supposed. If this be so, the first two cases were instances of the successful inoculation of secondary symptoms. In the third (admitting with Rollet that secondary symptoms give rise 1 The exact words of the original are as follows :— 1. II y a des accidents secondaires ou constitutionals de la syphilis manifeste- ment contagieux. En tete de ces accidents, il faut placer la papule muqueuse ou tubercule plat. 2. Ce fait s'applique a la nourrice et au nourrisson comme aux autres sujets, et il n'y a aucune raison de supposer que chez les enfants a la mamelle le produit de ces accidents ait des propriety differentes de celles qu'on lui connait chez l'adulte. SYMPTOMS OF SYPHILIS CONTAGIOUS. 473 to a chancre by contagion), the matter inoculated was that of a primary sore. In the fourth (if the lesion upon the forehead be correctly described by Gibert), the blood of a syphilitic patient was successfully inoculated. The interest attached to the decision of the Academy of Medicine, and to the occasion of Ricord's renunciation of a doctrine which he had so long and ably defended, is my reason for making Gibert's inoculations so prominent; but, as before stated, no one can for a moment suppose either from the character of the experiments or from reading the discussion before the Academy, that the event was anything more than the enunciation of a foregone conclusion. The contagiousness of secondary symptoms had already been proved by clinical experience, and its demonstration accomplished by the more carefully conducted experiments already referred to. Of the latter I shall only quote those reported by Rinecker, as entirely conclu- sive and sufficient in themselves to establish the point in question without the assistance of any others. Case 1. A woman by the name of Bronner, aged 28, was admitted to the hospital in the fourth month of pregnancy, to be treated for constitu- tional syphilis. Her symptoms were syphilitic acne, mucous patches and severe leucorrhoea, without any traces of primary symptoms. After a mercurial treatment she was dismissed, July 7, as cured. Nov. 17, she gave birth to a daughter, whom she was not able to nurse. Her child appeared to be healthy at birth, but, on Dec. 9th, was at- tacked with sore mouth and diarrhoea, which yielded to the administration of nitrate of silver. On the 13th, large condylomata were found upon the genital organs and on the internal surface of the thigh. Soon after a specific eruption appeared upon the face, and this was soon accompanied by the most clearly marked symptoms of hereditary syphilis: such as an affection of the nails, syphilitic nodus, etc. The child grew thin and pale, and died Jan. 12, 1852. A servant girl who took care of the infant during its illness, but who did not nurse it,became affected; mucous tubercles were developed at the right angle of the mouth, and followed their usual course; the genital organs were examined with the greatest care, and found to be intact. Prior to the death of the infant, a young physician, W. R., offered, for the interests of science, to allow himself to be inoculated with the secretion from the pustules of acne upon the child. He was 21 years old, of a robust and healthy aspect, had never had syphilis, and consequently was a very favorable subject for this experiment. Wallace's method was adopted with slight modifications ; and Jan. 5,1852, a blister three inches 474 GENERAL SYPHILIS. long by two inches wide was applied to his left arm; the serum was evacuated ; and the matter from several pustules upon the child's fore- head was introduced beneath the epidermis, which was not removed from the vesicated surface. Jan. 10, there was no appreciable effect; the blister had followed its usual course, and, with the exception of slight redness and exfoliation, was completely healed. Jan. 20, a short time after the healing of the blister, a papular erup- tion attended with severe pruritus, such as often follows the application of a blister, appeared over the whole arm, but disappeared without treat- ment. Feb. 2. The result of the inoculation appeared very doubtful, when, on Jan. 25, the surface which had been blistered became red again, desqua- mated, and itched. At this date (Feb. 2), twenty-nine days after the inoculation, the surface is of a deep red and copper color, corresponding exactly to the limits of the blister. The skin is hard and infiltrated es- pecially toward the circumference, and at the inferior and internal angle, where the matter employed in the inoculation was deposited in a larger quantity than elsewhere. In these portions, are seen a number of papular elevations, from the size of a lentil to that of a pea, and firm. Xo pain. Feb. 10. All the inoculated surface is covered with tubercles of a brownish-red color, hard to the touch, united in groups, and covered for the most part with scales. Those which first appeared bear upon their summits a dark scab, produced by an exudation of pus. Feb. 15 (forty-two days after the inoculation), the isolated tubercles, especially those at the internal and inferior angle, have decidedly increased in size. They are now quite prominent, and are covered by a conical scab which reminds one of rupia, and beneath which suppuration has taken place. The skin is very much infiltrated, especially around the margins. There is a little pain following the lymphatic vessels. The axillary gan- glia are swollen and tumefied. We now attempt to make the eruption, which is thus far local, recede by means of frictions with an ointment containing the biniodide of mer- cury. This treatment at first appears to succeed ; the tubercles diminish in size; the infiltration begins to disappear, and In a fortnight the largest tubercles are the only ones remaining visible. The ointment is suspended for some time, when the local affection grows worse, and, March 14, seventy days after the inoculation, the skin again becomes red and more infiltrated. Still we do not despair of preventing general infection, and apply a paste consisting of equal parts of chloride of zinc and starch to the local sore. After the fall of the eschar, healthy granulations appear, and cicatrization progresses rapidly. SYMPTOMS OF SYPHILIS CONTAGIOUS. 475 June 12 (one hundred and fifty days after the inoculation, and one hundred and thirty after the appearance of the local affection),1 R----, who until this time had been quite well, complained of malaise, gastric disturbance and headache. A week later, an erysipelatous redness ap- peared upon the anterior wall of the soft palate, and a few days, after a grayish-white exudation upon the same part, which was soon transformed into a superficial ulceration. A similar spot appeared upon the internal surface of the lower lip, and another upon the side of the frasnum lingua?, and the occipital ganglia were slightly affected. Mucous patches appeared at a later date upon the scrotum. Mercury internally and an appropriate regimen effected a cure in the course of a few weeks, and at the present time (Nov. 20), there have been no new symptoms of constitutional syphilis. I shall not quote in full Rinecker's second case, which is a mere continuation of the first, since the matter employed was taken from the tubercles upon the arm of R----, and, if we adopt the recent views of the nature of the sore produced by the contagion of con- stitutional syphilis, it was, as in Gibert's third case, the secretion of a primary and not a secondary lesion which was inoculated. Suffice it to say, that matter from this source was applied in the same manner as in the former case, to the arm of another physician, Dr. Warnery, of Lausanne, Feb. 13th. The phenomena which ensued were very similar to those in the preceding case. The blistered surface entirely healed, but, March 13th (twenty-three days after the inoculation), became red again, was infiltrated and thickened, and presented numerous firm, papular elevations, which, by March 21st, were transformed into prominent tubercles, covered with brownish scabs or thin grayish scales. An ointment of biniodide of mercury was used as in the former case, but about May 1st (from one hundred and sixteen to one hundred and twenty days after the inoculation, and from fifty-four to sixty days after the appearance of the local sore), Dr. "W. was attacked with numerous and unquestionable symptoms of constitutional syphilis, of which Rinecker gives a minute description.2 In discussing this question I have not considered it necessary to adduce proof from clinical experience in favor of the contagiousness of secondary lesions occurring in infants affected with hereditary 1 This long incubation of general syphilis was probably due to the mercurial frictions. 2 These two case3 were originally reported to the Physico-Medical Society of Wiirzburg, and are inserted in the third volume of their Transactions. 476 GENERAL SYPHILIS. syphilis, because examples of this kind abound in medical litem- ture The reader will find numerous instances recorded in Diday's work on Infantile Svphilis, a translation of which has recently been published by the New Sydenham Society. But let it not be for- gotten that this is the most favorable field for the study of this question, since syphilitic infants almost invariably present second- ary lesions upon the buccal mucous membrane, and the contact between the infant's mouth and the nurse's breast, is more frequent, prolonged, and intimate, than often occurs between any two surfaces in adults equally liable to be affected by constitutional lesions. Moreover, cases of transmission of secondary symptoms between grown persons are almost always open to the suspicion that the disease was contracted in some other way. A number of cases, however, of undoubted character, have been reported by Rollet,1 and others, thus disproving Diday's idea, that hereditary syphilis possesses a peculiar virulence, and is alone capable of. being com- municated by contagion. In the first of Rollet's cases, the disease was transmitted from the mouth to the breast, in the same manner. as commonly occurs in infants. Case 1. Mme. X----was delivered of a healthy female infant, Oct. 30, 1856. As the child did not readily take the breast, a woman was engaged to come to the house every day, and draw off the milk. By the month of Jan., 1857, a fissure had formed upon the nipple, attended with engorgement of the axillary ganglia, but had finally healed. The patient was under the care of Dr. Despiney, who afterwards dis- covered unmistakable signs of constitutional syphilis, but, fully persuaded of her virtue and that of her husband, suspected that he was mistaken in his diagnosis, and, the following May, referred her to Rollet, who found that she had syphilitic erythema, alopecia, scabs upon the head, engorge- ment of the suboccipital ganglia, mucous patches upon the mouth, grayish spots upon the tonsils, but no lesion of the genital organs. These symp- toms had existed for a fortnight. Her husband was perfectly well, and had never had any venereal trouble. Rollet, with considerable difficulty, ascertained the above mentioned particulars with regard to her milk having been drawn off, and, on examining her breasts, found at the base of the left nipple a large characteristic induration, and two glands of the size of a nut, not pain- ful, in the axilla. It was learned on inquiry that the woman who had sucked the breasts, 1 Archives Gen. de Med., March, 1859. SYMPTOMS OF SYPHILIS CONTAGIOUS. 477 was virtuous, but had had syphilitic lesions upon the genital organs, which were communicated by her husband, and which had healed without treatment. She had afterwards had mucous patches upon the fauces, and at the same time with her attendance upon Mme. X----. The infant was now examined and found affected with an ulceration of the lip, which disappeared under a mercurial course that was at once commenced. It, however, afterwards had mucous patches around the anus and the genital organs. The mother was cured for a time of her symptoms, but had several re- lapses. The husband never presented any syphilitic lesion. Case 2. Jules C----, silk-weaver, aged 25, entered the Antiquaille Hospital, Lyons, June 26, 1858. He had never had any venereal disease until April 11 preceding, when he was bitten upon the upper lip by Louis B., and the wounds produced by the aggressor's teeth remained open for two months. At his entrance into the hospital, two masses of induration were found in the upper lip ; each of which nearly equalled in size a twenty-five cent piece, and was slightly excoriated upon the surface. The submaxillary glands on each side were enlarged and indolent. He had had for several days scabs upon the head, alopecia, erythema upon the body, and mucous patches upon the scrotum ; nothing upon the penis. He was ordered to take pills of the protiodide of mercury, and baths containing corrosive sublimate, and left the hospital July 8, before he was quite well. His wife presented no trace of syphilis, and was nursing at the time a healthy infant. Louis B----, who bit him, and who was condemned for the act to six months' imprisonment, had been treated for general syphilitic symptoms at the hospital which he entered April 10, 1857, when, as shown by the records, he had an indurated chancre of the corona glandis, which healed at the end of three weeks. He afterwards had mucous patches upon the scrotum, engorgement of the posterior cervical ganglia, and alopecia; for which he remained under treatment until May 8, when he left the hos- pital. At the time when he seized Jules C. between his teeth, he had syphi- litic lesions in the mouth, and told the latter as he bit him that he would give him the pox. Case 3. Antoine S----, aged 20, contracted an indurated chancre upon the penis in April, 1858, which, after existing for some time, healed without treatment. He afterwards had a papular syphilitic eruption, sore throat, and excoriated patches upon the mucous membrane of the lips. 478 GENERAL SYPHILIS. He was examined by Rollet, Dec. 15, 1858, when he presented the fol- lowing symptoms : A large, cartilaginous, and pathognomonic induration, half of which was upon the glans penis, and half upon the prepuce towards the left side; well-marked multiple adenitis in the left groin; a mucous patch at the left commissure of the lips; traces of an eruption upon the legs and thighs. S. was a worker in a glass-foundry, where it is the custom among the men who blow the bottles to work by threes; the first blows the glass into a hollow globe, and passes the tube to the second, who modifies the form in some way, and he to the third, who finishes the bottle. S. was the first of a set who blew in the same tube. John J----, aged 21, the second of the same set, perceived, in Octo- ber, 1858, a hard lump, the size of a cherry-stone, on the anterior and right side of the lower lip, and a short time afterwards the sub-maxillary ganglia, especially on the right side, became engorged. At a later date, which the patient could not state with accuracy, an ulceration with a grayish floor appeared on the right tonsil and on the anterior wall of the palate. The patient was examined Dec. 10, 1858, when a reddish and indu- rated patch was found at the spot already mentioned upon the lip; there was multiple sub-maxillary adenitis; an ulceration upon the right tonsil; nothing whatever upon the genital organs. Flenry G----, aged 42, was the third of this set of glassblowers. He was examined Dec. 10, 1858, and presented several ulcerations, which he said had existed about a month. One was situated upon the mucous membrane of the lower lip near the median line ; its floor was reddish and raw, and partly covered with a blackish scab ; its edges irregularly cut; its diameter nearly half an inch. A second ulceration was seated upon the internal surface of the upper lip ; its floor grayish and pultaceous; its edges sharply cut; its depth less than the preceding. A third ulcer also occupied the upper lip; it was grayish, of small ex- tent, and would perhaps admit the head of a pin. On examining the mouth, a mucous patch was found between the uvula and the left posterior pillar of the palate ; the fauces were generally red, and the patient experienced difficulty in swallowing. The submaxillary ganglia were sensibly engorged, and also to a less degree those upon the side of the neck. G. has no lesions of the genital organs. He is married and the father of a family. His children are all well, but he states that he has communicated the disease to his wife, who, however, could not be examined. SYMPTOMS OF SYPHILIS CONTAGIOUS. 479 Case 4. M. X----, aged 25, of a good constitution, consulted Rollet in April, 1849, for an indurated chancre of the prepuce, which completely healed after three weeks' treatment. In the month of Aug., the patient presented symptoms of constitutional syphilis ; scabs upon the head, alopecia, engorgement of the sub-occipital ganglia, erythema of the fauces with superficial ulceration of the tonsils, mucous patches upon the sides of the tongue, a papular eruption upon the body and extremities, and mucous patches around the anus. Antisyphi- litic treatment was again administered, under which all the symptoms dis- appeared, with the exception of the mucous patches in the mouth, for which the patient refused to continue treatment. In September, 1850, Rollet was called to a family in which M. X. was quite intimate, and found a girl aged 18, who presented upon the lower lip a prominent patch, of a circular form, grayish at the centre, and ap- parently covered with a false membrane ; a similar but smaller patch was visible upon the corresponding part of the upper lip, and the sub-maxillary glands were engorged. The diagnosis was not at this time made out, although an ointment containing calomel was prescribed. Six weeks afterwards, the affection of the lips was nearly in the same condition, but other symptoms had supervened which left no doubt as to the nature of the disease. These were: mucous patches upon the sides of the tongue; erythematous inflammation of the fauces; a pustular eruption upon the scalp; lesions upon the vulva which her mother said resembled the mucous patches in the mouth. An antisyphilitic treatment was now commenced. As soon as Rollet recognized the syphilitic nature of the disease in the girl, he suspected M. X., whom he knew to be still affected with mucous patches of the mouth; and upon telling him his suspicions, he confessed that he had been in the habit of kissing her and had given her the disease in this manner. M. X. also stated that he had had sexual relations with another woman, whom he requested Rollet to visit lest he might have also infected her. Rollet did so, and found that she had an ulcer- ated patch upon the lower lip. She had recently become pregnant, and subsequently miscarried and exhibited unequivocal symptoms of consti- tutional syphilis. Case 5. One of the most esteemed druggists at Lyons, requested Rollet to visit Mrs. X., a woman of irreproachable charaoter, but in whom the druggist thought that he recognized symptoms of syphilis. The patient was 22 years old; of a lymphatic temperament; had been married three years, but had had no children. She was first seen by Rollet in April, 1857, in the presence of her mother. Three months before, this woman first perceived upon her lower lip an 480 GENERAL SYPHILIS. ulcer, which she supposed was a mere crack or fissure. It had gradually been enlarging, and the sub-maxillary ganglia had become indurated. About a month before, scabs had appeared upon the head, together with alopecia, sore throat, and a general eruption upon the body. When seen by Rollet, there was well-marked elastic induration of the lower lip; the sub-maxillary ganglia were swollen and slightly painful; the whole body was covered with a papulo-vesicular eruption. Erythe- matous inflammation of the fauces, pain in deglutition, engorgement of the sub-occipital ganglia, coryza and alopecia were also present. The genital organs were sound. There could be no doubt of the nature of the disease; but, before ex- pressing an opinion, Rollet requested the mother to retire, and then told his patient that she had syphilis, and asked her if she wished it to be kept secret. She did not hesitate a moment, but desired her-mother called in again, in whose presence the subject of the origin of the infection was dis- cussed. Neither the wife nor mother accused the husband, who was a man of very regular habits; and both expressed the wish that he should be present at the second examination. The husband was 35 years old, of a good constitution, and confessed that he had had syphilis at the age of 22, which had been perfectly cured at the Strasbourg Hospital. He had had no subsequent symptoms, and, upon examination, was found to be perfectly sound. Finding that the husband did not accuse the wife, nor the wife the husband, that there was no attempt whatever at concealment, and taking into consideration that the first symptom had been a chancre upon the lip, Rollet, after a long examination and inquiry, became convinced that his patient had derived her disease from her cook, who was found to have a copious eruption of mucous patches upon the fauces, a pustular eruption upon the scalp, alopecia, and other unequivocal syphilitic symp- toms ; and both she and her mistress were in the habit of tasting out of the same spoon the dishes prepared for the table. Rollet relates a number of other, and no less remarkable instances of the transmission of secondary syphilis between adults, all of which, considering the high standing of their author, are entitled to confidence. Fournier1 also gives the details of four cases, in which indurated chancres were undoubtedly produced by contagion from mucous patches or secondary ulcerations in adults affected with acquired syphilis. Dr. Samuel S. Purple, of New York, has also related to me several instances in which there could be no reasonable doubt that 1 De la Contagion Syphilitique, Paris, 1860, p. 77. SYMPTOMS OF SYPHILIS CONTAGIOUS. 481 syphilis was communicated by young men affected with mucous patches of the mouth to young women to whom they were engaged. But in spite of the immense amount of evidence in proof of the contagiousness of constitutional lesions (but a small portion of which has here been given), it may well be doubted whether this question could be regarded as satisfactorily and definitely settled, were it not for the recent investigations relative to the chancrous virus and the properties of the infecting chancre, which have removed all obstacles to the admission of this doctrine, and have thus furnished another beautiful instance in the history of science of the light thrown upon one subject by the study of another. So long as the two species of chancre were confounded, and the chan- croid was regarded as the chancre-type, it was impossible not to believe that a radical distinction existed between primary and secondary lesions, and that the former were inoculable and the latter not inoculable upon persons bearing them; and it was highly pro- bable, also, that as the properties of the one were known to be the same in respect to healthy individuals, those of the other were so also. But since the discovery that the infecting chancre alone pertains to true syphilis, and that it is not auto-inoculable, the same mode of reasoning, independently of direct proof, leads.to the conclusion that the properties of primary and secondary syphilitic lesions, in respect to contagion, are exactly the reverse in infected and healthy persons. The contagion of syphilis in its primary as well as secondary forms is now known to coincide with that of other infectious dis- eases, all of which are innocuous to persons already under their influence, but virulent to those who have never been affected by them; and while, in considering this subject, we cannot but be struck with the beautiful harmony of nature in disease, we may well feel humble at the thought that so plain a lesson from analogy should for so long a time have been disregarded. It is a remarkable fact, as noticed by Rollet, that artificial inocu- lation has frequently demonstrated the contagiousness of secondary, but seldom that of primary lesions. The number of successful inoculations of the former upon healthy individuals now amount to twelve or more, while those of the latter do not exceed three, and in two of these (the third of Gibert's inoculations and the second of Rinecker's already quoted), the authors supposed they 31 482 GENERAL SYPHILIS. were inoculating secondary lesions; the third was performed by Rollet. Repeated inoculations of the secretion of secondary symptoms upon persons afflicted with cancer have invariably failed, whence it has been supposed that an antagonism exists between the cancer- ous diathesis and syphilis. What Constitutional Symptoms are Contagious?—By far the larger number of successful inoculations of general symptoms have been performed with matter taken from mucous patches, condylomata, or superficial ulcerations of mucous membranes, all of which lesions may be regarded as essentially the same or nearly identical; and, so far as I have been able to ascertain, all cases of contagion from constitutional symptoms which have been observed in practice have been produced by matter from the same class of sores. In Rinecker's first case, the matter was derived from syphilitic acne, and Vidal has inoculated with success the contents of the pustules of ecthyma. Blood was used in one of Waller's cases. The same fluid was employed in nine inoculations by the anony- mous surgeon of the Palatinate, three of which were successful; and it is almost certain, I think, that this was also the active agent in Gibert's fourth case. The great frequency of mucous patches upon those parts of the body (the vulva in women, and the mouth in both sexes, especially in infants), which are most exposed to contact with other persons, explains why such lesions should be the most common source of contagion among constitutional manifestations. The artificial inocu- lations of Vidal and Rinecker prove that pustular syphilitic erup- tions are also contagious; and it is highly probable that the same property is possessed by all constitutional symptoms which are attended by a serous or purulent secretion, but it is difficult to believe that any of the dry forms of the disease, without the pre- sence of fluid capable of absorption, are communicable. The contagiousness of the blood of syphilitic persons—if merely, as is probable, in a slight degree only—is a fact of great importance, which is sustained by a large amount of evidence drawn from the communicability of other contagious diseases by means of the circulating fluid,1 and demonstrated by the five cases of successful ' A resume" of this evidence may he found in an admirable paper by Dr. Viennois on the Transmission of Syphilis by Vaccination, published in the Arch. Gen. de Med. for June, 1860. WHAT CONSTITUTIONAL SYMPTOMS CONTAGIOUS. 483 inoculation already referred to. It is, indeed, true that repeated attempts by other surgeons to inoculate this fluid have failed; for instance, eighteen inoculations performed by Diday (16 in June, 1848, and 2 in September, 1849) were all unsuccessful; but in a matter of this kind a few well conducted cases of success are of greater weight than many failures. Waller's inoculation was performed upon a boy aged 15, who had never had syphilis. From three to four drachms of blood were taken from a patient affected with secondary syphilis, and applied to the cuts produced by the application of a scarificator. At the end of three days, the wounds had entirely healed, but, thirty-four days after the inoculation, two distinct tubercles appeared, which finally coalesced and ulcerated. Sixty-five days after the inoculation, and thirty-two days after the appearance of the tubercles, a well-marked syphilitic roseola was developed upon the abdomen, back, chest, and thighs. The whole body became covered with the eruption, and some of the blotches upon the thighs were transformed into papulae. The diagnosis was con- firmed by a number of competent physicians who saw the case. In the experimental inoculations of the blood by the surgeon of the Palatinate, it is stated that those only succeeded in which the fluid was applied to an extensive absorbing surface, which was made raw by friction.1 Dr. Viennois has adduced satisfactory evidence to show that many instances of the transmission of syphilis by vaccination are due to the lancet having been charged with blood taken from syphilitic persons. No opportunity will be more convenient than the present to state the following results at which this author has arrived from his thorough and exhaustive researches relative to the connection between vaccination and the transmission of syphi- lis ; and I regret that my space will not permit a fuller notice of his investigations, for which I must refer the reader to the original paper in the Archives Gendrales de Me'decine for June, 1860. 1. Vaccination with pure vaccine matter is sometimes the ex- citing cause of the appearance of a syphilitic eruption in infants already under the syphilitic diathesis; in the same manner that it gives rise to non-specific eruptions in strumous subjects. The history of the case and the order of evolution of the symptoms 1 Revue Critique, par le Dr. Lasegue, Arch. Gen. de Med., May, 1858, p. 604. 484 GENERAL SYPHILIS. are generally sufficient to establish the diagnosis. For instance, the appearance of the eruption within a few days or weeks after the vaccination, without the ordinary period of incubation of syphi- lis, will render it probable that the disease was already latent in the system. 2. Syphilis cannot be transmitted to a healthy person by the inoculation of vaccine matter taken from a syphilitic subject, unless the lancet at the same time be charged with blood; in which case an infecting chancre is produced followed by general symptoms in their usual order of evolution. Two of the most remarkable instances of the transmission of syphilis by vaccination are those reported by M. Lecoq1:— Case 1. May 4, 1858. P., aged 25 years, was revaccinated in accord- ance with the regulations of the marine service to which he belonged; three punctures were made upon each arm. The vaccine virus was de- rived from healthy-looking pustules upon the arm of another soldier, who, it was afterwards learned, had had an indurated chancre upon the penis three months before. Eight days after P.'s vaccination, it was found that the pustules had aborted; one of them, however, became inflamed a short time after and took on ulceration, which gradually assumed the characters of an indurated chancre; its base was hard to the touch, and a number of indurated ganglia were felt in the corresponding axilla. Subsequently a syphilitic eruption appeared, and other constitutional manifestations. Case 2. D., aged 25, was also revaccinated on the same day and with matter from the same source. The result was similar to that de- scribed in the preceding case, viz., failure of the vaccination ; ulceration of one of the punctures, which spread, became indurated, and was attended by multiple engorgement of the axillary ganglia; at a later period, con- firmed constitutional syphilis. In a letter to M. Viennois, M. Lecoq gives the following additional details relative to these cases: "The matter was taken from perfect vaccine pustules, which had been normally developed, upon the arm of a soldier who, though we were ignorant of it at the time, had had an indu- rated chancre upon the penis three months before, for which he was treated for two months at the hospital. He had not the slightest trace of syphilitic symptoms at the time the matter was taken from his arm. " The lancet employed in the operation was new; had never been used 1 Guyenot, These de Paris, 1859. See also Gazette Hebdomadaire, 27 Janv. 1860. WHAT CONSTITUTIONAL SYMPTOMS CONTAGIOUS. 485 for the purpose before, and cannot be supposed to have been in any way at fault. " Several soldiers were vaccinated on the same day, with the same matter, and by the same person; and in only two did any unpleasant results occur. "The two soldiers, in whom syphilitic symptoms supervened, had never had any venereal disease, and were remarkably healthy. Every induce- ment was offered to make them confess that they had been exposed by impure coitus, but without effect; they persisted in their denial, and no cicatrix could be found upon the genital organs." (In another letter M. Lecoq states that these two men were the last of those who were vacci- nated that day; and that he recollects that the pustule being nearly ex- hausted of lymph, a little blood was drawn by the lancet.) " The development of the vaccine pustules in these two men was care- fully watched, and, after the fourth day, was found to be quite irregular. The pustule was not umbilicated as usual, and was soon covered with a thick scab, beneath which there was an ulceration, which was at first small, but which rapidly increased in size and in depth; so that in a few days it involved the whole thickness of the derma, and equalled in size a two-franc piece. Its edges were irregular and abrupt; its surface very painful; it bled readily, and during the night became covered with a scab, beneath which sanious pus was imprisoned ; its edges were very decidedly indurated and the axillary yanglia engorged. These ulcers did not heal for two months, and required to be cauterized several times. The cica- trices were swollen, a little painful, and indurated, and prone to ulcerate if rudely handled; they did not become firm until after anti-syphilitic treat- ment. Three punctures were made upon each arm, but only one in each patient followed the above course. " About Bix months after vaccination, eruptions appeared, which, to our great surprise, were decidedly syphilitic. " One of the men had a persistent roseola, pustules of acne upon the back and arms, pustules of impetigo upon the scalp, engorgement of the cervical ganglia; and, at a later period, copper-colored patches of pso- riasis upon the back and arms. "The other had impetiginous scabs upon the head, engorgement of the cervical ganglia, and mucous patches upon the scrotum and internal por- tions of the thighs, and, later, around the anus. "The symptoms in both patients disappeared under the administration of the bichloride of mercury and iodide of potassium." Numerous instances of a similar character, in some of which the disease spread to a large number of persons, have been collected by M. Viennois, and are sufficient to show that although vaccination 486 GENERAL SYPHILIS. is commonly a harmless operation, yet that it may, if proper pre- cautions be omitted, be the means of transmitting a fearful consti- tutional disease. Admitting the contagiousness of the blood of syphilitic persons, we might from d priori reasoning suppose that the various fluids which are secreted from the blood, as the saliva, milk, sweat, and semen, are also contagious, and this was the belief of the earlier writers on syphilis. At the present day, however, we find but few advocates of the contagiousness of any of the secretions mentioned except the milk and semen, and the latter alone will at present occupy our attention. It is an established fact that the seminal fluid of a syphilitic father may infect an ovum in the womb of a healthy mother, who may herself be contaminated through the foetal circulation; but the question at issue is whether a woman, without becoming pregnant, may contract syphilis by cohabitation with a man affected with the syphilitic diathesis, but who at the time presents no syphilitic lesion; in other words, whether the semen possesses the same contagious properties that are known to exist in the secretions of primary and secondary lesions, and in the blood. Now the supposition that this is possible is not at all unreasonable, but it is an axiom in the study of the natural sciences that nothing should be admitted as true which is not susceptible of demonstration, or which is not supported by the strongest analogy, and if we receive as a fact that which is merely not improbable we at once open the door to error; more- over, now that the contagiousness of syphilis is known not to be con- fined to primary sores, we must carefully guard against the reactive tendency which will probably follow to extend its limits beyond the bounds of truth. It should be required of all cases adduced for the purpose of proving the contagiousness of the semen, that the fact should be well established that the man had no syphilitic lesion at the time of intercourse; that the woman was not otherwise exposed, and did not become pregnant; and that the evolution of her syphilitic symptoms coincided with that which invariably follows contagion from other sources; hence that a primary sore appeared at the point where the virus entered the system, and that general symp- toms ensued in their usual order, and after their usual period of incubation, as after the transmission of the disease by the secretion of a primary or secondary symptom, or by the blood; and I do not WHAT CONSTITUTIONAL SYMPTOMS CONTAGIOUS. 487 hesitate to say that these conditions have never been fulfilled in a single instance. One of the ablest advocates of the contagiousness of the sperm is Dr. W. H. Porter, of Dublin, the author of a series of Essays on the Natural History of Syphilis,1 which have deservedly attracted much attention. While entertaining the highest respect for the opinion of this writer, I feel obliged to dissent from his views upon this subject. The cases which he reports appear to me to be unre- liable, because based upon the statements of patients alone, and not upon accurate observation; in some of them, it is by no means cer- tain that the disease was not communicated through impregnation or otherwise, and it is assumed in all that no primary sore existed, a fact not material to the question, in the opinion of Dr. Porter, who says: " Often, in discussions on this subject, I have been met by an inquiry whether the woman spoken of had been examined by the speculum, and if it was not quite possible that chancres might have existed deep in the recesses of the vagina or the uterus. / never did make such examination, nor will one ever be made under similar circumstances, because there is no symptom to attract atten- tion in that direction; but if a chancre did so exist, it must either have been the product of illicit intercourse, or communicated by a husband, who had no ulcer on himself, and, consequently, no pus in which the poison could be conveyed. It is of no consequence whether there was a chancre or not, for its existence or non-existence forms no part of the case sought to be established, which has refer- ence to the poisoning powers of the seminal fluid." I have taken the liberty of putting in italics those portions of this quotation to which I would especially call the reader's attention, and which I think support the conclusion above expressed with regard to the slight value of Dr. Porter's cases. While admitting that he never examined the genital organs of a woman under these circumstances, I am at a loss to understand how Dr. Porter can lay down the pro- position, as an established law of syphilis, " that the semen of a diseased man deposited in the vagina of a healthy woman will, by being absorbed, and without the intervention of pregnancy, contami- nate that woman with the secondary form of the disease, and that without the presence of a chancre, or any open sore, either on the man or the woman;" and to establish this proposition, so contrary 1 Dublin Quart. Jdurn. of Med. Sci., May, 1857. 488 GENERAL SYPHILIS. to all that is known of the contagion of syphilis, would require a large amount of unquestionable evidence, in which there should be no possibility of the disease originating through impregnation, or " illicit intercourse." It is highly improbable that the transmission of syphilis, by means of the semen in the absence of pregnancy, if possible at all, should follow laws differing widely from those which govern contagion arising from other sources. Syphilis pursues essentially the same course, whether derived from a primary or secondary symptom; in the lat- ter case, as in the former, the initial lesion is a chancre.— At a discussion before the Societe Medicale du Pantheon, of Paris, in 1856, relative to the contagiousness of secondary symptoms, Dr. Edward Langlebert stated his suspicions, founded upon two cases of secondary contagion which had come under his observation, that the initial lesion was a chancre.1 This idea, at first advanced with- out any adequate proof, excited but little attention, until, in 1858, it was taken up anew by a distinguished surgeon of Lyons, M. Rollet, who subjected it to the test of comparison with a large number of cases of secondary contagion which were to be found in medical literature, adduced additional facts from his own experience in its favor, and, in short, was able to sustain it by such an amount of evidence, that there could remain but little doubt of its truth. Judging from my own impressions, upon first reading Rollet's con- clusions, which were published in the Archives Generates de Mede- cine, for February, March, and April, 1859, they will appear to one who has never heard of them before as novel and ingenious, but not entirely satisfactory; but they certainly grow in favor the more they are thought of; and, above all, the more closely they are com- pared with those cases of secondary contagion which have been published without any preconceived notions as to the phenomena which would ensue, the more reasonable and reliable do they ap- pear. I would recommend the reader to peruse again the cases of transmission of syphilis from secondary lesions and the blood, which have been quoted in the present chapter, at the same time bearing in mind the evolution of the disease when following contagion from a primary sore, and he cannot fail to observe the great simi- ' Proceedings of the above society for 1856, p. 8. See also a letter from M Langlebert to M. Diday, Gaz. Med. de Lyon, July 1, 1859. SECONDARY CONTAGION PRODUCES A CHANCRE. 489 larity between them; in fact, so slight is the difference as to con- stitute no serious objection to the doctrine of MM. Langlebert and Rollet. It may be remarked at the outset that this doctrine is supported by analogy. All other contagious diseases follow the same course, whether the disease from which they were contracted was, at the time of contagion, in its commencement or near its termination. If one person communicate variola, scarlet fever, or measles to an- other, the symptoms in the latter do not exhibit any variation in consequence of the early or late stage of the affection existing in the former at the period of communication. A slight difference in the time occupied by the vaccine pustule in reaching maturity in vaccinations with the fresh lymph and those with the dry scab has been noticed, but no variation in the symptoms has ever been detected. Hence we may reasonably suppose that syphilis will also pursue the same course, whether derived from a primary or second- ary lesion; but, after all, this is a question which must be decided by an appeal to facts. In submitting this doctrine to the test of experience, I propose to compare in general the phenomena following contagion from each of these two sources, but to pay particular attention to the initial lesions, with regard to which there is most likely to be a diversity of opinion. It will be well, therefore, in the first place to inquire what constitutes a chancre. I have elsewhere defined a chancre "the initiatory lesion of ac- quired syphilis, arising at the point where the virus enters the sys- tem, and separated from the general manifestations of constitutional infection by a period of incubation." The essentials of a chancre, then, as I understand them, are, a sore developed at the point of contagion as the earliest symptom of acquired syphilis, the appear- ance of which is followed by a period of latency as regards the virus, and subsequently by general syphilis. We shall presently see that if this definition be received as correct, there can be no hesitation in admitting that the initial lesion of syphilis from second- ary contagion is a chancre. But there are minor conditions which enter into our ideas of a true infecting chancre (as at present understood), and which are as follows: a period of incubation between contagion and the appear- ance of the primary sore; ulceration varying in extent and depth, and which may involve only the epidermis or epithelium; and, in 490 GENERAL SYPHILIS. the great majority of cases, induration of the base of the sore and of the neighboring lymphatic ganglia. It is only with respect to a few of these points that any doubt is admissible as to the identity of the chancre following primary and that produced by secondary contagion. With these preliminary remarks I proceed to a comparison of the phenomena in the two cases. 1. The earliest symptom following secondary (as in cases of primary) contagion is a sore developed'at the point where the virus enters the sys- tem.—Artificial inoculations, to which we can alone refer for the establishment of this fact, prove it to be true without exception. 2. This sore is preceded by a period of incubation, like the ordinary infecting chancre.—In all cases of artificial inoculation of secondary symptoms and of the blood, the inoculated point has remained qui- escent for a number of days before the appearance of the initial lesion. In twelve cases collected by Eollet, this period was 29, 27, 35, 9, 33, 27, 15, 42, 28, 17, 25, and 34 days respectively, which give a minimum of 9 days, a maximum of 42 days, and a mean of 26 days.1 This average is somewhat greater than that of the pri- mary infecting chancre, as deduced from clinical experience ;2 but if, as Rollet claims ought to be done, we compare artificial inocula- tions with artificial inoculations, we find that the difference is very small. Thus, in Einecker's inoculation of an infecting chancre, the interval was 25 days; in Gibert's, 24 days; and in Rollet's, 18 days; making an average of 22 days. 3. It is generally a papule, which in most cases becomes ulcerated and indurated, and is attended by engorgement of the neighboring lymphatic ganglia, and hence closely resembles a frequent form of the ordinary infecting chancre.—I must recall to the mind of the reader the fact that the chancre-type, as formerly received, originating in a pustule and consisting of an excavated ulcer with sharply-cut edges, is now known to belong to the chancroid; and that, as proved by the observations of Bassereau and others, the infecting chancre is most frequently a superficial • erosion, not extending beyond the epidermis or epithelium, and which, in many cases, becomes papu- lar, and is elevated above the surrounding surface; in a small proportion of cases only does it involve the whole thickness of the integument or mucous membrane. In nearly all the reported cases of syphilis following the inocu- 1 Gaz. Med. de Lyon, Dec. 16, 1859, p. 567. ' See p. 370. SECONDARY CONTAGION PRODUCES A CHANCRE. 491 lation of a secondary symptom, the initial lesion is said to have been a papule, which was gradually developed into a tubercle, and (sometimes after an interval of several days) took on superficial ulceration, which, if not explicitly mentioned, is indicated by the description of such a scab as could only be formed by the desicca- tion of lymph or pus. In one instance only—Gibert's fourth inocu- lation—do we find that there was no abrasion of the surface during the whole duration of the papule. Diday also refers to a case of secondary contagion from an infant to a nurse, in which a papular elevation upon the breast, which was followed by general syphilis, did not at any time ulcerate in the slightest degree.1 In the two cases of contagion from inoculation of the blood in performing vaccination, reported by M. Lecoq, the initial lesions were excavated ulcers, presenting exactly the same appearances as the so-called Hunterian chancre. Induration of the base of the sore and engorgement of the neigh- boring lymphatic ganglia, those two important symptoms of an infecting chancre, have been found in most of the initial lesions of syphilis from secondary symptoms, whether the result of artificial inoculation or infection by contact. Invariable constancy could not be expected, when they are transitory or absent even in some cases of primary sore. It should also be remembered that most artificial inoculations have been performed without any suspicion that a primary sore would be developed, and generally by persons who attached but little importance to induration, and who may therefore have overlooked it in cases in which it is not noted. If aware of its importance they would have distinctly mentioned its absence. Wallace's and Waller's cases are somewhat imperfectly reported, and yet we find induration of the initial lesion spoken of in two of the three cases pertaining to the former, and in one of the two cases of the latter. Each of these symptoms was present in Einecker's, and in both of Lecoq's cases. Of Gibert's three inoculations of secondary lesions and of the blood, the initial sore was indurated in two, and in the third, the patient was absent from observation at the usual time for its development; the neighboring ganglia were engorged in all. I have not been able to refer to a full account of the cases reported by the surgeon of the Palatinate. The testimony of those cases of secondary contagion not artifi- cially inoculated, which have been observed in practice, is still 1 Traite" de la Syphilis des Nouveau-n6s, Paris, 1854, p. 295. 492 GENERAL SYPHILIS. more conclusive. In those occurring in adults, recorded by Eollet and Fournier, induration of the base of the sore (with one excep- tion) and engorgement of the ganglia were present in all, and as fully developed as in the most perfect infecting chancre. Indura- tion of the axillary ganglia in nurses infected by syphilitic infants attracted attention many years ago. Diday says: "Nothing is more common than to see engorgement of the glands of the axilla in women contaminated through the medium of the breast. Mahon1 observed this fact, and laid it down as a general rule, which has proved true in the majority of cases which have come under my observation."2 The same fact is noticed by Bosquillon3 and other writers on infantile syphilis. 4. The period of incubation of general symptoms is nearly the same whether the disease be derived from a primary or secondary lesion.— In the twelve cases collected by Eollet, this second incubation of the virus was 37, 26, 92, 42, 31, 128, 26, 107, 48, 37, 12, and 38 days respectively; making an average of 52 days, which will be reduced to 45 days, if the case be omitted in which the interval be- tween the appearance of the chancre and that of general symptoms was 128 days, and in which mercury was administered. It will be recollected that Diday's accurate investigations relative to the dura- tion of the same period after contagion from a primary sore give a mean of 46 days—a correspondence with the average duration after contagion from a secondary lesion, which is truly remarkable. 5. The earliest general symptoms are of the same character after contagion from a secondary as from a primary lesion.—The truth of this proposition is evident upon examination of the cases which I have quoted, and in which the earliest general symptoms have been mucous patches, an erythematous or papular eruption, acne 1 Histoire de la MeVlecine Clinique, suivie d'un MSmoire sur la Nature et la Communication des Maladies Veneriennes des Femmes enceintes, des Enfants et des Nourrices. Paris, 1804, p. 440. 2 Traite de la Syphilis des Nouveau-nes, p. 293. Diday proceeds to say that this engorgement by no means proves that the lesion upon which it depends is a pri- mary chancre. This was written, however, before Rollet's doctrine was known, and Diday has since modified his opinion, as appears from the following quotation of his words in a recent discussion before the Imperial Society of Medicine of Lyons, Feb. 20, 1860 : "Quel est done la nature de cet accident initial ? C'est un chancre, je Vadmets; mais un chancre a caracteres effaces, mitigSs, attenuGs." (Gaz. Med. de Lyon, No. 8, 1860, p. 209.) 3 French translation of Bell on Venereal, vol. ii. p. 620, as quoted by Fournier. SECONDARY CONTAGION PRODDCES A CHANCRE. 493 capitis, alopecia, post-cervical engorgement, etc., as after contagion from a primary sore. In reviewing the above comparison we find a general correspond- ence between the phenomena following contagion from primary and from secondary symptoms. In the latter the period of incuba- tion preceding the appearance of the initial lesion is perhaps longer than in the former, but our statistics are yet too meagre to render it absolutely certain, and a difference in this respect cannot at any rate be considered of much importance. The greatest difficulty lies in reconciling the aspect of the initial sores in the two cases; for even with the modification of our views as to the characteristics of the chancre-type brought about by modern investigations, it must be confessed that the earliest lesion following secondary contagion differs in some respects from that which appears after primary; it is more frequently papular, is generally slow in taking on ulceration, and, in a few instances—if the statements of observers can be implicitly believed—is not moistened by the slightest secretion during its whole existence. But are these points of difference sufficient to induce us to make a distinction between syphilis derived from a primary and that from a secondary symptom, and to deny that the first effect of the virus is in both a chancre? I think not. The main features of the initial lesions in the two cases are the same; the slight varia- tion may be accounted for by the seat selected for the artificial inoculations, which has always been either the arm or thigh ; and, as I have already stated in the present work, I believe that our ideas of the objective symptoms of a chancre have been by far too limited, and that it is unreasonable to expect invariable uniformity in its aspect. The ulcerated and indurated papule, attended by engorgement of the neighboring ganglia, which appears after inoculating the secretion of a constitutional manifestation of syphi- lis, cannot be ranked among secondary symptoms from which it is separated by a period of incubation; it is evident that it can only be called primary, and I believe, with Langlebert, Eollet (whose line of argument has for the most part been followed in the present section), and Fournier, that it is fully entitled to the name of chancre. Eicord has as yet failed to express himself upon this subject, but the opinion of his pupil, M. Fournier, who is associated with him in the publication of his Lecons sur le Chancre, may be taken as an indication that he regards this new doctrine with favor, even if he does not yield it his full sanction. 494 TREATMENT OF SYPHILIS. CHAPTER V. TREATMENT OF SYPHILIS. The opinion very generally prevails, that syphilis is a disease which, if left to itself, will always go on from bad to worse, attack in its progress the deeper and more important organs, and probably terminate in death. The correctness of this opinion, at least so far as concerns its invariability, may well be called in question, since syphilitic patients are rarely, if ever, allowed to go without treat- ment, and consequently little opportunity is afforded for observing the natural progress of the disease; and we cannot logically infer, because certain cases, in spite of remedies, pursue a disastrous course, that the same would have been true of others, which have terminated favorably, if the treatment had been less thorough, or had been altogether omitted. It would be more reasonable, though less flattering to ourselves, to conclude that as art has been com- paratively impotent in the former, it can claim for itself but a por- tion of the credit in the latter. I have had no unusual facilities for observing the natural course of syphilis, but several circumstances have led me to believe that, in many instances, under favorable circumstances, this disease tends to self-limitation. I have been struck with the fact that some pa- tients, who either through neglect or ignorance fail to pursue any continued course of treatment, still live in comparative comfort, and, after several attacks of general symptoms, extended through a number of years, are finally free from farther annoyance; the dis- ease probably remaining dormant in the system, but ceasing to betray itself by any external manifestation. But still stronger evidence of a tendency to self-limitation is found in many cases°in which treatment is faithfully pursued, and in which the disease, under the best management on the part of the surgeon, and the utmost obedience of orders by the patient, repeatedly recurs for a time, and yet ultimately disappears, without our being able to TREATMENT OF SYPHILIS. 495 attribute this happy termination to the accumulated effect or pro- longed use of remedies, which have failed to afibrd permanent relief in the earlier attacks. I have so often found this to be the case, that I do not hesitate to assure patients when discouraged by the reappearance of symptoms which they supposed were cured, that the tendency to relapse will probably cease after a time, and leave them in the enjoyment of a fair state of health; although never, after treatment however prolonged, do I promise certain immunity for the future. I can recall to mind quite a number of patients whom I treated for constitutional syphilis eight or ten years ago, and whose disease repeatedly returned, and was appar- ently uncontrollable by medicine for a period of from one to three years, but who have since been exempt from farther trouble, and some of whom have married, and become the fathers of healthy children; and I cannot honestly ascribe their present immunity wholly to the remedies employed, but in a measure to the fact that the activity of the disease has been exhausted.1 This belief in a tendency to self-limitation—or, as it may be called, spontaneous quiescence—of syphilis, derived from my own experience, coincides very nearly with that of Diday, which has but recently fallen under my notice. This surgeon's mode of prac- tice has afforded him a most excellent opportunity for deciding this point, since, in the great majority of syphilitic cases, he with- holds all treatment, unless compelled to its resort by the urgency of the symptoms. As the results of his'experience since adopting this course, Diday remarks, in the first place, that he has been struck with the regular evolution and succession of syphilitic phenomena, and afterwards goes on to say that, in most cases, the disease never passes beyond the secondary stage; that, after several successive attacks—as, for instance, of mucous patches, exanthematous or papular eruptions, etc.—the symptoms diminish in intensity; the virus appears to be eliminated by the natural powers of the system; the tendency to fresh manifestations disap- pears, and a permanent and spontaneous cure is obtained. In a t few persons, on the contrary, he has found the disease become more serious and more deeply rooted by time; hence, he admits two classes of cases, in one of which syphilis naturally decreases, and 1 " That all the constitutional forms of syphilitic affections, if left to the unaided powers of nature, have a constant tendency to wear themselves out, I am fully convinced." (Egan, Syphilitic Diseases, p. 245.) 496 TREATMENT OF SYPHILIS. in the other increases in intensity; in the former, he resorts to hygienic measures alone; in the latter, he employs specifics, but not to the neglect of hygiene.1 I do not propose, however, to recommend such an expectant course of treatment for syphilis, for we have as yet too little evi- dence of its safety. He would be a bold man who should attempt it out of France, in opposition to the opinion of the whole profes- sion throughout the world with a few rare exceptions. Moreover, even admitting that syphilis will often cease spontaneously with the lapse of time, I firmly believe that it should receive active treat- ment, both for the good of the patient and the safety of society; for the former, that he may escape injury to important organs, and avoid the ignominy which would result from his misdeeds being betrayed to the world; for the latter, that the sources of contagion may be dried up, and the extension of the disease prevented. At the same time, if the idea which I have advanced with regard to the spontaneous quiescence of syphilis in many cases, be correct, it is not without a practical application of such importance, that I have desired to give it a prominent position at the commencement of this chapter upon treatment, where it has not been out of place to consider what the natural termination of the disease would be without the intervention of art. Experience has long since shown that specific remedies, in order to be of any avail, must not be pushed to the detriment of the general health or be administered at all when the system is greatly depressed, otherwise the disease will acquire a firmer hold, and the patient's condition be rendered worse instead of better; yet in spite of this lesson, in undertaking the treatment of a case, the surgeon finds it a difficult matter to refrain from administering mercurials, provided he believes that these alone are capable of eradicating the disease; but if convinced that nature is not alto- gether powerless to eliminate the virus, he can wait patiently until the general health has been improved, satisfied that any delay which will give the vital powers a better chance to act, will not be time wasted. Again, who has not been disappointed and chagrined at. the return of syphilitic symptoms after the most thorough course of treatment? But may it not be that nature is still carrying on the work of cure, which will be brought to a happy conclusion at 1 Nouvelles Doctrines sur la Syphilis, p. 302 et seq. HYGIENE. 497 a time which art can no more hasten than it can arrest the progress of an eruption of variola or scarlatina? In short, I am not willing to acknowledge, especially with the evidence existing to the contrary, that the vital powers afford a certain amount of protection against all other known diseases, but are impotent against the ravages of syphilis; and a proper appreciation of these views will not render the surgeon inactive, but will, by holding out a better hope of suc- cess, induce increased efforts. The treatment of early general symptoms and of the infecting chancre is the same. The latter as well as the former, according to the views which have been advocated in this work, is an effect of the contamination of the blood by the syphilitic virus, although in the mysterious order of nature the two are separated by an interval of time which justifies the distinctive appellations of primary and secondary. So soon, therefore, as an infecting chancre can be recognized by the induration of its base and the engorgement of the neighboring lymphatic ganglia, the syphilitic diathesis is to be regarded as already established, and appropriate remedies are to be employed for as long a time and with as much care, as if secondary manifestations had appeared. Hygiene.—The successful management of any case of constitu- tional syphilis undoubtedly depends in a great measure upon attention to hygiene. The most careful administration of specific remedies will be of little avail, unless the patient be willing to submit to the necessary restrictions with regard to diet, exercise, exposure, etc. Many syphilitic patients who enter our hospitals begin to improve at once, simply from the fact that they are brought under better hygienic influences, and are obliged to lead a regular course of life and abstain from excesses which have hitherto de- pressed the vital powers and thwarted all attempts of nature or of art to eliminate the virus from the system. Yet, admitting the full force of this truth, it is impossible to give minute directions which will be applicable to all cases, when the circumstances in which different persons are placed are so various, and where so much must necessarily be left to the judgment of the surgeon. Supposing the daily life of a patient to be completely under our control, and that his general health is in a good condition, our directions will be somewhat as follows: "You must for a time make it your chief business to get rid of your disease. All other objects 32 498 TREATMENT OF SYPHILIS. which conflict with this are to be laid aside. The more exclusively you devote yourself to this purpose the better will be your chances of regaining and retaining your health. Your habits must in all respects be systematic and regular, especially as regards your meals, sleep, and exercise. Excesses of all kinds must be scrupulously avoided. You are not to indulge in stimulants, tobacco, or coitus. Your food is to be of the very simplest kind, consisting only of stale bread or toast, and other farinaceous articles, with a small quantity of butter; water, milk, or weak black tea for your only drink; fresh meat or fish, sparingly, once a day; boiled potatoes, and a moderate amount of fruit in its season; and you are to leave the table as soon as you feel that your appetite is satisfied. Take daily exercise out of doors, but do not carry it to fatigue. Guard against sudden changes of temperature, the extremes of heat and cold, wet, and exposure to a damp, chilly atmosphere. Let your room be well ventilated. Wear flannel next your skin, and change it frequently. Take a hot bath two or three times a week at night before going to bed. See that your bowels are open every day. Employ your mind in reading, or seek the society of a few friends who will not interfere in any way with your carrying out these directions; and let your thoughts dwell as little as possible upon your disease." It is evident that the calls of business will often interfere with the full execution of this programme, but the cases are rare in which it cannot be carried out in its more important details; and if this can be done, there is no objection but rather an advantage in occupying a portion of the day in some quiet employment which will divert the patient's thoughts from himself and his disease. We must remember, however, that increased activity of life demands a greater supply of nourishment, and a more liberal diet than the one proposed will often be required especially for laboring men. If at any time while pursuing this regimen the patient's strength appears to flag, and he becomes debilitated and loses his appetite, greater freedom must be allowed him, and such changes be made in his diet as will readily suggest themselves to the surgeon; since although it is desirable to keep the general condition a little below the full standard of health, anything like depression of the system must be carefully avoided. Attention to hygienic measures, similar to those here recom- HYGIENE. 499 mended, has been recognized as of great importance by nearly every surgeon who has written upon the treatment of syphilis, and plays an important part in certain methods for which rules have been laid down with mathematical exactness; as in the so-called hunger, and the mercurial cure, the treatment by Zittman's decoc- tion, and the dry treatment of the Arabians.1 It is not desirable, however, to adopt any invariable routine, in which the varying condition of the system in different cases shall be ignored, and the exercise of the judgment be set aside; and which shall render the duties of surgeon and patient almost automatic. No such labor- saving system can succeed in the treatment of syphilis. Each individual case is a problem by itself the conditions of which are ever changing, and requiring the constant exercise of watchfulness and judgment. The essential features of the hygienic plan here proposed, and which I have long adopted in my own practice, are general regu- larity of life, simple diet, abstinence from stimulants, and attention to the functions of the skin and bowels; and these may be carried out to advantage even in case the patient be debilitated by dissipa- tion, long continuance of the disease, or other causes. This is a point which I desire to have distinctly understood, since nothing could be farther from my thoughts than the idea that it is ever necessary or desirable to depress the system in order to effect a cure of syphilis. On the contrary, the general health, whenever below the normal standard, should be raised by every means in our power which will give it a real and not fictitious improvement; and it is often necessary to administer the vegetable tonics, qui- nine, iron, or cod-liver oil, at the same time with specific remedies, and sometimes entirely to omit the latter until the system has been brought into a proper condition to bear them. Even with those who have been long addicted to intemperance, the means indicated will usually be sufficient to supply the place of their daily pota- 1 The dry treatment of the Arabians, as communicated by an Arab physician who visited Marseilles, is described by M. Benoit, who has tried it with very satisfactory results, as have also Lallemand, Broussonnet, L. Boyer, Tribes, Jaumes, and Malinowski. The patient is directed to abstain from his usual articles of food; lives on biscuit, dried almonds, figs, and raisins; takes for his only drink in the twenty-four hours a glass or two of a decoction of sarsaparilla ; and a mercurial pill morning and evening. Gaz. Hebdomadaire, May 4, I860, from the Montpellier Medical, 1860, Nos. 1 and 2. 500 TREATMENT OF SYPHILIS. tions, though in rare instances it is necessary to allow a small quantity of wine, ale, or brandy to be taken with the meals. It is an interesting fact that important truths are sometimes arrived at by the simple observation of men entirely destitute of medical knowledge. The "sporting papers of the day," prior to the recent trial of strength and skill between the "Champion of England" and the "Champion of America," recorded the fact that the latter was afflicted with " a constitutional disease of the worst type," which was no other than syphilis, and which was kept down by generous living, but was always developed by the hardships incident to training for the prize-ring. The chief remedies employed in the treatment of syphilis are mercurials, and iodine and its compounds. The former exert their therapeutic action mainly upon secondary and the latter upon ter- tiary symptoms, so that the susceptibility of a given lesion to one or the other will indicate to which stage of syphilis it belongs. This rule, however, is not so invariable as the above statement would make it appear, and requires explanation. There is no distinct line of demarcation in respect to treatment between secondary and tertiary lesions, but a gradual transition from one to the other. By far the most powerful agent in the treatment of. the indurated chancre and the earlier general symp- toms is mercury; as the disease progresses, iodine gradually begins to exercise a therapeutic influence; those symptoms which border upon the boundary line between secondary and tertiary manifesta- tions, and which constitute the stage of transition—so-called by Eicord—require a combination of mercury and iodine; finally ter- tiary symptoms yield with great facility to iodine and with difficulty to mercury, though it is very doubtful whether the former agent without the assistance of the latter, can effect their permanent re- moval. Mercurials.—Mercury came into general use in the treatment of syphilis within fifty years after the appearance of the Italian epi- demic,1 and, in spite of the many attempts which have been made to supplant it by other remedies, still holds its ground as the only reliable agent for combating secondary lesions. At the present 1 Hjesek (Historisch-Pathologische Untersuchungen, vol. i. p. 230), according to Vikchow, quotes a satirical poem composed by Georgius Summaripa, of Verona, in 1496, in which the use of mercury in syphilis is mentioned. MERCURIALS. 501 day its efficacy is admitted both by regular and irregular practi- tioners, though the latter generally administer it furtively and under the guise of some other name. It is the active ingredient of most of the "life-balsams" and "essences of sarsaparilla," the marvellous virtues of which for the cure of "private diseases" are proclaimed in our daily and weekly journals (religious as well as secular). The elastic principle of " similia similibus " is also made to cover it; the more conservative Homoeopaths giving it (generally in the form of the protiodide) in the doses prescribed by the U. S. Pharmacopoeia, and even the extremists not trusting to the "dynamic action" of high potencies, but employing the first trituration (one part to ninety-nine of sugar of milk), put up in bottles carefully coated with black paper to protect it from the action of the light. No one form of mercury can be used exclusively in all cases and in all stages of the disease. A preparation which agrees with one person will not unfrequently disagree with another, and it is sometimes necessary to make a trial of several before the one best adapted to the case can be selected. Again, after employing one form for a time, when the system has become accustomed to it, it is often desirable to change to another; in this manner the thera- peutic action may be increased without resorting to large doses, which are liable to disarrange the bowels. When administering mercurials for an indurated chancre, which it is desirable to heal as soon as possible either to avoid communi- cating it to others, or to remove the inconvenience of the local sore, or when commencing the treatment of general symptoms which are of such a character as to confine the patient to the house, or which are liable to expose him to his associates, some preparation should be selected, as the blue mass, calomel, or gray powder, which will most speedily affect the system. At first, however, mercury should be given very cautiously, and in small and infrequent doses, since the patient's susceptibility is generally not known before trial, and salivation should be carefully avoided. Contrary to a very general but mistaken idea, at least as applied to the treatment of syphilis, the mouth is much more readily affected by the first mercurial course than ever afterwards; hence particular caution should be exercised at this time. Analysis of the blood of persons with 1 I was recently treating a case of syphilitio iritis with half a grain of the pro- tiodide three times a dny, when a friend of the patient, a distinguished homoeopath of this city, advised him to take the same quantity four times a day. 502 TREATMENT OF SYPHILIS. infecting chancres has shown it to be deficient in corpuscles, and to contain an excess of albumen, and at the time of the appearance of secondary manifestations, marked symptoms of chloro-anaemia are often present; hence it is desirable to associate a tonic with the mercurial, as in the following formulas:— #. Pilulse hydrargyri 9ij. Ferri sulphatis exsiccati 9j. Extracti opii gr. v. Mix and divide into twenty pills. ty. Hydrargyri cum creta £)ij. Quiniae sulphatis 9j. Mix and divide into twenty pills. I have been led by observation to believe that the addition of quinine renders mercury less liable to salivate, and thus serves a double purpose. When there is special reason for desiring speedy mercurial action, a combination of several preparations may effect the purpose sooner than one alone. R. Pilulae hydrargyri £)j. Hydrargyri chloridi mitis gr. x. Hydrargyri cum creta 9j. Ext. opii gr. v. M. In twenty pills. It is best to commence with one of the above pills morning and night, and, if no effect be perceptible by the fourth or fifth day, to increase to three a day. So soon as the chancre begins to assume a more healthy aspect, or the secondary symptoms to subside, no farther change in the treatment is required, unless, on the one hand, the mouth become tender, or, on the other, the symptoms cease to improve; in the former case the remedy must be suspended, and in the latter increased. Except under the circumstances above indicated, I decidedly prefer and in my own practice commonly employ one of the iodides or the bichloride of mercury in the treatment of secondary symp- toms. The dose of the protiodide is half a grain, which is to be given in a pilular form two or three times a day. I sometimes increase the dose to two grains in the twenty-four hours, but have never derived any benefit from exceeding this quantity, which alone is apt to produce diarrhoea. Indeed, the chief objection to this pre- MERCURIALS. 503 paration is the abdominal pain and intestinal irritation which it often occasions; but these may in most cases be avoided by direct- ing the patient to take his pill about an hour after meals, when the stomach is not entirely empty, or, if necessary, by the addition of opium; if these measures fail, some other form of the mineral must be employed. The sugar-coated granules of the protiodide, pre- pared by Gamier, Lamoureux, and Co., each of which contains one fifth of a grain, afford a very convenient and elegant mode of administration, and, by their minute division, enable the surgeon to graduate the dose from day to day according to the exigencies of the case. The protiodide is Eicord's favorite form of mercury, and has acquired a wide-spread and well-deserved reputation. Sigmund,1 however, whose extensive experience entitles his opinion to con- sideration, speaks disparagingly of it on account of its tendency to produce diarrhoea, and thinks it of little value except in papular and pustular syphilitic eruptions, and even then inferior to some other forms of mercury. A convenient mode of exhibiting the biniodide of mercury is by decomposing the bichloride by means of the iodide of potassium, and dissolving the precipitated biniodide with an excess of the iodide of potassium, as in the following formula. R. Hydrargyri bichloridi gr. ij. Potassii iodidi 5ss. AquaB §viij. M. Dose.—A dessertspoonful an hour after eating, two or three times a day. Gibert's favorite formula, which is much employed at the Saint Louis and other hospitals of Paris, where it is known as the "syrup of the ioduretted biniodide of mercury," is as follows:— I£. Hydrargyri biniodidi gr. j. Potassii iodidi 9ijss. Aquas 3j. Filter through paper and add— Syrupi £v. M. Dose.—A tablespoonful. Such combinations of mercury and iodide of potassium are the more valuable, the longer the time which has elapsed since con- tagion. In late secondary lesions, I often administer a grain of the 1 Wien Wochenschrift, 1859, No. 39. 504 TREATMENT OF SYPHILIS. protiodide of mercury at noon and the iodide of potassium morning and night. But above all other preparations of mercury, the bichloride commends itself from its slight tendency to produce salivation, the tolerance with which it is borne by the system, the safety with which it may be continued for a long period, and the satisfactory results which follow its administration; it is, therefore, especially worthy of employment in patients living at a distance from their surgical attendant; in those who are peculiarly susceptible to the morbid action of mercury, in persons of a broken-down constitution, and in all cases in which it is necessary greatly to prolong the use of remedies either for the relief of existing symptoms or as a pro- phylactic against future attacks. In my own practice in most cases of secondary symptoms in which I do not employ the bichloride from the first, I resort to it after using one of the iodides, and continue it for a number of months. The bichloride of mercury may be administered in solution or in a pill. It is very liable to undergo decomposition, and, with the intention of preventing this, is usually associated with muriate of ammonia. The average dose for an adult is one-sixteenth of a grain, but is sometimes raised to a fourth or even half a grain; in the treatment of syphilis, however, I have rarely found it bene- ficial to exceed one-eighth or one-sixth of a grain, given three times a day upon a stomach not entirely empty; even in this quantity it is difficult to prevent intestinal pain and irritation. This preparation of mercury was extensively used by Van Swieten,1 and is the active ingredient of the "liquid" known by his name, the formula for which is as follows:— R. Hydrargyri bichloridi 1 pt. Aquas 900 pts. Spiriti rect. 100 pts. The average dose of Yan Swieten's liquid is a tablespoonful, which is given in a glass of sweetened water. ^ The solubility of the bichloride of mercury in alcohol and water facilitates its administration in any of the vegetable tinctures and infusions which are often required in angemic subjects. When given in this form, it doubtless undergoes partial decomposition, but does not appear to lose its therapeutic effect. I frequently employ as a menstruum the tincture of the chloride of iron. 1 Commentaries, xvil. 292. FUMIGATIONS. 505 R. Hydrargyri bichloridi, Ammonias muriatis, aa gr. iij. Tinct. cinchonas comp. J iij. Aquae §iij. M. From a teaspoonful to a tablespoonful two or three times a day. R. Hydrargyri bichloridi gr. iv. Tinct. ferri chloridi giv. M. Eight drops contain very nearly one-sixteenth of a grain of the bichloride. The pilular form is more convenient for many persons. Equal parts of the bichloride of mercury and the muriate of ammonia may be dissolved in a very small amount of pure water, with which finely-powdered cracker is to be mixed in sufficient quantity to ab- sorb it; syrup of gum acacia is added to give it consistency, and the mass rolled into pills containing the desired quantity of the bichloride. Extract of dandelion is also a convenient vehicle, but is more liable to decompose the mercurial. It is a fact but little known that the bichloride may be adminis- tered in cod-liver oil by first dissolving it in a few drops of sul- phuric ether. If the bottle be kept tightly corked it may be retained in solution for an indefinite time: but if the ether be allowed to evaporate by exposure to the air, the bichloride will be precipi- tated and cannot be redissolved by the addition of more ether. R:. Hydrargyri bichloridi gr. ij. Etheris sulphurici 5j- Dissolve and add— Olei morrhuas Sjvj. M. A dessertspoonful contains one-twelfth of a grain of the bichloride. The preparations of mercury above mentioned are those which are found to be the most serviceable in the treatment of syphilis, though others, as, for instance, Plummer's pill or mercury with chalk, may sometimes be employed to advantage; the latter is Mr. Acton's favorite remedy, given in doses of five grains three times a day. Montanier states that the acetate of mercury has sometimes proved successful when other preparations have failed.1 Fumigations.—Mercurial fumigations, although employed from a very early period in the history of syphilis, never acquired much 1 Gaz. dea Hopitaux, No. 19,1856. v 506 TREATMENT OF SYPHILIS. reputation until of late years, since they have been strongly recom- mended by Mr. Langston Parker, of Birmingham, Eng., who con- siders the treatment of syphilis by this method as "safer, quicker, more certain, less frequently followed by relapses, and more efficient in obstinate cases" than by any other. I have had considerable experience in the use of mercurial fumigations, and although I am not prepared to indorse to their full extent the encomiums which Mr. Parker bestows upon them, yet I believe them to be a very valuable mode of treatment in some cases, and one which I should be quite unwilling to dispense with. In most of our large cities1 men are to be found who make a business of administering these baths, and whom the surgeon, when within their reach, will find it most convenient to employ; but the necessary apparatus can be manufactured by mechanics such as may be found in nearly every village. A light frame, sufficiently large to inclose the patient when seated upon an ordinary chair, is to be made of strips of wood and covered with oilcloth lined with flannel. A door in front serves for ingress and egress; and there should be a circular opening upon one side, to which is attached a cloth funnel projecting inwards, into which the patient may insert his head for the purpose of gaining fresh air if the mercurial fumes become oppressive. A small trap-door near the floor enables the attendant to superintend the evaporation of the mercury which is placed within the inclosure upon a metal plate supported by a tri- pod with a spirit-lamp beneath. Steam, which is an indispensable requisite of Mr. Parker's method, may be generated from a metallic basin containing water heated by a second spirit-lamp beneath the patient's chair, but a more copious and rapid supply is required than can readily be obtained in this manner, and it is better to have a boiler, easily made by any tinsmith, without the framework, and connecting with it by means of a tube of tin or India rubber; a shallow vessel beneath, holding alcohol, will afford a broad volume of flame and produce a large quantity of steam. The mercurial vapor may be generated from metallic mercury, but preferably from calomel, the gray oxide, or the binoxide, from one to three drachms of which are required for each bath. The patient of course divests himself of his clothing, ajid any • In New York, Mr. Cohen, at the Fifth Avenue Hotel building, corner of 24th 6treet and Broadway, deservedly enjoys the confidence of the profession. FUMIGATIONS. 507 gold ornaments worn upon the person should be removed to pre- vent their being coated with an amalgam of mercury. The effect of the bath is increased when the head is immersed and the vapor inhaled, especially in affections of the mouth, throat, or nose. As soon as the patient is seated in the chair, the spirit-lamp beneath the mercurial is lighted and steam let on from the boiler. In the course of a few moments profuse perspiration is induced, when it is better to shut off or slacken the steam until within five or ten minutes of the termination of the bath; for if continued in full force it is apt to debilitate the patient. The whole bath occupies about twenty minutes or half an hour. The patient is allowed to cool gradually, and is rubbed thoroughly dry with a towel, and Mr. Parker recommends that he should drink a cupful of warm decoc- tion of guaiacum or sarsaparilla immediately afterwards. The baths may be repeated two or three times a week, their fre- quency being determined by the strength of the patient, and the effect produced. During their administration, the patient should wear flannel next the skin, should observe the rules with regard to diet, etc., heretofore laid down, and mercury in minute doses or iodide of potassium may be given internally. Salivation is rarely induced, though the gums often become tender. Two or three repetitions generally produce a sensible effect upon the symptoms, which rapidly disappear under a continuance of the fumigations. From twelve to twenty baths in all are usually sufficient. I am not in the habit of resorting to moist mercurial fumiga- tions, except in inveterate cases of syphilis, or when the internal use of mercury cannot be supported; and under these circumstances they are extremely valuable. Cases, in which mercurials by the mouth, though carefully guarded by opium, cannot be pushed to such an extent as to subdue the existing symptoms, without excit- ing an undue amount of intestinal irritation or salivation, and those cases in which the disease has repeatedly returned after being ap- parently cured, are better treated by this method than by any other with which I am familiar, except, perhaps, by inunction. Still, relapses will occur as after other modes of treatment, and I have not found that degree of security for the future which appears to have been obtained in Mr. Parker's own practice. The greatest objection to mercurial fumigations is their liability to produce headache and debility. I have endeavored to obviate this difficulty, by diminishing the amount of steam, and shortening 508 TREATMENT OF SYPHILIS. the duration of the baths, but with only partial success. Some patients suffer so much in this way, that it is necessary to suspend, or entirely abandon the treatment, and, in most cases, considerable care is required to avoid unpleasant effects. If the patient become debilitated, his diet should be more nourishing, and he may be allowed a small quantity of wine with his meals. It is well to remind the reader that mercurial fumigations should not be given in an apartment which is used as a sitting or bed- room; and that free ventilation should be resorted to after each bath, otherwise the atmosphere, walls, furniture, etc., may become so saturated with mercury, as to exert an injurious influence both upon the patient and attendant. Inunction.—The treatment of syphilis by mercurial inunction is attended with rather more inconvenience than other methods, and is, therefore, not generally employed, although in the opinion of many, and especially the German physicians, it is held in high esteem. Sigmund, for instance, who used mercurial inunctions in 9,379 cases, occurring at the Vienna Hospital between the years 1842 and 1855, states that this is the simplest and most efficacious mode of treating the various forms of syphilis.1 The manner of employing mercurial inunction is as follows. The warm weather of spring, or the beginning of summer, is best adapted for the purpose. The patient should be prepared by taking several warm baths, in order to render the skin clean and soft. The frictions are to be made upon the inner surfaces of the thighs, arms, and axillae, which are to be used alternately, so as to avoid irritation or abrasion of any one part. The evening, before retiring, is the most favorable time of day, when from a scruple to a drachm of strong mercurial ointment is to be rubbed for ten or twenty minutes upon the part selected, as, for instance, the inner surfaces of the thighs; if by an attendant, his hand should be covered with a soft leather glove, previously soaked in fat, to prevent its absorbing the ointment; the parts are then to be covered with flannel for the night; the remains of the ointment are washed off in the morning with warm soap and water, after which Sigmund advises that perspiration should be promoted, for two or three hours, by wrapping the patient closely in blankets. The whole Times and Gazette, May 2,1857; from the Wien Wochenschrift, 1856, INUNCTION. 509 day, with the exception of five or six hours, is thus spent in bed, or under warm coverings in the bed-room. The clothes and bed- linen should be frequently changed, and the apartments be well- ventilated ; but care should be taken to prevent the patient from being chilled. The diet should be of the simplest kind, and tobacco and alcoholic stimulants forbidden, though anemic patients may be allowed a little wine or beer with their dinner. Sigmund states that he has rarely found it necessary to resort to more than forty frictions in all—counting one to each day—and that twenty or thirty usually suffice. In weak subjects it is sometimes desirable to suspend the frictions for a week or fortnight, once or twice in the course of the treatment; and excessive debility, inordinate per- spiration or salivation may, though rarely, require the entire aban- donment of this method. In my own practice, I have rarely been able to carry out the above treatment so methodically as Sigmund recommends, but I frequently resort to mercurial inunction, without the sweating process and the confinement to the house, and have been very much pleased with the results. Whenever a patient, undergoing a mercurial course, suffers from diarrhoea which opium will not check, or complains that he has lost his appetite and strength or that all food tastes alike, the substitution of tonics for the mercurial internally and the employment of inunction externally, will gener- ally produce a most satisfactory change in his feelings, and act equally well upon his syphilitic symptoms. In infantile syphilis by far the best mode of employing mercurials is by inunction. The older writers on venereal advised that mercurial inunction should not be performed over a serous cavity, as upon the abdo- men or thorax, and not without reason, if we can believe the fol- lowing case reported by Bassereau:—1 " I once made the autopsy of a woman who died of acute peritonitis, and who had been treated for five days with copious mercurial inunction upon the abdomen. On opening the body, I found in the peritoneal cavity, between the uterus and rectum, nearly a teaspoonful of metallic mercury. I think I have read of similar cases. If the woman had not died of peritonitis, what would have become of the mercury which had thus filtered through the skin and abdominal muscles?" What shall we think of this case? In itself, it appears incredi- 1 Affections de la Peau, etc., p. 518. 510 TREATMENT OF SYPHILIS. ble; yet Bassereau was a keen observer, and a man of unimpeach- able honesty. Let the reader decide. Before commencing treatment for constitutional syphilis, a pa- tient is often weighed down with languor and general malaise, which are the effect of his disease; under the use of remedies, his strength and spirits improve, and he becomes light, active, and buoyant; after continuing treatment for some time, however, it is frequently the case, that although his symptoms have constantly improved, he is again subject to depression, but if questioned as to the cause or nature of his feelings, can give no satisfactory reply; his low spirits and uncomfortable sensations cannot be defined or explained, but are none the less real. This condition is unques- tionably due to the influence of mercury, since I have always found it yield to a suspension of specific remedies, whether aided or not by a cathartic, and a change of air and scene for a few days, when this is practicable. Bearing in mind this effect of mercury, I believe that the combination of opium with the mercurial, which is commonly adopted, is not only serviceable in restraining action upon the bowels, but also in diminishing the sensibility of the nervous system, and enabling it better to support the continued use of specific remedies. Salivation.—The most frequent unpleasant effect of the adminis- tration of mercurials, and the one which it is especially necessary to guard against, is salivation, though this formerly was thought to be a desirable result of treatment, and to favor the cure of syphilis. The therapeutic effect of mercury undoubtedly precedes its morbid action, although the two are often separated by a short interval only, and sometimes appear to be synchronous. If we carefully observe the phenomena which ensue after commencing a mercurial course, selecting by preference a case which has as yet re- ceived no treatment, and in which the effects of mercury are gener- ally most clearly marked, they are usually found to be as follows: for the first few days, no improvement is perceptible in the symp- toms, which may even become aggravated; the chancre may spread over a larger extent of surface, or new secondary lesions may ap- pear; suddenly, however, the primary sore begins to assume a more healthy aspect, and the process of cicatrization to advance from its circumference towards the centre; the indurated base and neigh- boring lymphatic ganglia lose somewhat of their hard and cartilag- inous feel; or the syphilitic eruption commences to fade away. If SALIVATION. 511 now the mercurial be continued, even though the quantity admin- istered be not increased, tenderness of the mouth rarely fails to appear in the course of a very few days, and frequently as soon as the second or third day after the first improvement was noticed in the symptoms. In a few instances only does an amelioration in the symptoms appear to coincide with decided salivation, and in such cases the action of the mercurial has generally been so rapid, that an interval between the two may readily have been overlooked. Again, if mercury be continued after salivation has taken place, its therapeutic action is not increased, but, in most cases, on the con- trary, the symptoms are aggravated. The practical inference from the above remarks is, that the specific treatment of syphilis may be carried to tenderness of the gums, in order to afford assurance that its full therapeutic effect has been obtained, but that it should not intentionally be pushed to complete salivation, and never in any case be continued beyond this point. I have already called attention to the fact that a patient is much more liable to be salivated by the first than by any subsequent course of mercury; the system becoming tolerant of its presence by repeated use. This fact has been so evident in my own practice, that I am surprised that it has not attracted more attention, although it has been by no means unnoticed by other writers. A remark- able instance has recently been under my observation. A gentle- man applied to me with syphilitic roseola, for which I prescribed mercurials, which caused the disappearance of the eruption in the course of ten days, but which gave him so sore a mouth that I dis- continued the remedy, intending to resume it again in a short time. Several circumstances occasioned delay, when, in about three weeks, a papular eruption appeared in patches, which became covered with scales. I immediately resumed treatment, but found the greatest difficulty in producing the slightest effect either upon the symp- toms or upon the gums, and it was only after the lapse of six weeks, and a trial of various mercurial preparations, and different modes of administering them, including fumigation, that the mouth was a second time affected, and the symptoms improved. Patients who have supposed themselves extremely sensitive to the action of mer- cury, founding their opinion upon past experience, are often sur- prised at the large amount which they are able to take, not only with impunity, but with decided benefit to their symptoms and 512 TREATMENT OF SYPHILIS. their general condition, while under treatment for constitutional syphilis. The earliest indication of the morbid action of mercury upon the mouth, which is likely to attract the patient's notice, is tenderness of the gums; this is soonest felt just back of the superior incisor teeth, and in the lower jaw, posterior to the last molars. I always warn patients of these symptoms at the commencement of a mer- curial course, and direct them immediately upon their appearance to suspend treatment until they can see me. This precaution is desirable, although it sometimes leads timid persons to imagine the mouth affected long before this result has actually taken place. I have met with several instances in which the soreness attendant upon the development of a wisdom tooth has been mistaken for mercurial salivation, and various other causes may also produce tenderness of the gums, and a fetid breath. It is, therefore, always desirable for the surgeon carefully to inspect the mouth before commencing treatment, in order that he may be able to determine, at a subsequent period, how far to attribute its unhealthy condition to the influence of mercury. Other prominent symptoms of mercurial stomatitis are a metallic taste in the mouth; a fetid odor of the breath—which, however, is not characteristic, since it may be perfectly simulated by the offen- sive smell proceeding from a want of cleanliness, or gums diseased from other causes; an increased flow of saliva; a sensation as if the teeth were elongated, and tenderness when they are struck together- swelling of the tongue, which bears the impress of the teeth upon its sides; tumefaction of the mucous membrane of the gums, cheeks, and lips; difficulty in talking and swallowing; enlargement of the neighboring ganglia; sometimes general febrile disturbance and great nervous irritability; in extreme cases ulceration of the soft parts, which may perforate the cheeks; loosening and detachment of the teeth; and even caries of the alveoli and of the maxillary bones. Under the cautious method of administering mercury which is now adopted, excessive salivation is rarely induced, and, even when left to itself, usually subsides in the course of a week or ten days after the suspension of treatment. Much, however, may be done to shorten its duration and alleviate the sufferings of the patient. The bowels, if confined, should be freely purged, and the action of the skm promoted by warm baths and underclothes of flannel SALIVATION. 513 The most distressing symptoms are the great difficulty in swallow- ing, nervous excitability, and inability to sleep. Nourishment should, therefore, be administered in a liquid and concentrated form, as strong beef-tea; and rest be secured by the exhibition of Dover's powder, aided by a hot mustard pediluvium at night, which will also act as a derivative from the head. Half an ounce or an ounce of Labarraque's solution of chlorinated soda in half a pint of water forms an excellent gargle for such cases. Although the above measures should by no means be neglected, the most direct and effectual treatment of salivation consists in the administration of the chlorate of potash. I usually order a few drachms or an ounce of this salt in powder, and direct the patient to dissolve from one to two teaspoonfuls in a pint of water, milk and water, flaxseed tea, decoction of marshmallow, or in whatever other vehicle may be most agreeable. This solution is to be used warm, and is to be kept constantly within reach of the patient, so that he may frequently rinse his mouth with it, and afterwards swallow a portion. From one to two pints are sufficient for the twenty-four hours; and about half of this quantity, containing one or two drachms of the chlorate, should be swallowed. It cannot be doubted that the amelioration in the symptoms which almost always takes place under the use of the chlorate, is due to the remedy and not to the mere suspension of the mercurial, since the stomatitis will often relapse if the salt be too soon dis- continued. The therapeutic action of the chlorate is also proved beyond question by Eicord's experiments, which show that the sto- matitis will subside under its use if the mercurial be continued, and, in many cases, even if the dose be increased; and that the chlorate may be employed as a prophylactic from the commencement of treatment in persons who are peculiarly susceptible to the morbid action of mercury, without interfering with the remedial effect upon the syphilitic symptoms.1 This statement has been confirmed by Laborde.2 During the use of mercury, much may be done to prevent sali- vation by attention to cleanliness of the mouth, and by avoiding exposure to sudden changes of temperature and to moisture; and these precautions should be continued for some little time after the 1 Ricord, Lecons sur le Chancre, p. 336. 2 Laborde, Gaz. des Hop., Apr. 24, 1858. 33 514 TREATMENT OF SYPHILIS. suspension of treatment. The teeth should be brushed several times a day, or the mouth be rinsed with some astringent gargle, as diluted tincture of myrrh, or equal parts of brandy and water with the addition of alum. The influence of cold and wet must not be regarded as chimerical. I have known a country physician to be profusely salivated a month after the cessation of a mercurial course, as a consequence of exposure to the rain while attending to his practice. But the apprehension which is often entertained by patients in regard to the use of cold drinks, provided other hygienic conditions be favorable, is probably groundless. Other morbid effects of mercury, as the eruption upon the skin (eczema mercuriale) which sometimes follows mercurial inunction; mercurial trembling, and other affections of the nervous system; mercurial spanaemia and cachexia, etc., are so infrequent at the present day, that I shall refer the reader for their minute descrip- tion to the standard works upon Materia Medica, and especially to the admirable treatise of Prof. StilK1 It would hardly seem possible that any physician who has been educated in the modern views of the treatment of syphilis could carry the use of mercurials to such an extent as to produce the more severe morbid effects of this mineral. Mercury has undoubtedly been charged with many evil results of which it is entirely innocent, and it is much to be regretted that such errors have been promulgated and strengthened in the minds of a timid public by some members of our own profession. Let it be observed that I do not deny the powerful agency of this mineral for evil as well as for good, nor that it is often used unnecessarily and injudiciously, to the detriment of the general health and aggravation of the disease which it is intended to cure; but to ascribe to its employment many of the later manifestations of syphilis, as iritis, orchitis, and tertiary lesions in general, which are known to occur in cases where no mercurial has been given, and which are never met with when this mineral is administered for other diseases than syphilis, nor among those who constantly work in mercury, is an unfounded and dangerous doctrine, and one which returns upon the profession and impedes its action on occasions when this mineral is one of the greatest boons from nature to man. 1 Therapeutics and Materia Medica, by Alfred Stille, M. D., Phil. 1860. SALIVATION. 515 The public mind is so prone to receive any marvellous account of the disastrous effects of drugs, and so many charlatans find it for their interest to foster such delusions, that the utmost caution is required to avoid being carried along with the tide beyond the bounds of careful observation and of truth. As an instance in point, we may cite the supposed identity of affections of the bones from mercurial dyscrasia and from syphilis, which chiefly rests upon a report by Hermann1 of the diseases prevailing among the workers in mercury in the mines of Idria, and this account has assumed such importance as to justify my quoting an able criticism upon it by the well-known German physiologist, Virchow, in which its inconclusive character is fully shown. Virchow says: "Hermann has published some investigations upon diseases occurring at Idria, based upon personal observation and information furnished by Dr. Goerbez, from which he concludes that a series of affections which are commonly regarded as belonging to constitutional syphilis, are due to mercurial intoxication. I must confess that after reading his paper it is difficult for me to agree with him. In the year 1856, 122 of 516 workmen had diseases which were regarded as the effect of mercury. Among them there is not a single case of iritis, orchitis, or tubercles of the skin, and only two cases of caries occurring in patients who were not em- ployed at the furnace where there is the greatest exposure. Her- mann himself saw thirty patients, including two with caries, one with softening of the spinal column, one with periostitis and necrosis, and fi\te with pains in the bones. In the two cases of caries, the disease affected the joints, which scarcely ever occurs in syphilitic caries. And, after all, what do these cases prove ? Is it at all sur- prising that out of 500 workmen two should be found suffering with caries? Why are we to conclude that the periostitis with necrosis was mercurial and not traumatic, rheumatic, or strumous? There is nothing to show that the pains in the bones, resembling those syphi- litic pains which precede deep lesions of the osseous tissues, really had a specific character. Everybody knows that there is a mercurial cachexia, neuralgia, rheumatic pains (mercurial arthritis), affections of the mouth and pharynx, mercurial tremor, etc., but to infer that these lesions are identical with those of constitutional syphilis would 1 Wien. Wochenschrift, Nos. 40-43, noticed in the Times and Gazette, June 11, 1859, p. 616. 516 TREATMENT OF SYPHILIS. require much care in the choice of arguments and very careful ob- servation. Eeder very truly says that any one who has ever seen secondary symptoms can refute Hermann's observations and conclu- sions."1 Virchow adds that he has not been able to find any proof of the frequent assertion that men working in mercurial mines are subject to diseases of the bones identical with those produced by syphilis, and that, on the contrary, information derived from his colleagues is entirely opposed to this belief. M. Mitscherlich ascer- tained at Idria that the workmen were not subject to caries and gum- my tumors, and this statement is confirmed by the official report of two physicians at Almaden. Singer2 ascertained that those work- men who are exposed to the fumes of mercury, as gilders and hatters, are not affected with such diseases, and Pappenheim,3 who describes the affections of men employed in the preparation of rabbit-skins, does not mention a single lesion resembling constitu- tional syphilis. In short, any direct action of mercury upon the bones is at best very questionable. For myself, I can say that I have never seen any effect of mercury which could, for a moment, be mistaken by an experi- enced person for any form of syphilis; and the only affections of the osseous tissues, which I have observed to follow the use of this remedy, have been caries of the teeth and alveoli, in a few persons- who had frequently been salivated; but such lesions are evidently merely secondary to changes in the soft parts. Some authors who admit that mercury is alone incapable of producing any symptoms resembling syphilis, still believe that it may in some way combine with the syphilitic virus, and give rise to a mongrel disease which has been called " hydrargyro-syphilitic." I suspect that the only foundation for this idea, which is certainly contrary to all analogy, is the fact that mercury when administered injudiciously, depresses the system, and aggravates the existing disease; and the simple enunciation of this important truth is more likely to attract the attention it deserves, than when the fact is concealed beneath a very questionable hypothesis. There are two golden rules for the administration of mercury, and he who follows them will have no occasion to fear doing his patient harm:__ ' Virchow, La Syphilis Constitutionnelle, traduit de l'Allemand, par le Dr. Pi- card, Paris, 1860. 2 Wochenblatt der Zeitsch. der Wiener Aerzte, 1857, No. 12, .p. 197. » Handb. der Sanitaets Polizei, Berlin, 1858, vol. ii. p. 5. DURATION OF TREATMENT. 517 1. Never give mercury unless the disease be clearly syphilitic; except in a few doubtful cases, in which it may be cautiously em- ployed and its effects narrowly watched, until the propriety of con- tinuing it can be determined. 2. Avoid the use of mercury in subjects already depressed; and, in all cases, suspend the treatment the moment the general health appears to suffer. I have often been surprised at the large amount of mercury which may be administered with benefit in some obstinate cases of syphilis; and occasionally when the disease has repeatedly relapsed and I have felt reluctant still farther to increase the quantity, pa- tients who had at first feared the effects of mercury, but who had been convinced by experience of its benefits, have insisted upon its repetition. Duration of Treatment.—It is hardly necessary to remark that treatment should be persevered with as long as any syphilitic symptoms remain. While these persist, specific remedies must be continued in doses graduated according to the effect produced and the general condition of the patient, increasing the quantity if fresh symptoms appear or old ones cease to improve; diminishing it, or suspending treatment altogether for a time, if intestinal irritation, salivation, general malaise, or decided cachexia supervene; in all cases seeking the aid of hygienic influences, and in many that of tonics. In the early stages of the disease, induration of the base of the primary sore, and more frequently that of the neighboring ganglia, will remain after the more evident symptoms of constitu- tional infection have disappeared, and treatment must be continued until they also have been dissipated. No permanent relief can be anticipated unless the base of the chancre has resumed its normal suppleness, or retains only the products of simple inflammation, and the ganglia have lost their characteristic hardness, although these bodies will, of course, always remain perceptible to the touch, and may be somewhat larger than they were originally. Yet after all this has been accomplished, and when no trace remains to mark the radical change which has been brought about in the system, experience shows the necessity of still farther pro- longing treatment, if we would hope to secure immunity for the future. Unfortunately no definite rules can be laid down to deter- mine for how long a time this should be, and it is probable that no invariable period can ever be fixed upon, since the tendency of the 518 TREATMENT OF SYPHILIS. disease to relapse varies greatly in different subjects, and all stand- ards must be more or less arbitrary. We, accordingly, find that while authorities upon syphilis are nearly unanimous in recom- mending a continuance of treatment after all symptoms have dis- appeared, yet that there is no uniformity in their statements as to the time required. Some take as a standard the period which has already been occupied in subduing the previous symptoms, and would have the treatment still continued for half or the whole of the same length of time. Others are content with a month or six weeks, irrespective of the previous duration of treatment; while many prudent practi- tioners advise a period of from six months to two years. Again, there is an equal diversity in the recommendations as to the form of mercurial to be employed, the mode of its administration, and the extent to which it should be made to affect the system; some preferring the bichloride in small doses, and never pushing it to the extent of touching the gums; others employing some more active preparation at repeated intervals, and pushing it on each occasion until the mouth is slightly affected; and others still keep- ing their patients upon the verge of salivation during the whole period of prophylactic treatment. With regard to the short periods of a few weeks, recommended by some authors, I do not hesitate to say that, in my opinion, they are entirely inadequate to prevent a relapse, although they cannot, in many instances, be exceeded, owing to the unwillingness of patients to take medicine for a long time after its necessity has ceased to be apparent; and I am convinced that the belief in the efficacy of prophylactic treatment, continued for such short periods, has been derived from cases in which no secondary symptoms ever appeared, and in which chancroids have been mistaken for true chancres. I would, therefore, range myself decidedly among those who advocate the use of remedies for a period varying in different cases from six months to a year, or even longer, after all secondary manifestations have disappeared. Especially with patients who are already married, or who intend to marry, every precaution should be used to prevent a relapse. The advantages of the bichloride, under these circumstances, are very great, and probably sufficient to entitle it to the prefer- ence in most cases. It is less likely to salivate than other forms of mercury, has a less depressing effect upon the system, may gener- DURATION OF TREATMENT. 519 ally be continued with impunity for a long period, does not neces- sitate such frequent attendance upon the surgeon, and thus relieves the patient, in a measure, from the irksomeness of treatment, or enables him to absent himself for the purposes of business or of pleasure;—advantages which may render him more willing to con- tinue treatment for the necessary time, and which are of no small value, provided always they do not lead to imprudence or neglect. In administering the bichloride as a prophylactic against future symptoms, I have found it desirable to employ as large doses as can conveniently be borne—as, for instance, one-eighth of a grain two or three times a day—for a period of, at least, six weeks or two months, after which time the quantity may be gradually diminished. In several cases, in which I have relied upon one-sixteenth or one- twentieth of a grain, I have had the mortification of seeing fresh symptoms appear, just as I was about to terminate the treatment and dismiss the patient as cured. During the continuance of prophylactic treatment, the same hy- gienic rules should be observed as at an earlier period, and the patient should be particularly cautioned not to be led, under the mistaken idea that his recovery is now secure, into any imprudence which will be likely to favor a relapse. If the system be depressed from any cause, this should, if possible, be removed. If the strength fail, it should be supported by tonics; the treatment must be tem- porarily suspended, if salivation, intestinal irritation, or nervous de- pression ensue; in short, the general condition of the patient should be maintained as nearly as possible at the normal standard of health. After continuing the bichloride for six months or a year—when this can be done without injury to the constitution, and when the patient can be induced to submit—it is important to resort to the iodide of potassium, either alone, or alternated with the iodide of iron, for an additional period of several months. The use of the bichloride, as above recommended, is the treatment best adapted to the majority of cases, but other forms of mercury are sometimes to be preferred. Thus, I have met with instances in which the bichloride appeared to be entirely inadequate to pre- vent a relapse, and in which it was necessary to resort to one of the iodides, or to mercurial fumigation. The reader will also un- derstand that I have been speaking of the secondary and not of the tertiary stage of syphilis. In the latter, some modification of the above measures, to be described presently, is required. 520 TREATMENT OF SYPHILIS. Ricord's method of treating secondary syphilis is deserving of description, on account of the extensive field of observation and the just celebrity of this eminent surgeon. So long as any symptoms of constitutional syphilis remain, Ricord relies upon them as a guide to determine the quantity of mercury which should be given; being satisfied with any amount which produces an amelioration, and increasing it whenever no improvement is manifest. After the disappearance of all syphilitic manifestations, he continues mercu- rials in the largest dose which can be borne without producing salivation, in order to be sure that the system is fully under its influence. This is done by increasing the dose until irritation of the gums is produced, and then slightly decreasing it so as to avoid salivation; afterwards continuing the same quantity for several weeks, and again trying the effect of an increase. By a succession of such experiments on the power of the system to support the mercurial, and by giving as large doses as can be borne without salivation, the full effect of the remedy is constantly maintained. With regard to the total duration of treatment, Ricord says: " It remains to determine for what length of time treatment should be continued in order to insure the greatest probability of no farther symptoms occurring. No treatment continued for any length of time will afford certain immunity; all we can do is to render im- munity probable. To stop treatment as soon as all syphilitic symp- toms have disappeared, is to leave our patient with almost a cer- tainty of their return. To continue treatment for as long a time after as has been required to effect their disappearance, is also an unsatisfactory rule. In many cases it would be too short, in others too long. Clinical observation of a large number of cases can alone furnish a reliable guide. Six months of treatment by mercury, in such doses as to exert a curative action on the symptoms as long as they remain, and after their disappearance to show by its physio- logical effects that it is still acting on the system; and afterwards, three months of treatment with iodide of potassium, in order to prevent late manifestations of the diathesis; such is the mode and length of treatment which I have found most successful, and which, in the great majority of cases, neutralizes, as it were, the syphilitic poison. It is to be understood, however, that this rule is frequently to be modified to suit the circumstances of individual cases."1 1 Author's edition of Ricord and Hdnter on Venereal, 2d ed., p. 498, DURATION OF TREATMENT. 521 The only peculiarity of the above method is the extent to which mercurials are carried in the prophylactic treatment pursued after the disappearance of all syphilitic manifestations. When secondary symptoms subside, as they frequently do, in a few weeks after com- mencing treatment, and in all cases of infecting chancre unattended as yet with general manifestations, Ricord would keep the patient upon the verge of salivation for a period of nearly or quite six months. I must confess that if I were the patient, I should hesitate whether to prefer a cure on these conditions or the disease itself; and I am convinced from several trials of this plan that but few persons can support it, if at all, without injury. In the only case in which I have felt justified in carrying it out to its full extent, the result did not tend to inspire confidence in its efficacy. The patient, an intelligent merchant, had conscientiously pursued six months' treatment with mercury (the protiodide) in as full doses as could be borne without producing salivation, and three months' with iodide of potassium, when about six weeks after completing the latter, he was suddenly attacked with epileptiform convulsions, of which he had six within twenty-four hours, and which were pre- ceded by no symptoms except a constant headache for several weeks previous. He recovered sufficiently in a few days to resume his business, but a month after had a recurrence of the convulsions which left him in a state of nervous excitement bordering upon mania. I could not believe that his symptoms were due to his con- stitutional disease for which he had so recently and so thoroughly been treated, but I came to the contrary conclusion a fortnight later when a specific eruption made its appearance, and when I immedi- ately put him upon the use of the bichloride combined with tonics, under which he rapidly improved and has since been free from similar attacks. Except in this one case, I have always been obliged to slacken the severity of Ricord's method, in consequence of the general health of patients appearing to suffer, and yet, as I have before remarked, it is not well to rely upon too small doses of mercury and run the risk of seeing relapses appear in the midst of treatment. The happy mean has seemed to me to be to give mercurials as freely as can be done consistently with the general health; and slight tenderness of the gums on several occasions during the course of treatment should be regarded as desirable. Mr. Thomas Hunt, of London, has recommended another mode of conducting the treatment of syphilis which I have employed in 522 TREATMENT OF SYPHILIS. some instances with very satisfactory results, and which is deserv- ing of mention, since in a disease so obstinate as this sometimes proves to be, the resources of the surgeon cannot be too numerous. Mr. Hunt's method1 is founded upon the idea that mercury exerts its therapeutic action suddenly and within a limited period only, beyond which its effect is null or injurious. He, therefore, advises that it should be administered in short and vigorous courses, giving such doses as will most speedily affect the system until its action becomes manifest, then entirely withholding it for a time, and sub- sequently resuming it in the same manner, as often as may be neces- sary. Mr. Hunt prefers blue pill to other preparations of mercury on account of its greater activity. In the first course, he administers from two to seven grains morning and night until some improve- ment in the disease is manifest, and does not persist for a single day beyond this, but substitutes aperients and tonics for the mercurial. In two or three weeks he commences the second course, giving mercury in increased and, in most cases, doubled doses, to provide against the tolerance which is acquired by use. Thus he goes on with repeated and energetic courses, always aiming to produce an impression upon the disease as rapidly as possible, and stopping as soon as this effect is attained, and when all symptoms have disap- peared he administers a final course as a preventive and pursues it until fetor is perceptible in the breath or the patient complains of a metallic taste in the mouth. In the later courses he often combines inunction with frequent internal doses, with or without opium, in order to obtain more speedy mercurial action. Mr. Hunt's method is especially adapted to weak and cachectic subjects in whom I have repeatedly employed it with success, although the occurrence of relapses in some cases has shown that the author's anticipations as to the immunity afforded by the final preventive course, are some- what too sanguine. In concluding these remarks upon the mercurial treatment of syphilis, it would be interesting to ascertain what results are generally obtained in practice, and to know in what proportion of cases, after treatment has been faithfully pursued, no further trou- ble is experienced. Unfortunately there are no reliable data which enable us to decide this point. Our views of the nature of ' On Syphilitic Eruptions, etc., with especial reference to the Use and Abuse of Mercury, by Thomas Hunt, F. R. C. S., 2d ed., London, 1854. , DURATION OF TREATMENT. 523 syphilis, as a constitutional disease in which the system undergoes a modification similar to that which takes place in vaccination and variola, render it improbable that any treatment, however pro- longed or however faithfully pursued, will afford certain immunity for the future. The extreme rarity with which syphilis is con- tracted twice by the same person shows that as a general rule the diathesis, when once acquired, exists for life; and we can no more hope to eradicate it by mercury than we could expect that medicine would restore the system to its original condition after vaccination; and while the diathesis exists, however long it may have been latent, there can be no certainty that it will not at some future time resume its activity. These deductions from the nature of the disease are confirmed by experience. Those who have enjoyed the greatest facilities for observing the effect of treatment are nearly unanimous in the opinion that absolute security can never be attained, and I would caution the student against placing the slightest confidence in the contrary statements of a few authors who have some favorite mode of practice to recommend. My own experience leads me to believe that most cases of in- fecting chancre are sooner or later followed by secondary manifes- tations in spite of any treatment which may be adopted. I have met with some unquestionable cases in which remedies have been faithfully employed for six months or a year, and in which no general symptoms have ever appeared, but they have been so infrequent as to be almost exceptional. The majority of patients whom I have been able to watch for two or three years have not escaped further trouble, though often of a slight character, and observation of cases which have been under the care of other surgeons and many of which have been subjected to treatment that has been pronounced infallible, has convinced me that my own experience is that of the profession generally, although it is seldom acknowledged, and is not apparent to those who confound the two species of chancre and treat both alike with mercury. I would not go so far as Diday, who somewhere says that " mercury pre- vents those secondary symptoms alone which would never have appeared without it," but I believe that most cases of infecting chancre are followed by some general symptom in spite of any treatment which it is practicable to adopt. When secondary symptoms have already appeared I have found 524 TREATMENT OF SYPHILIS. the results of treatment more satisfactory, and in many cases after a thorough course of mercurials no subsequent trouble has been experienced; and, as was stated at the commencement of this chapter, even when repeated relapses have taken place, persever- ance in the use of remedies has been crowned with ultimate success, with but few exceptions; the tendency of the disease to reappear has finally ceased, and the patient has been left in a con- dition of apparent health which has been maintained until the present time. At the close of treatment the patient should always be cautioned to lead a regular course of life and avoid all depressing influences, especially for the first year or two, during which the disease ex- hibits its maximum tendency to relapse and is very likely to reap- pear if the general health be much reduced; though, indeed, the fact that a man has once had constitutional syphilis should ever afterwards lead him to take good care of himself. Iodine and its Compounds.—The therapeutic effect of iodine and its> compounds upon syphilitic symptoms is in direct ratio to the duration of the disease. Although possessing little if any power over early secondary manifestations, their action upon tertiary lesions and those of the transition stage is very decided. In deep tubercles of the cellular tissue, rupia, syphilitic orchitis, affections of the bones and periosteum, syphilitic cachexia, etc., the results of their employment are frequently almost magical. An unfortunate patient whose life has been rendered miserable for months by pains in his bones which have deprived him of sleep, by a pustular eruption upon his face which has debarred him from society, by deep ulcerations about the pharynx which have ren- dered speech and deglutition almost impossible and which finally threaten suffocation, or who has suffered from any other of the numerous late manifestations of syphilis, will in most cases obtain comparative ease and comfort in the course of a few days or weeks from the administration of the iodides. It would be difficult to name the circumstances under which the surgeon feels more pride in his profession, or in which he finds more conclusive evidence of his power over disease, than when he is able to recognize the symptoms which indicate the exhibition of these remedies and can watch their marvellous effects from day to day. Unfortunately the iodides possess greater power to subdue tertiary symptoms for IODINE AND ITS COMPOUNDS. 525 a time than to cause their permanent removal. The disease rapidly declines and disappears under their use, but in most cases returns in a few weeks or months after their suspension; and thus the patient becomes the slave of medicine, or is obliged to resort to mercury for an effectual cure. # But these preparations are none the less of very great value. Mercury, when given at the commencement of the treatment of tertiary syphilis, cannot, as a general rule, be supported, and rarely fails to aggravate the symptoms. By the use of the iodides the patient finds almost immediate, though temporary relief from suf- fering, his appetite improves, he gains flesh and strength, and his system is brought into a proper condition for the administration of remedies which will prove of more lasting benefit. The ground above taken with regard to the therapeutic value of iodine and its compounds is at variance with that assumed by some most eminent authorities and especially by Ricord, who considers the iodide of potassium as much a specific for tertiary as mercury is for secondary symptoms. In my own practice, however, I have rarely been able to secure permanent relief for my patients unless the former agent was accompanied or followed by the latter, and this experience coincides with that of Sir Benj. Brodie, Langston Parker, and Mr. Hunt, of Eng., and Drs. Mussey, Willard Parker, John Watson, Wm. H. Van Buren, Blackman,1 and other eminent surgeons of this country. Persons are frequently met with who have taken the hydriodate of potassa for years and years, and who are still obliged to continue it if they would keep their symptoms in check. They generally become familiar with its use, purchase and mix it for themselves, and take it as regularly as their daily meals. An old man is now in attendance upon the New York Eye Infirmary, whose face is deeply scarred and nose sunken from the effects of syphilis. I am informed by Dr. Geo. Wilkes, for- merly surgeon of this Institution, that this man was a patient there ten years ago, when he was in the habit of buying the iodide of potassium for himself by the pound and taking the enormous quantity of an ounce a day; and I find on inquiry that he has continued its use from that time, although he has gradually reduced the amount, and now takes but about half a drachm per diem. The observations of MM. Melsens and Guillot have proved that 1 See Blackman's Vidal on Venereal Diseases, 1st ed., p. 320. 526 TREATMENT OF SYPHILIS. iodide of potassium is capable of rendering soluble mercury or any of its compounds retained within the tissues of the body and of causing their elimination through the urinary secretion, in which they may be detected by chemical analysis. In this manner, mer- cury which has been retained in the system is again rendered solu- ble, and before elimination may exercise any of its therapeutic or morbid effects. Thus iodide of potassium administered subse- quently to a mercurial course has frequently been known to excite profuse salivation. The question has been raised whether iodide of potassium by itself has any power over syphilis, and whether its therapeutic action may not be entirely explained by the facts above stated. According to this view it is only curative because it has the power of rendering active mercurial preparations which have been accu- mulated in the system by previous treatment; while others who believe that tertiary syphilis is an effect of mercury have ascribed the action of iodide of potassium to the elimination of this mineral and the consequent removal of the supposed cause of the disease. Neither of these suppositions will bear the test of examination. Cases of tertiary syphilis in which mercury has not previously been given, and in which, therefore, the independent action of iodide of potassium may be tested, are not common; but a sufficient number have been met with to prove that this agent does not play so secon- dary and insignificant a part as has been attributed to it. Of 195 cases of syphilis successfully treated with iodide of potassium by Hassing, of Copenhagen, in 70 no mercurial treatment whatever had been employed.1 A woman recently entered Nelaton's wards with numerous exos- toses upon the tibias, the femoral bones, the bones of the forearms and the thoracic fibro-cartilages, which were attended with such severe pain as totally to deprive her of sleep. She stated that she had had this disease for three years and had never received any treatment whatever. The iodide of potassium was administered in the dose of fifteen grains a day, and by the third day she was able to pass a quiet night, and at the end of a week the osseous tumors had lost their sensibility and resolution had commenced.2 This case can leave no doubt that the administration of the iodide of potassium may effectually control tertiary syphilis when mercury 1 British and Foreign Medical Rev., Oct. 1845, p. 482. 1 Gaz. des Hopitaux, Jan. 28, 1860. IODINE AND ITS COMPOUNDS. 527 has not been previously given. This conclusion, however, does not conflict with the belief that its therapeutic action may some- times be due in part to the liberation of mercury. The solubility of iodide of potassium enables it to be adminis- tered in any aqueous or alcoholic mixture, while its deliquescent properties poorly adapt it for the pilular form. Five grains three times a day is the usual dose with which to commence treatment in an adult, and if the case be properly selected, marked improvement will generally take place within a week. In old cases of syphilis, however, this quantity is often insufficient, and it may be necessary to increase the dose to a drachm, and, in exceptional cases, to two drachms or more per diem. When the symptoms appear to indi- cate the use of the hydriodate, the case should not be pronounced intractable to this remedy unless a trial has been made of full doses and these have been found to be without effect. Ricord, who was one of the first to follow Wallace, of Dublin, in the use of this agent, and whose experience with it has probably been greater than that of any other surgeon, administers from fifteen grains to a drachm and a half per diem, and rarely exceeds the last named quantity. His colleague at the Hopital du Midi, M. Puche, fre- quently employs an ounce and a half (50 grammes) in the twenty- four hours, and states that he has rarely observed any bad effects; this practice, however, is not deserving of imitation. The following are convenient formulas:— R. Potassii iodidi §ss. Aquae cinnamomi 5SS. M. Seven drops of this solution contain nearly five grains of the iodide. R Potassii iodidi gij. Aquae §iij. M. A teaspoonful three times a day. The action of the iodide of potassium is increased by combination with muriate of ammonia, which is a favorite addition with my venerable friend, Dr. John P. Batchelder, of this city. R. Potassii iodidi, Ammoniae muj-iatis, aa 5j- Tinct. cinchonas comp. Jiv. M. A tablespoonful three times a day. 528 TREATMENT OF SYPHILIS. Experience shows that the most favorable time for the adminis- tration of the iodide of potassium is half an hour or an hour after eating, although Dr. Budd remarks that it should be taken fasting, "lest it be decomposed by the hydrochloric acid of the gastric juice." It not unfrequently excites griping pains in the bowels, which may be avoided by the addition of a syrup containing tannic acid, as the syrup of cinchona or of orange-peel.1 The addition of a small quantity of tannic acid to solutions of the iodide in a syrup which does not contain tannin answers the same purpose. The fol- lowing formula is employed by Ricord and Nelaton:—2 R.. Potassii iodidi 3j. Syrupi corticis aurantii ^vj. M. Dose.—A tablespoonful. Dr. Durkee states that he is in the habit of combining the iodide of potassium with carbonate of ammonia, which he thinks renders this substance more agreeable and efficient. He employs the fol- lowing formula:—3 R. Ammoniae carbonatis 5iss> Potassii iodidi 5iij- Syrupi sarzae comp., Aquae, aa §iiss. M. Dose.—One drachm three or four times a day. The iodide of sodium4 and the iodide of ammonium5 have been recommended as substitutes for the iodide of potassium by Dr. Gamberini, of the Hospital of Saint Orsola, Bologna. The iodide of iron cannot be said to possess any special anti- syphilitic power, but is an extremely valuable tonic in cachectic or chlorotic subjects either with or without the iodide of potassium. I am in the habit of employing it in nearly all cases of constitu- tional syphilis, especially towards the close of treatment and after the use of mercury. Blancard's pills are the most convenient form of administration, or the liquor ferri iodidi may be employed. As the iodide of iron is frequently given to women who pride them- ' B°7™' Trait6 d'IodothgraPie» Paris> 1855, p. 102, and L'Union Med., 1858 p 487 ; also same journal for March 6, 1860. ' 1 Richelot, L'Union Med., Feb. 28, I860. 3 Gonorrhoea and Syphilis, p. 325. 4 Dublin Quarterly Journ., No. 28, Nov. 1852. s Gaz. des Hop., Dec. 1, 1859. IODINE AND ITS COMPOUNDS. 529 selves upon their complexion, it is well to know that it sometimes gives rise to papular, tubercular, and furuncular eruptions, like other compounds of iodine. This fact is denied by Mr. Langston Parker,' but I have met with a number of unquestionable instances in my own practice from the use of Blancard's pills, though I cannot recall any when the syrup has been employed. The contra-indications to the use of iodide of potassium are acute or chronic inflammation of the digestive organs, plethora, and a disposition to hemorrhages. A few persons are entirely insensible to its influence, and it is useless to persist in its employment if a fair trial, commencing with moderate doses and gradually increas- ing to large ones, prove unsuccessful. In cases adapted to its use, the effect of the iodide of potassium, if given in sufficient quantity, is usually perceptible in the course of a week. The appetite increases, the digestive powers improve, and the patient rapidly gains in flesh and strength. Grassi's anal- yses of the blood show that this remedy possesses a much greater power than mercury to increase the proportion of blood-corpus- cles, and hence is especially adapted to the treatment of syphilitic cachexia. Iodide of potassium rarely occasions such unpleasant effects as to demand more than a mere temporary suspension of its employ- ment. Its morbid action is chiefly manifest upon the various mu- cous membranes. Some patients, shortly after commencing its use, are seized with coryza, which is sometimes quite severe, and accom- panied with acute pain in the frontal sinuses; others are attacked with oedema of the conjunctiva oculi and swelling of the lids; irri- tation about the fauces' and bronchitis are occasionally met with, and even oedema of the glottis. Gastro-intestinal irritation is a frequent symptom which has already been adverted to. Loss of vision, apparently dependent upon sub-retinal effusion, has been observed in a few rare instances. Salivation sometimes occurs, but is never as severe as that occasioned by mercury, nor is it ever attended by ulceration like the latter. It has been asserted that iodide of potassium produces atrophy of the breasts and of the testicles; but this is denied by Ricord, who states that he has accu- rately measured the scrotal organs before and after treatment, and has never found any diminution in their volume, unless they were 1 Modern Treatment of Syphilitic Diseases, Am. ed., Phil. 1854, p. 258. 34 530 TREATMENT OF SYPHILIS. affected with syphilitic orchitis, which generally terminates in atro- phy. Iodide of potassium may hasten this result, when it would inevitably have taken place without it, but cannot produce it in healthy organs. Langston Parker also coincides with Ricord in the opinion that the prolonged use of the iodide does not produce wasting of the testes and mammae. One of the most frequent morbid effects of this remedy consists of various eruptions upon the integument, generally in the form of papules or pustules resembling acne, and often of furuncles or boils. They are quite common about the neck and face, where they present an unsightly appearance and are the source of much annoyance to patients who frequent society; and also upon the trunk and upper extremities. The eruptions produced by the ad- ministration of iodide of potassium and other compounds of iodine have been carefully studied by Dr. H. E. Fischer,1 of Vienna, who divides them into the erythematous, papular, tuberculo-pustular, and eczematous. In the erythematous form, the skin, and especially that covering the forearm, assumes an intense red color, which is sometimes iso- lated in points, and at other times covers the whole surface; the temperature of the part is also heightened. This erythema disap- pears if the treatment be suspended, or, if the latter be continued, runs into the following form. The papular, which is by far the most common form, may ap- pear over the whole integument, but is chiefly met with upon the extremities and abdomen. The papules are but slightly elevated above the surface; are of an intense red color, which disappears on pressure; measure from half a line to two lines in diameter, and resemble urticaria; the larger papules are surrounded by a red areola, and are sometimes isolated and at other times in groups. They are developed without any general febrile disturbance, have no injurious effect upon the general system, and disappear without desquamation upon the suspension of the iodide. The tuberculo-pustular form is rarer than either of the preceding, and is chiefly met with in strumous subjects. A red spot, attended with itching, is first observed, which is soon transformed into a small tubercle, with or without an areola; in most cases a vesicle or pustule forms on its summit, which sometimes bursts and discharges ' L'Union Medicale, Jan. 31, 1860; from the Wien Medizin. Wochenschrift. IODINE AND ITS COMPOUNDS. 531 its contents, and at other times dries into a scab, which falls off, leaving only the tubercle behind it. The tubercles are of a bluish color, throw off scales in the process of resolution, and are very slow to disappear, even if the iodide be suspended. They leave behind them stains of a bluish-red color, which are often indelible. Intermediate forms, consisting of vesicles, pustules or boils, have been noticed by several writers. The eczematous variety, which closely resembles ordinary eczema, is very rare. It most frequently affects the hairy scalp and the neighborhood of the scrotum, and soon disappears on stopping the iodide. M- Mercier1 describes a case in which moderate doses of iodide of potassium, upon two occasions in the same person, brought out an eruption of eczema rubrum over the whole body, attended by severe fever and dyspnoea, and so copious an exudation of fluid that the bed on which the patient lay was completely wet through. In all the cases upon which these observations were made, the preparation of iodine employed was either the iodide of potassium or of sodium. The eruptions did not appear to depend upon the quantity administered, since they were often produced by small doses, and were frequently absent when the remedy was pushed to iodism. Mr. Langston Parker has described a hard, tubercular condition of the tongue, which is sometimes cracked and fissured, consequent upon the long-continued use of iodine.2 This affection closely resembles syphilitic tubercles, from which it may be distinguished by its disappearance soon after the discontinuance of the iodine. In addition to the morbid effects already mentioned, iodide of potassium in large doses sometimes gives rise to a combination of symptoms known under the name of " iodism," and consisting of a sensation of oppression in the head, tinnitus aurium, neuralgia, spasmodic action of the muscles, impaired voluntary motion, and sluggishness of the intellect. Rilliet has also described a form of iodic intoxication which he calls " constitutional iodism," charac- terized by rapid emaciation, an enormous appetite, and nervous palpitation, and which is, moreover, peculiar in this respect that it is produced by minute rather than by large doses of the iodide of 1 Observations Nouvelles sur le Traitement des Valvules du Col de la Vessie, Paris, 1847, and L'Union Medicale. Feb. 11, 1860. 1 Provincial Medical and Surgical Journal, No. 3,1852 ; also, Syphilitic Diseases, p. 211. 532 TREATMENT OF SYPHILIS. potassium and other compounds of iodine. Rilliet's observations were all based upon cases in which iodine was employed in the treatment of goitre in Switzerland. His paper was the subject of a lengthy discussion before the French Academy of Medicine in 1860, in which Ricord, Velpeau, Gibert, Trousseau, and Bou- chardat took a prominent part, and in which no very definite con- clusion was arrived at. It was generally confessed, however, that Rilliet's observations, coming from so accurate an observer, were worthy of confidence, but that the affection described was unknown to the members of the Academy, many of whom had had very ex- tensive experience in the use of iodine and its compounds; and it was suggested that the goitre, for which the remedy was given, might have had some influence in the production of the above mentioned symptoms. Vegetable Decoctions and Infusions.—Decoctions and in- fusions of sarsaparilla, saponaria, water-dock, stillingia, and other vegetable substances have at times enjoyed considerable reputation with the profession for the cure of syphilis, and are still held in high repute by the public. When used alone they are found to be en- tirely destitute of anti-syphilitic properties, and when given in combination with mercurials and iodide of potassium, do not appear to add to the effect of the latter. This statement coincides with the opinion of most surgeons1 who have had the largest experience in their use, and has recently been confirmed, so far as regards sarsa- parilla, the reputation of which has exceeded that of all the others, by a series of careful experiments conducted by Sigmund, of Vienna, who concludes that this substance does not exercise the slightest perceptible influence on the course or termination of syphilitic dis- eases.* Whatever virtues are possessed by these substances can only be ascribed to their influence as tonics, stomachics, diuretics, or diaphoretics, to which the ordinary mode of their administration in a large amount of fluid greatly contributes. When employed with these purposes in view they may prove useful adjuvants of mercury and iodide of potassium, but alone are unworthy of con- fidence. The ordinary decoctions and infusions are very bulky, and their '•See Stilll's Materia Medica, ii. p. 948. 2 British and For. Med.-Chir. Rev., Am. ed., July, 1860,p. 183. NITRIC ACID — SYPHILIZATION. 533 preparation not always convenient; I am therefore in the habit of using Thayer's fluid extracts, which I have found very reliable. A teaspoonful of the compound fluid extract of sarsaparilla, prepared by this chemist, may be mixed with a tumblerful of warm water at the time of using. Zittman's decoction (Vid. U. S. Dispensatory), which enjoys a high reputation in Germany, is of two kinds, the stronger and the weaker. " Of the former, the patient is required to drink eighteen ounces every morning before rising, and of the latter, thirty-six ounces every afternoon, and of the stronger decoction, again, eighteen ounces every evening, during four or five days." These prepara- tions contain an appreciable amount of mercury, and their adminis- tration is associated with a rigid diet, aperients, and rest in bed. Nitric Acid.—Nitric acid was formerly recommended by Alyon, and others, for the treatment of syphilis, and is still a favorite remedy with the homoeopaths. I have employed it as a tonic with satisfactory results in the late stages of syphilis- when mercury was inadmissible, but the iodide of potassium is, in most cases, more reliable. SYPHILIZATION. About the year 1844, M. Auzias-Turenne, of Paris, undertook a series of experiments to test the accuracy of the doctrine advanced by Hunter and Ricord, that syphilis was not communicable to the lower animals, and after protecting the inoculated points in such a manner that the animal could not lick the sore and thus remove the virus, succeeded in developing soft chancres upon monkeys, cats, rabbits, and horses; and that the ulcers thus pro- duced were truly chancroids was fully proved by four successful inoculations of their secretion upon the person of M. Robert de Welz, of Wiirzburg, who offered himself for the purpose. These results were afterwards confirmed in three experiments performed by Diday, of Lyons, in one of which he inoculated the secretion of a chancroid upon the ear of a cat, thence transferred the virus to the opposite ear of the same animal, and finall/inoculated matter from the second sore upon his own penis. The result was a phagedenic chancre and bubo, which remained open for four months before cicatrization took place, and seriously affected his general health, 534 TREATMENT OF SYPHILIS. although neither then nor since have any constitutional symptoms appeared. ' These experiments conclusively prove that the virus of a soft chancre may be inoculated upon the lower animals and from them back again to man. The same has been maintained of the virus of true syphilis, several instances having been reported in which secondary and tertiary lesions are said to have occurred in animals after artificial inoculation, but in none of which is the fact estab- lished beyond a doubt, and this point must therefore be left open for future observation. On November 18, 1850, M. Auzias announced to the French Academy of Sciences that while performing these experiments he had observed that the first chancre inoculated upon an animal was more rapidly developed, was of a larger size, secreted a greater quantity of matter, was surrounded by more intense inflammation, and was more persistent than the second; that the second bore the same relation to the third; the third to the fourth, and so on, and that finally a period arrived when further inoculations entirely failed. The condition of the animal after immunity was attained was compared by the author to the protection afforded by vaccina- tion against variola, and the process was denominated syphilization. I find that similar phenomena had been observed before the time of M. Auzias; since Dr. Graves,1 in quoting Dr. Fricke, of Hamburg, says: "If a person affected with chancre were inocu- lated with the matter of that chancre on a fresh spot, and from this on a third and so on, it will be found that this process can be repeated only a few times with success. The individual becomes, as it were, habituated to the virus, and less capable of its influence." These remarks, however, of Fricke, had attracted but little attention, or had been forgotten when Auzias announced his discovery in 1850. The facts now stated are the basis of the modern doctrine and practice of syphilization. Although their discoverer had not at this time subjected them fully to the test of experiment upon man, yet he did not hesitate to draw from them certain general conclu- sions which may be summed up as follows :— 1. The system may be so saturated with the syphilitic' poison ' London Medical Gazette, 1838-9, vol. i. p 697 nizTandTu^r ***** ^W °f *" ^ S*°™* of cha"cre ™ «*og- mzed and Auz.as, like many subsequent observers, erroneously supposed that his experiments were performed with the true syphilitic virus SYPHILIZATION. 535 by successive inoculations, that the further application of the virus will prove innocuous. 2. Syphilization may be resorted to as a prophylactic against syphilis in healthy persons, in the same manner as vaccination is employed as a preventive of variola. 3. Syphilization is capable of curing persons already infected with syphilis. The proposition to employ syphilization as a prophylactic agent in healthy persons did more than anything else to prevent the new doctrine from receiving the attention it deserved, and was the chief cause of the violent opposition it received and of its final rejection before the Academy. This idea was never, I believe, entertained by any one except its author, who himself soon aban- doned it. It would serve no useful purpose to enter into a minute account of the history of syphilization from that time to the present. Suf- fice it to say that it was for the first time put in practice upon a large scale, in January, 1851, by Sperino, Physician and Surgeon in Chief to the Syphilocome or Venereal Hospital at Turin, who, in May of the same year, made a report to the Medico-Chirurgical Society of that city, in which he gave the histories of fifty-two prostitutes who had been cured of syphilis by the new method; and in 1853 he published a large work upon syphilization in which the whole subject was thoroughly discussed, and the number of cures reported was increased to ninety-six. Meanwhile Gam- berini at Bologna and Gulligo at Florence pursued similar investi- gations with results which were equally favorable to the new doctrine. The practice of syphilization for the cure of syphilis thus origi- nating among the ardent temperaments of the South of Europe was destined to be still further investigated by the cooler heads of a more northern clime, where it has since been pursued with a degree of candor, impartiality and scientific research which absolve it from the charge of being the wild scheme of crack-brained en- thusiasts, and which entitle it to profound consideration. Dr. Wil- liam Boeck, Professor of Medicine in the University of Christiana, while travelling in Italy in 1851, heard of Sperino's experiments, and upon his return home determined to repeat them upon patients under his charge. He was not able, however, to obtain inoculable virus until October, 1852, when his first inoculations were made, 536 TREATMENT OF SYPHILIS. and in March, 1858, he had already syphilized more than two hun- dred persons.1 Other Scandinavian physicians soon took up the same practice, and hence the results obtained in Norway and Swe- den are those which chiefly claim our attention, and which afford the most reliable data for arriving at the correct explanation of the phenomena first observed by Auzias-Turenne and Sperino. The method of performing syphilization is very simple, and consists of successive inoculations of chancrous matter upon some convenient part of the body, either the lower part of the abdomen or the arms and thighs being generally selected. Sperino prefers the former and Boeck the latter regions. The virus on each occa- sion subsequent to the first is taken from the sores produced by the preceding inoculations, of which Boeck makes from eight to ten every three days. More frequent or more numerous punctures are not considered desirable, since it is stated that when the process of syphilization is carried on with great rapidity, immunity is at- tained before the syphilitic symptoms are cured. Boeck never resorts to syphilization for primary syphilis alone, regarding it as uncertain whether general symptoms will follow, and limits the practice to the secondary and tertiary forms of the disease. He states that it is only the first twenty or thirty chancres which attain any considerable size; that the subsequent ones become smaller and smaller; and that finally inoculation of the matter which was first employed ceases to have any effect whatever when implanted beneath the epidermis. When immunity to the first virus is obtained, he takes fresh matter from another source, with which he is able to produce a new series of inoculations, but the sores are never so large nor can as many be made as in the pre- ceding series. A third or even a fourth or fifth fresh quantity of matter may succeed in exciting a few insignificant pustules, but finally complete and permanent immunity is obtained, when chan- crous matter from any source whatever has no more effect than so much water. We shall see hereafter, that this statement of Dr Boeck is denied by Dr. Faye and others. Boeck states that in a few instances he has been able to effect a permanent cure of syphi- lis with matter from one source alone. Boeck resolutely pursues the treatment in spite of any alarming Med0^""1;011 ^ ;heAMef C0-Chir-gical Soc. of Edinb., March 3,1858, Edinb. Med. and Surg. Journal, April, 1858. SYPHILIZATION. 537 symptoms which may supervene. He regards the occurrence of phagedena as an indication for persevering in the inoculations, and even looks upon intercurrent iritis without apprehension, and says that it disappears spontaneously and without any special treatment. In respect to the results of this practice, Boeck divides patients into two classes, those who have been exempt from all previous treatment, and those who have already taken mercury. He has found that the former without a single exception can be cured by syphilization alone. The latter do not improve with the same uni- formity; relapses frequently occur, and it is often necessary to administer preparations of iodine in conjunction with the treatment by syphilization. Boeck resorts to syphilization in the syphilis of infants as well as of adults. The effect upon the general health is decidedly bene- ficial. Patients are allowed to eat and drink what they please, and to continue their usual avocations. Weak subjects never fail to gain in flesh and strength, and after being fully syphilized are as strong and healthy as they were before they were attacked with syphilis. At the time when his communication to the Medico-Chirurgical Society of Edinburgh was written, Boeck had met with only three relapses in one hundred cases, and these were cured by a second syphilization, in which but a small number of inoculations was requisite. The average duration of treatment in ordinary cases was about six months, and in the more severe cases of inveterate syphilis from seven to eight months. In summing up the results of his practice, Boeck says: " I have, indeed, the most sincere con- viction and proof— " 1. That there is no fact more certain, in medical and surgical therapeutics, than the fact of the curability of constitutional syphilis by syphilization. " 2. That this method of curing constitutional syphilis is infinitely more certain than the methods of cure by mercury, iodine, hunger- cure, or any other means yet proposed. "3. That it is free from the dangers attending the mercurial treatment; and " 4. That relapses are more rare after this than after any other known method of treating secondary or tertiary syphilis."1 • Letter to the Medical Times and Gazette, Sept. 19, 1857, p. 305. 538 TREATMENT OF SYPHILIS. Boeck has wavered somewhat in his opinion as to the necessity of continuing the treatment after the syphilitic symptoms have dis- appeared and until absolute immunity to the virus is attained, but his last as well as his first statements are in favor of this course. Dr. Faye, of Christiana, who has taken a prominent part in the discussions relative to syphilization, although he has had no per- sonal experience in the practice, does not deny its power to cure syphilis, but maintains that the supposed immunity is fictitious, and that if the chancrous virus be applied in larger quantities and more deeply beneath the skin, the inoculations will almost inva- riably succeed. He relates two instances in which he was thus able to produce chancres in persons who had passed through a course of syphilization, and who were thought to be insusceptible of farther inoculation. Numerous other physicians of Norway and Sweden have resorted to the practice of syphilization, of whom the most eminent is Dr. Danielssen, of Bergen, who has employed inoculations of chancrous virus both for the purpose of curing syphilis, and with the hope (which does not appear as yet to have been realized) of so modifying the constitution of persons affected with lepra, though free from syphilitic taint, as to destroy the leprous diathesis. Dr. Danielssen believes that the so-called immunity to the chancrous virus, which has been supposed to be attained by saturation of the system with the poison of syphilis, is simply a loss of reacting power in the skin which it sooner or later regains; and in accordance with this view, which I believe to be correct, the immunity is not permanent, but merely temporary. Sufficient has now been said with reference to the manner of per- forming syphilization, and its origin and progress up to the present time. It remains for us to inquire what credit can be given to the results reported by the advocates of this new mode of practice, and how the phenomena which are said to have been observed are to be explained. 1. Is syphilization an efficient and safe method of treating constitu- tional syphilis f—With the testimony before us, there can be but one answer to this question, and that in the affirmative. The inocu- lations of Boeck, Danielssen, and others, have been performed not in private practice and under the observation of a few persons only but in public hospitals, where they could be seen by any one who chose to witness them. The novelty of the practice has naturally SYPHILIZATION. 539 attracted numerous visitors, not only from the neighborhood, but also from a distance, and, from among them all, not a single voice has been heard to call in question the truth of the cures reported; on the contrary, the testimony in favor of their authenticity is universal. At an animated discussion relative to the theory of syphilization before the Norwegian Medical Society, which was con- tinued for six meetings, it was generally admitted that the facts in the case could not be impugned, and several members who had formerly been violently opposed to the new practice, but who had been led to examine it more carefully, publicly gave in their adhesion to it. Among the visitors from abroad who, from personal examina- tion, have reported in favor of syphilization, and whose position adds weight to their testimony, are the editor of the Dublin Quar- terly Journal of Medicine, and the author of an able article in the Medico-Chirurgical Review. The former says: "During a visit paid by the editor of this journal to Stockholm, last autumn (1856), he saw under the care of his friend, Professor Malmsten, in the Sera- phim Hospital, some cases of secondary syphilis which had been cured, and some which were progressing towards cure, by the syphilization treatment, after having obstinately resisted all other therapeutic means. He was much interested in this subject, the more especially as he had previously altogether discredited the statements which had been published as to its efficacy as a thera- peutic agent, but could no longer doubt the living evidence which was there submitted to his observation, and the testimony of several of the most celebrated physicians and surgeons of the Swedish capital."1 The latter says: "It seems, indeed, a bold assertion to maintain that one of the most intense animal poisons can be annihilated, as it were, by the introduction of fresh poison into the system, until at length the venereal virus has no more effect on the patient than a drop of water. That sujm immunity does take place, we must concede as an undoubted fact. The unanimous testimony of Boeck, of Danielssen, of Sperino, and of Auzias-Turenne, of Carlsson, and of Stenberg, in Stockholm, all concur on this point; nor could we anywhere obtain a denial of this fact, either from the patients or from Dr. Boeck's colleagues, when we visited Christiana this past summer." 1 Dublin Quarterly Journal of Medical Science, Feb. 1857, p. 77. 540 TREATMENT OF SYPHILIS. With reference to the improvement of the general health during the process of syphilization, this reviewer says: "Singular as this may seem, it is^ most certainly true, as we have ascertained from personal observation in the Christiana and Bergen hospitals. We conversed with several of the patients, and questioned them upon this point, and all declared that their general health had greatly improved under the treatment. Full diet was allowed, and it may be suggested that this contributed much to the improvement ob- served, as it is, perhaps, of a more nourishing character than the ordinary diet of the Norwegian laborer. The sensations of weari- ness, the sleeplessness, and the pains resembling rheumatism, rapidly disappeared, and the aspect of many of the patients presented an appearance of health such as could not have been expected. More- over, the patients, when cured, could at once return to their ordi- nary occupations—they could expose themselves to the vicissitudes of the climate, to wet and to cold, without the fear of evil conse- quences, such as might justly be apprehended in those who had undergone a mercurial course."1 A distinguished writer on venereal, M. Melchior Robert, of Mar- seilles, has published five cases of successful treatment of syphilis by means of syphilization, and has declared himself a convert to the new doctrine.3 Prof. Hebra—if we may believe a paragraph in recent medical journals—has taken the same ground; and, finally, Diday,3 in a review of Melchior Robert's paper, admits that syphilitic symptoms disappear under repeated inoculations of the chancroidal virus, but only, as he maintains, in consequence of depuratory action, and not from absorption of the poison. With such an amount of evidence before us, we must either altogether deny the value of testimony or admit the safety and efficiency of syphilization in the treatment of syphilis. 2. How are the facts of syphilization to be explained?—Auzias- Turenne and Sperino both believed th#t the therapeutic effect of ' British and Foreign Med.-Chir. Rev., April, 1857, p. 319 and 324. I desire to acknowledge my indebtedness for much that is contained in the present section to this review, and especially to another by the same author in the number of this journal for January, 1S59. In the latter, the able writer abandons the theory that the system becomes saturated from absorption of the virus, and adopts the opinion of Dr. Danielssen, that the disappearance of the symptoms is due to prolonged sup- puration. 2 Pamphlet in 8vo., pp. 45, Marseilles, 1859. * Gaz. Med. de Lyon, No. 19, 1860. SYPHILIZATION. 541 syphilization was due to the absorption of the virus and the satu- ration of the system with the poison; but as Dr. Faye remarks, "no system of physiology or pathology has as yet made us ac- quainted with a chronic zymosis or blood-poisoning, which, under a constant reintroduction of the poison, operates in one case bene- ficially and in another is followed by the most serious consequences;" and this theory of syphilization, advanced by its founders, was so contrary to all rules of pathology that it was a great obstacle to the speedy reception of the new doctrine. Boeck was unwilling to adopt this theory, to which he objected that if saturation really took place the symptoms would become worse instead of better. He did not, however, attempt to offer a substitute, and confessed that he adopted the practice on empirical grounds alone. It should be observed that neither of these three authors admits a distinction between the virus of the soft and that of the hard chancre. The first approach to the true explanation of the facts observed in syphilization was made by Prof. Faye, who, as before stated, denied the prophylactic power of this method, and asserted that the alleged immunity to the virus was only "a temporary immunity of the over-stimulated skin, and that the cure of the syphilitic symp- toms was due to the depuratory action of the sores excited by successive inoculations." This theory, which was much more in accordance with our general ideas of pathology than the one ad- vanced by Auzias and Sperino, was yet deficient in that it was not sustained by any known facts, and it consequently failed to attract the attention it deserved. The proof which was wanting has since been supplied by Danielssen, whose experience with syphilization in lepers not affected with syphilis has conclusively shown that no absorption of the virus takes place, and consequently that the cure of syphilitic symptoms cannot be due to saturation of the system with the poison. He gives the histories of six cases in which ino- culations were performed upon persons untainted with syphilis with the virus commonly used in syphilization, but in which the treatment was not pushed to the extent of so-called immunity, and in not one of the six did any general symptom appear. With reference to these cases, Danielssen remarks: "It appears from the above details, that neither one chancre, nor two, nor three, nor six, nor thirty-six, nor one hundred and thirty-six have in the preceding cases induced secondary syphilis, and that, therefore, the direct operation of the inoculations has been exclusively limited to 542 TREATMENT OF SYPHILIS. the spot where the chancres had shown themselves. If such be the case, we are justified in assuming that no greater number of chan- cres will produce a different result. And this is confirmed by our experience; for with one exception, to which we shall subsequently allude, not one of those individuals, previously free from all syphi- litic taint, whom I have syphilized, have been affected by secondary syphilis; nor have they shown any signs of the existence of the venereal diathesis in their systems. Nor, in those already affected with syphilis, have I observed under syphilization the slightest evidence of their having imbibed the poison afresh. So far from seeing in syphilization a new physiological fact, as Boeck denomi- nates it, I have, on the contrary, found it confirm a long-established axiom, viz., that the simple soft chancre does not affect the system, and consequently does not produce constitutional syphilis. Among the many thousand artificial chancres that I have seen, I have not observed one (with a single exception) which was not of this char- acter, both in my own practice and in that of my colleagues, and as inoculated on every part of the body. Even on the face, the soft chancre followed inoculation, contrary to Ricord's experience, who had always observed the indurated chancre there."1 The exceptional case referred to in the above remarks is highly important, since it strongly confirms the position here assumed. Syphilization had been performed upon a leper with the virus of the soft chancre to the extent of nearly 400 inoculations, when the secretion of an indurated chancre was accidentally inoculated. The inoculated point healed, but a month afterwards an indurated sore appeared followed by unmistakable signs of secondary syphilis, show- ing that the previous inoculations with the chancroidal virus, which had been striotly local in their action, had afforded no protection whatever against true syphilis. Danielssen's conclusions as to the kind of virus which has been employed in reported cases of syphilization are borne out by an examination of the writings of Boeck and others. Boeck, for in- stance, states that the best matter for the purposes of syphilization is that derived from a chancre attended by a suppurating bubo- but a primary sore with this accompaniment is generally a chan- croid and not a true chancre. Again, all observers state that a pustule is so far developed by the second or third day after inocu- 1 Medico-Chirurg. Rev., Jan. 1859, p. 98. SYPHILIZATION. 543 lation, as to furnish matter for fresh inoculations; but the absence of a period of incubation and a pustular form at the outset are characteristics of the soft and not of the hard chancre. The value of this testimony from Boeck is increased, because given uncon- sciously by one who does not recognize the distinction between the two kinds of primary sore. Yet, after all, there is no necessity to search for these minor indications to enable us to determine what species of virus has been employed in successful inoculations of persons already infected with syphilis, since the experiments of Ricord, Fournier, Rollet, and many others, have conclusively shown that under these circumstances those only can succeed which are performed with the secretion of the chancroid. As already stated, Danielssen attributes the disappearance of the syphilitic symptoms during the process of syphilization to depura- tory action, and in confirmation of this opinion, calls attention to the fact that in tertiary syphilis, nature herself often produces deep suppurations under which, if the strength holds out, all secondary symptoms disappear. Admitting the plausibility and in all probability the correctness of this explanation, we cannot, therefore, infer that the same effect would be obtained from issues or setons; since the soft chancre, when once implanted beneath the epidermis, spontaneously main- tains its hold upon the integument for weeks or even months, and is with difficulty eradicated; while a sore produced by the knife or caustic constantly tends to heal, and can only be kept open by irri- tants or the introduction of some foreign substance; and since the conditions of the existence of these two lesions are so widely differ- ent, it is not unreasonable to suppose that the effect will not be the same. Farther observation and experiment are, however, requisite to fully settle this point. The only attempt in this direction, so far as I am aware, has been made by Cullerier,1 who has experimented with a rapid suc- cession of numerous blisters in the treatment of syphilis, and states that they gradually lose their effect upon the integument and finally excite but little if any irritation. The effect of this treat- ment upon the syphilitic manifestations does not appear to have 1 Parisot, Traitement de la Syphilis par les Vesicatoires Multiples. These de Paris; reviewed in the Arch. Gen. de Med., July, 1858, p. 93. 544 TREATMENT OF SYPHILIS. been very satisfactory, although several cures are said to have been 0boteJresent knowledge of the results and theory of syphilization may be summed up in the following propositions :— 1 The evidence appears to be indubitable that the treatment of syphilis by syphilization in efficiency and safety is equal and proba- bly superior to the treatment of the same disease by mercury. 2 The susceptibility of the skin to the development of chancroids diminishes under repeated inoculations, until finally apparent im- munity is attained. . 3 The secretion of simple chancres has alone been employed m the successful inoculations of syphilization upon persons tainted with syphilis. 4. No absorption of the virus takes place, and the therapeutic effect is probably due to the depuratory action of prolonged sup- puration. 5. The immunity which is acquired is probably neither absolute nor permanent, and consists in a partial and temporary loss of reacting power of the skin consequent upon over-stimulation.1 6. The facts of syphilization do not conflict with, but, on the contrary, sustain the doctrine of the duality of the chancrous virus. While the study of science should never be pursued at the ex- pense of morality or modesty, no false ideas of morality or modesty should deter scientific men from the investigation of truths which are likely to benefit mankind. The only immorality and im- modesty in syphilization as originally proposed, was the wild scheme of its founders to subject to this process those persons who were free from syphilitic taint. Of how little value such a course would be is evident from Donalssen's case referred to above. The idea itself was soon abandoned by the men who originated it, and has not at the present day a single advocate. Divested of this folly and sustained as it now is by the testimony of high minded and honorable men, syphilization is a subject of pure scientific interest which no one need fear to discuss nor carefully to experiment upon, 1 Every practitioner must, I think, have noticed the fact that, in employing liniments containing croton oil, aqua ammonia, etc., it is necessary from time to time to increase the proportion of the irritant, or otherwise the application ceases to affect the skin. SYPHILIZATION. 545 with the laudable object in view of obtaining a more certain cure of syphilis, the treatment of which by mercury and iodine is con- fessedly imperfect. At the same time it must be conceded that the method by which syphilization is accomplished is repugnant to the feelings, and it is safe to predict that this mode of practice will not be generally adopted, at least in this country, until the already strong evidence in its favor shall be followed by proof that is per- fectly irresistible. 35 546 SYPHILITIC FEVER. CHAPTER VI. SYPHILITIC FEVER; STATE OF THE BLOOD; EN- GORGEMENT OF THE LYMPHATIC GANGLIA. In many cases of constitutional infection, the appearance of the earliest secondary eruption is preceded by certain symptoms which resemble those that usher in the exanthemata. The patient suffers from a general feeling of uneasiness, is listless and disinclined to attend to his ordinary occupations, has a pale, sallow, and haggard look, and is attacked with severe headache and rheumatic pains in various parts of the body, which are worse at night and deprive him of rest. The only statistics that I know of from which the frequency of this eruptive fever may be accurately determined, are those given by Bassereau, who met with it in 143 of 199 cases of syphilitic erythema; and its apparent absence in at least a portion of the re- maining cases is attributed, by this author, either to the fact that it was overlooked, or to the administration of mercurials for the pri- mary sore.1 Victor de Meric2 is inclined to doubt the constancy of this precursory febrile disturbance, but I have met with it in the majority of cases of early secondary symptoms in persons who had not taken mercury. Although this fever usually precedes by eight or ten days an early secondary eruption, it is impossible to regard it as a mere forerunner of the latter, since it frequently continues after the eruption appears, and in some cases commences at the same time or even follows it. The headache, which is a prominent symptom, is generally, though not always, most severe at night, and appears to be seated in the periosteum. It is sometimes diffused over the whole cra- nium, and at other times confined to the frontal region. Not 1 Bassereau, op. cit., p. 163. * Lettsomian Lectures, p. 29. STATE OF THE BLOOD. 547 unfrequently the patient has periodical attacks, consisting of a chill, followed by a hot stage and sweating, which recur with great regularity at a certain hour of the day, generally towards evening, and are liable to be mistaken for intermittent fever. Indeed, several cases, in which this error has been committed, are reported by Bassereau and Yvaren.1 The osteocopic pains of this early stage of general syphilis differ from those which belong to the tertiary period in affecting chiefly the neighborhood of the joints and in their transitory character. They are most severe at night when the patient is warm in bed, generally subside towards morning, and are absent during the day unless brought on by motion. The larger joints of the upper and lower extremities are most frequently attacked, and in some cases motion is rendered difficult and painful. Bassereau relates a case occurring in Ricord's wards, in which the elbow-joint was swollen, red, and incapable of extension, and which a young surgeon had mistaken for a dislocation and attempted to reduce. In most cases, however, there are no symptoms of local inflammation, except perhaps slight tenderness on pressure, and the pain passes from joint to joint, or is felt in other parts of the body, as the back of the neck, the lumbar region, upon the sternum, etc., and occasionally the continuity of the bones is involved. In some cases the digestive functions are disordered; the appetite is diminished, the tongue coated, and the patient is attacked with nausea and diarrhoea. In others, these symptoms are absent and the appetite may even be inordinately increased. Epistaxis, oedema of the lower extremities, palpitations, and a bruit de souffle accompanying the first sound of the heart and audible both in the cardiac region and over the carotids, have also been noted. According to Bassereau, these symptoms generally become more severe and persist for some time after the appearance of the erup- tion, though in some instances they suddenly cease upon the out- break of syphilitic erythema or papulae, or diminish and gradually disappear in the course of one or two weeks. State of the Blood.—The general malaise, lassitude, headache, pallor of the countenance, palpitations, and bruit de souffle, belonging to this category of early general symptoms, are indicative of chloro- 1 Metamorphoses de la Syphilis, p. 173 et seq. 548 syphilitic fever. anosmia, and that this condition of the system really exists at this period of constitutional infection, is still further proved by a series of analyses of the blood performed by M. Grassi under the direction of Ricord; from which it appears that in persons bearing infecting chancres, there is a diminution of the blood-corpuscles and an in- crease in the proportion of albumen; the amount of fibrin is not affected. This chloro-ansemia is confined to the early stage of consti- tutional infection; the blood soon recovers its normal composition and retains it throughout the whole course of the disease unless syphilitic cachexia supervenes. Though foreign to our present subject, it may be mentioned incidentally, that the blood of persons affected with simple chancres was shown in a second series of analyses by Ricord and Grassi to remain unchanged; and thus these experiments, which were performed before the question of the duality of the chancrous virus had been mooted, are confirmatory of the distinction which is now recognized between the chancroid and the infecting chancre.1 Engorgement of the Cervical Ganglia.—A very important symptom of the early stage of constitutional infection, and one which the surgeon should never fail to look for in cases of difficult diag- nosis, is engorgement of the lymphatic ganglia in various parts of the body, and especially those situated upon the lateral and poste- rior portions of the neck. We are not here speaking of the indu- ration of the ganglia in anatomical connection with primary sores —the indurated buboes so-called, which assume their cartilaginous hardness about the same time as the base of the chancre. The symptom referred to is an engorgement—not induration—of glands at a distance from the point where the virus entered the system, and first appears some six or eight weeks after the chancre in conjunction with other early secondary manifestations. This symptom is present in a large majority of cases at this stage of the disease. Ricord speaks of it as " perhaps the most constant, the earliest, and the most characteristic symptom of constitutional syphilis."2 Bassereau3 found it in ninety per cent, of all the cases of syphilitic erythema which came under his observation; and in 1 Ricord, Lecras sur la Chancre, 2d ed., p. 184. * Iconographie, Remarks on the case figured in Plate XLV. 3 Op. cit., p. C8. ENGORGEMENT OF THE CERVICAL GANGLIA. 549 most of the exceptional cases the patients had taken mercury or were not seen for some time after the eruption appeared. It is an early symptom of constitutional infection, and occurs, if at all, within a year after contagion. Ricord states that it is rarely seen in persons who contract syphilis after forty years of age, though Bassereau met with one case in a man aged sixty-three, and another in one aged seventy-four; from which it would appear that this rule is by no means invariable. The glands most frequently affected are those situated along the upper two-thirds of the posterior border of the sterno-cleido mas- toideus muscle; but those on the back of the neck beneath the occiput, and one just posterior to the ear and over the mastoid pro- cess may also be involved. All the glands in the regions mentioned are not, however, implicated in the same person; the number is frequently but one or two, and rarely exceeds six or eight. In a state of health these bodies can with difficulty be detected; but, when enlarged by syphilis, they may attain the size of a bean or almond, and are often so prominent as to be recognized by the sight as well as the touch, and even to attract the notice of the patient's unprofessional associates. As a general rule, their number and size correspond to the extent and severity of the neighboring erup- tion upon the scalp. Other glands besides those of the neck may be engorged in the same manner. Sigmund has especially insisted upon enlargement of a lymphatic gland situated between the biceps and triceps muscles just above the internal condyle of the humerus, where I have in several instances observed it, although I do not believe it to be as constant as Sigmund's remarks would lead one to suppose. Bassereau has found the glands of the axilla affected, but only in case there was a papular or pustular eruption in the neighborhood of the shoulder. The submaxillary ganglia are also not unfre- quently tumefied, when the throat is the seat of syphilitic angina or when the mouth is made sore by the use of mercury. This engorgement of the ganglia almost invariably terminates in resolution. In one case only, so far as I am aware, has suppura- tion been known to take place. This occurred in a patient, aged 30, of a scrofulous habit, under the care of Bassereau, in whom two collections of matter were formed in the cellular tissue around the gland, attended by severe febrile excitement and requiring puncture. 550 SYPHILITIC FEVER. Some difference of opinion has been entertained as to the ques- tion whether this engorgement is necessarily dependent upon a neighboring eruption upon the scalp or integument. Ricord be- lieves that it is not, and states in support of his opinion that it often occurs before the slightest trace of an eruption is visible; and to meet the objection that a pustule of ecthyma might be concealed in the hair and escape notice, this surgeon has repeatedly shaved the head and proved the scalp to be intact. Admitting, however, that the engorgement of the glands precedes the eruption, it does not disprove the connection between the two, which is rendered probable by the correspondence in their intensity; and swelling of the submaxillary glands, as is well known, is often anterior to an eruption of erysipelas upon the face. SYPHILITIC AFFECTIONS OF THE SKIN. 551 CHAPTER VII. SYPHILITIC AFFECTIONS OF THE SKIN. Syphilitic are distinguished from other eruptions by certain peculiarities, no one of which by itself possesses absolute value, but several of which combined are generally sufficient to establish the diagnosis. The color of a syphilitic eruption will often indicate its origin. No very definite idea of this color, however, can be conveyed by words. To be appreciated, the eye must be educated to detect it upon the living body, and the student should neglect no oppor- tunity to compare this and other objective symptoms of specific eruptions with those pertaining to their congeners of different origin. The older writers on venereal compared it to the cut sur- face of a ham;1 it is now commonly known as the copper color; but both these comparisons fail to convey a perfect idea of the exact hue that is intended. It is best described as a reddish- brown with a slight admixture of yellow, which in many cases is modified by the natural color of the skin and by the age of the eruption. The copper color of syphilitic eruptions, however, is by no means constant, and may be simulated by various forms of skin disease which are not dependent upon the syphilitic virus. Thus it is never seen in mucous patches, which are either red or of a grayish white hue. It is absent in most cases of syphilitic erythema at the commencement of the eruption, and only appears as the blotches begin to fade away; and, as a general rule, in nearly all syphilitic eruptions, the copper color is less marked at an early than at a late period. Again, the cicatrices of lupus, acne, and variola, may assume a reddish-brown color which is readily mistaken for ' "Secate per transversum pernam, talis est color pustularum sine cortice." Gabriel Fallopius. 552 SYPHILITIC AFFECTIONS OF THE SKIN. the copper color of syphilis. In spite of these various sources of error, which with care may generally be avoided, the peculiarity referred to is one of the most valuable means of distinguishing syphilitic eruptions from those of simple origin. A circular form, although frequent, is less constant in syphilitic eruptions than the assertions of some authors would lead us to be- lieve. It is often absent in the erythematous and papular eruptions of the early stage of syphilis, and is chiefly confined to the pustular and tubercular forms which appear at a later period. It is also as- sumed by lepra, herpes, and other eruptions of non-specific origin. Cazenave has especially insisted upon the thinness of the scales, and upon the thickness, greenish color, and tendency to split, of the scabs; and Biett upon the narrow whitish fringe which often sur- rounds each patch of a syphilitic eruption, and which is merely the remains of the exfoliated epidermis; but these signs are un- reliable. Those syphilitic eruptions which are attended by ulceration, as impetigo, rupia, ecthyma, and tubercles, are often arranged in cir- cular groups; their cicatrices, as a matter of course, assume the same form, and are, moreover, of a dirty brown or bronzed color, which gradually fades away, and gives place to a dull white. Within these circles there is generally a portion of the integument which has escaped ulceration, and the presence of isolated depres- sions due to distinct pustules or tubercles upon this portion of sound skin, or around the outer border of the circle, is highly characteristic of the scars of syphilitic origin. Ordinary lupus pro- duces cicatrices which are somewhat similar, but the tubercles are so closely approximated that the scars run into each other, and are also less deep than those just referred to.1 In general, the cicatrices of syphilitic eruptions retain, for some time, the copper color of the preceding lesion, but this gradually disappears. The syphilodermata are very persistent, but so also are cutaneous eruptions of non-specific origin, and in this respect these two classes may at first sight appear to be entirely identical; and yet there is a difference, for certain affections belonging to the former, either remain for an indefinite period under the same type, or run into other forms, while the corresponding affections in the latter are transitory and immutable. Thus, ordinary roseola entirely disap- Bassebead, op. cit., p. 31. SYPHILITIC AFFECTIONS OF THE SKIN. 553 pears in the course of a few days, while syphilitic roseola, unless arrested by treatment, often persists for months, or gives place to syphilitic papules or pustules which may continue for years. The entire absence, or small amount of pruritus attendant upon the syphilodermata is a characteristic and highly important symp- tom. It is surprising to observe how little inconvenience is ex- perienced by the patient even when the eruption covers a large extent of surface; instead of suffering from a constant sensation of heat and itching, as is usual in other affections of the skin, he will disregard its presence, or even be entirely ignorant of its existence. Some little caution is requisite, however, in receiving the state- ments of patients upon this point. Many persons when questioned as to the amount of pruritus, will at first represent it as very con- siderable, while an examination of the surface will indicate, by the absence of scratches made by the finger nails, that their sen- sations are exaggerated, and close inquiry will satisfy the surgeon of the correctness of this conclusion. More or less irritation, however, often attends syphilitic eruptions in the neighborhood of the genital organs and upon the scalp, and may be occasioned in other parts of the body by an accompanying eczema of simple origin or by scabies. Still the insensibility of the skin referred to is, in most cases, a very valuable symptom of the syphilodermata, and the presence of severe pruritus should lead the surgeon to suspect some other cause than syphilis. On two occasions, when called to treat patients supposed to be affected with a syphilitic eruption, the attendant itching has induced me to make a careful examination of the skin, and has led to the discovery of pediculi which were the sole cause of the disease. Bassereau has called attention to the frequent coexistence of various forms of syphilitic eruptions upon the same person, as an important element of diagnosis. In other affections of the skin, we rarely, if ever, find a union of blotches, papules, vesicles, and pus- tules ; while in the early stage of constitutional infection, owing to the rapidity with which one syphilitic eruption runs into another, all these different forms are frequently observed at the same time upon the same person. This tendency to polymorphism is not manifested by the later syphilitic eruptions.1 1 A fine specimen of a polymorphous syphilitic eruption, composed of blotches vesicles, and pustules, is figured by Ricord, Iconographie, PI. X. 554 SYPHILITIC AFFECTIONS OF THE SKIN. The same author has also dwelt upon the entirely distinct char- acter of some forms of syphilitic eruptions, and upon the differ- ences which exist between others and their congeners among the simple affections of the skin. Thus mucous patches are only occa- sioned by the syphilitic virus, and certain forms of papules and tubercles are exclusively dependent upon the same cause. Again, syphilitic vesicles often consist of a papular base, with a slight effu- sion of serum at the summit, and syphilitic pustules of impetigo rest upon prominent and thickened portions of the integument— characters which are never present in the corresponding simple affections of the skin. The seat of an eruption will sometimes indicate its origin. Thus simple acne is confined to the face, trunk, and upper extremities, while syphilitic acne frequently involves the thighs and legs. Again, ecthyma of the hairy scalp is almost invariably produced by the syphilitic poison. The coexistence of undoubted syphilitic symptoms will afford a strong probability that an eruption is of specific origin; although it should not be forgotten that constitutional infection is no bar against the outbreak of simple affections of the skin. The history of the case must be taken into the account, and the symptoms of the preceding chancre and its complications are espe- cially worthy of attention as a means of determining whether the sore was of the simple or infecting species. The length of time since the supposed contagion, taken in connection with the elemen- tary lesion of the eruption, is also of value; thus a roseola cannot be due to a chancre contracted eight or ten years, nor tubercles to one contracted two months ago. Finally, the influence of treatment may aid in establishing the diagnosis, since in cases in which the history of the patient is im- perfect and the symptoms obscure, a cautious trial of mercury and iodine will often enable us to determine, by the effect produced, whether a cutaneous eruption be due to syphilis or to other causes. It should not be forgotten, however, that all syphilitic patients do not improve under the administration of specific remedies, so that the effect of treatment cannot be regarded as infallible. I shall follow the classification adopted by Cazenave, and describe syphilitic eruptions under the following heads:— 1. The exanthematous. 2. The papular. SYPHILITIC ERYTHEMA. 555 3. The squamous. 4. The vesicular. 5. The bullous. 6. The pustular. 7. The tubercular. In describing these eruptions, I shall have frequent occasion to refer to the work of M. Bassereau, which is one of the most recent, and probably the most thorough, that has appeared on this subject. I propose also to indicate in foot-notes the plates of Ricord's ad- mirable representations of venereal disease in which the various eruptions are figured, in order that they may readily be referred to by the student who has access to the work. Syphilitic Erythema (Syphilitic Roseola).—Syphilitic erythema is the earliest and most frequent of all the syphilodermata. This eruption consists of irregular spots of a rose or pale red color which disappears on pressure, upon a level with the surrounding surface, and either isolated, or variously grouped together, so as to form crescents, circles, etc.1 Sometimes the blotches are of a brighter red which is only partially effaced by pressure, are slightly pro- minent, and studded with minute elevations, due to distension of the cutaneous follicles. This eruption is generally slow and insidi- ous in its development, appears by preference upon the abdomen, thorax, axilla?, and the superior portions of both the upper and lower extremities, and is so free from febrile excitement, heat, and pruritus, that the patient may not discover its presence unless by accident. In some cases, however, when hastened by alcoholic stimulants, a hot bath, or prolonged exercise, it makes its appearance suddenly, is attended by general disturbance of the system, and may cover the whole surface of the integument including the face, which, under other circumstances, usually escapes. I have known of two or three instances in which a hot bath taken a short time before going to a party has brought out a syphilitic roseola upon the face and neck which was first detected by the man's associates in the ball-room. The hands are in most cases unaffected, but may also be involved, and in a few instances the only traces of the eruption are two or 1 Iconographie, Pis. XV., XV. bis, ter, et quater. 556 SYPHILITIC AFFECTIONS OF THE SKIN. three blotches upon the palms. Upon the dorsal surface the erup- tion assumes the same appearance as upon other parts of the body, while upon the palms the blotches are seated upon thickened por- tions of the integument, which are slightly prominent and sensitive upon pressure, exhibit the copper color to an unusual degree, and often become squamous.1 Syphilitic roseola gradually assumes a faint copper color, which in some cases, however, is absent during the whole course of the eruption; unless arrested by treatment it rarely disappears in less than six weeks and may continue for as many months; as it passes off slight exfoliation of the epidermis takes place, and the blotches are succeeded by dingy discolorations of the skin, which remain for some time. Relapses often take place within a period of a few weeks or months, in consequence of the premature suspension of treatment, indulgence in alcoholic stimulants or other depressing influences, and are not unfrequently accompanied by a reappear- ance of the induration at the site of the chancre. I have already quoted in another chapter2 the statistics of M. Bassereau relative to the time of the appearance of syphilitic ery- thema, and will at present merely state the general conclusions upon this subject arrived at by this able and reliable observer. When no mercurial is administered for the primary sore, this eruption generally appears between the thirtieth and sixtieth day after con- tagion ; it is not uncommon from the sixtieth to the ninetieth day; but is seldom met with as late as the fourth month, and is exceed- ingly rare in the fifth; beyond which time it only occurs in the form of a relapse, or in case it has been delayed by mercurials. It should be observed that we are here speaking of the earliest appearance of the eruption, which having once broken out may persist for a long time after the period mentioned. Syphilitic roseola should be carefully distinguished from the erythematous eruptions which sometimes follow the administration of large doses of copaiba and cubebs, and which have frequently led to the erroneous supposition that gonorrhoea may occasion constitutional infection. The fact that the patient has been taking the anti-blennorrhagics should always induce caution in forming a diagnosis; and roseola dependent upon this cause may be recog- nized by the febrile excitement and pruritus which generally 1 Iconographie, PI. XV. ter. 2 See p. 455. SYPHILITIC PAPULES. 557 attend it, by the absence of other suspicious symptoms, by its situation upon parts of the body which are not commonly affected in syphilitic erythema, and by its spontaneous disappearance soon after the suspension of the anti-blennorrhagic. The most frequent concomitants of syphilitic erythema are scabs upon the hairy scalp, a crown of copper-colored papulae upon the forehead, pustules and papules upon other parts of the body, engorgement of the cervical ganglia, rheumatic pains about the joints, alopecia, mucous patches within the mouth and in the neighborhood of the anus and genital organs, and minute yellow- ish scabs surmounting papular elevations at the junction of the alae nasi and cheeks, and upon the commissures of the lips (im- petigo). Syphilitic Papules (Syphilitic Lichen).—Like syphilitic ery- thema, syphilitic papules belong to the early stage of constitutional infection, but are less common than the former eruption, which in many cases precedes them. They consist of small solid elevations of the superficial layers of the skin,1 and the neighborhood of the hair follicles appears to be most frequently involved, since at an early period of their develop- ment, each papule is traversed by a hair which soon falls out. They may be scattered irregularly over the surface, arranged in annular groups or closely aggregated. Their color is at first roseate or a bright red, which disappears on pressure; but they rapidly assume a yellowish red or copper color which cannot be entirely effaced. Three forms of syphilitic papula? may be recognized: the lenti- cular, in which the papules are somewhat broad and flat; the conical, the height of which exceeds their breadth, and which most closely resemble ordinary lichen; and the miliary, which are very small, and the summits of which, on their first appearance, are generally surmounted by a slight effusion of serum. Papules are most common upon the abdomen, thorax, back, fore- head, and the upper and lower extremities; but unless arrested by treatment they frequently extend over the whole integument; they are rare, however, upon the hairy scalp, which is generally the seat of syphilitic pustules. Their development is in most cases slow and 1 See Ricord's Iconographie, PI. XVII. bis. 558 syphilitic affections of the skin. by successive invasions, so that papules in their various stages may generally be found upon the same person at the same time. In some instances, however, they spring up suddenly and may in a few days cover the whole body; and when thus rapidly developed, their summits are often covered with a slight effusion of serum, which desiccates and forms a scale seated upon a papular base. Syphilitic papules are frequently found upon the forehead, ex- tending from the roots of the hair to the frontal eminences, where they constitute the most frequent variety of the corona veneris so- called, which, however, may be made up of other elementary lesions; and it is in this situation especially that the scales which form upon the summits of the papules fall off) and leave small, shining and copper-colored elevations which are highly characteristic of syphi- lis and which betray the disease to an experienced observer. Syphilitic papulae are very persistent, and even when subjected to appropriate treatment, rarely disappear until after the lapse of one or two months. As resolution progresses, the copper color fades first into a tawny and then into a grayish hue, and copious desquamation of the epidermis sometimes takes place, attended by slight pruritus. They very rarely terminate in suppuration and ulceration, and yet not unfrequently are succeeded by depressions in the skin which are due to interstitial absorption of the tissues, and which disappear in the course of a few months. In 30 cases of syphilitic papula? observed by Bassereau in which no mercury had been administered, the eruption appeared between the twentieth and thirtieth day after contagion in 3; in the course of the second month, in 16; and during the third month, in 11; thus showing that this eruption belongs to a very early period of constitutional infection. The concomitants of syphilitic papula? are for the most part the same as those of syphilitic erythema. Iritis is sometimes observed, but less frequently than was supposed by Carmichael, who regarded it as the most common attendant upon this form of eruption. Syphilitic papules may be confounded with syphilitic tubercles, with common lichen, and with acne indurata. Tubercles may be distinguished by the later stage of their development, their larger size, the greater depth to which they involve the tissues, and by their tendency to ulceration. Lichen is attended with considerable febrile excitement and severe pruritus, and is rapid in its course and termination. It is sometimes extremely difficult to distinguish SYPHILITIC SQUAMiE. 559 syphilitic lichen when occupying the usual seat of acne, as the face, shoulders, or back, from the latter eruption. In such cases the presence or absence of other syphilitic symptoms must chiefly be relied upon to establish the diagnosis. Syphilitic Squama (Syphilitic Pityriasis, Psoriasis and Lepra).— Many of the syphilodermata in their later stages are attended by desquamation of the epidermis, and may assume the appearance of scaly eruptions, when they have had for their initial element ery- thema, papula?, or even vesicles and tubercles; hence some authors have been disinclined to admit squama? among the syphilodermata, and have referred those cases generally included under this head to other eruptions. Syphilitic pityriasis, in which the scales are thin and furfura- ceous, is chiefly met with upon the scalp, and sometimes upon the eyebrows and those portions of the face which are occupied by the beard. It may succeed an eruption of erythema or papules, or form upon the cicatrices left by vesicles or pustules. Upon the head, where it is most common, the epidermic scales are thrown off in large quantities, or collect in a continuous scurf about the roots of the hair, which generally falls off to a very great extent. Syphilitic psoriasis, in which the scales are larger and thicker than in the preceding variety, may be developed upon all parts of the body. In most instances it succeeds an eruption of papules or tubercles, and sometimes of pustules; while in a few cases it would appear to be squamous from the outset. Like common psoriasis, it is divided into several varieties dependent upon the form of the patches, which in psoriasis guttata are small and scattered; in pso- riasis diffusa, of larger size and more or less continuous; while in lepra they assume the form of circles. The integument beneath these patches is the seat of a low form of inflammation, and is of a red color, in which the copper hue is often absent. Unlike the patches of common psoriasis which are most elevated at the centre, those of the syphilitic form of the disease are centrally depressed, and are most prominent at the circumference. Slightly depressed cicatrices are left after the falling off of the scales, and are due to interstitial absorption of the tissues. Syphilitic psoriasis of the hands and feet is a very characteristic symptom of constitutional syphilis.1 A red blotch or papule, and ' Iconographie, PI XXII. 560 SYPHILITIC affections of the skin. sometimes a pustule, first appears, generally near the centre of the palm of the hand, beneath which the skin is thickened, dry, and elevated; an irregular-shaped patch is formed of variable extent, from which the cuticle exfoliates and exposes a red and tender surface surrounded by a fringed border consisting of the remains of the epidermis. In some cases it commences as a complete ring of inflamed and thickened cuticle, including sound integument in the centre, and gradually enlarges by peripheral growth; and three or four successive rings may spring up within the one first formed. These patches are generally raw and tender, and are traversed by cracks and fissures, which bleed readily and sometimes give exit to a little pus. Complete extension of the fingers may be rendered difficult or even impossible. In this as in all other affections of the skin, the history of the case and the coexistence of undoubted syphilitic symptoms are of the utmost value in establishing the diagnosis. Syphilitic psoriasis generally appears in weak and ana?mic subjects, in whose treatment tonics should play an important part. Syphilitic Vesicles.—A vesicular eruption is the rarest of all the syphilodermata, although it is now admitted to be more frequent than was at one time supposed. It is one of the earliest syphilitic affections of the skin. Of twelve cases observed by Bassereau at the Llopital du Midi, none occurred later than the sixth month, and the earliest one month after contagion. The parts which are most frequently affected are the back, face, and extremities. The vesicles may either be large and globular, small and acuminated, scattered irregularly over the surface, or arranged in groups. Many of them are found to be traversed by a hair, showing that the chief seat of the eruption is the hair follicles. Several varieties are admitted, most of which find their analogues in the non-specific eruptions of the skin. In the variety which resembles varicella, the vesicles are large, either acuminated or globular, scattered over the surface, in some cases umbilicated, and each is surrounded by a copper-colored areola. Their contents remain serous for a short time only, and soon become purulent. In the eczematous variety the vesicles are smaller, and either diffused or collected together in groups. They may continue trans- parent, or the contained serum may be absorbed, and the eruption syphilitic bull^:— pemphigus. 561 terminate in fine desquamation without the formation of scabs, this being frequently the case upon the scrotum. Sometimes, as in common eczema impetiginodes, a thin, yellowish crust is formed, beneath which the integument is found to be superficially ulcerated. The herpetic variety may consist of large, globular vesicles con- taining a citrine-colored fluid, and arranged in irregular groups seated upon a dark-red base, resembling the patches of herpes phlyctenodes; or the vesicles may be smaller and collected into groups which are either circular or ovoid, as in herpes circin- natus. In a fourth variety described by Bassereau, the bases of the vesi- cles are hard and firm papular elevations, which remain for some time after the fluid has been absorbed or has escaped by rupture of the vesicles. They may even undergo still farther development, and assume the appearance of a papular syphilitic eruption. These eruptions rarely retain their vesicular form for a long period, but terminate in the formation of scabs or scales, which are v.ery persistent, and are finally succeeded by small, depressed, and copper-colored cicatrices, which are not permanent. Syphilitic vesicles are almost always accompanied by some other specific eruption, as erythema, papules, or pustules. Syphilitic bullae (Syphilitic Pemphigus and Rupia).—Two syphilitic affections of the skin are characterized at their com- mencement by the larger form of vesicles known under the name of bulla?, viz., pemphigus, which is chiefly met with in infants affected with hereditary syphilis, and rupia. Pemphigus.—Pemphigus was unknown to the older writers on venereal, and has only attracted attention since the commencement of the present century. In 1834, Krauss1 collected a large number of instances of this affection in infants, and carefully described its symptoms, but did not suspect that it was due to hereditary syphi- lis, as the researches of M. Dubois2 have since rendered probable. The bulla? of pemphigus are from half an inch to an inch or more in diameter, but are not greatly elevated above the surround- ing surface, owing to the fact that the sacs are not fully distended with fluid; their outline is circular or ovoid; they rest upon a 1 De Pemphigo neonatorum, Bonnae, 1834. 2 Bulletin de l'Acad. Nationale de Med., 1851, t. xvi. 36 562 SYPHILITIC AFFECTIONS OF THE SKIN. violet-colored base which extends for a short distance beyond the elevated epidermis; their contents consist of a serous, sero-puru- lent or sero-sanguinolent fluid which is discharged by rupture ot the'sac; and the eruption generally terminates in desquamation, but sometimes in ulceration. # In most cases of syphilitic pemphigus of hereditary origin, the eruption is present at birth, is confined to the palms of the hands and the soles of the feet, and is soon followed by the death of the infant. Ricord figures a case in which it covered the whole body.1 I have recently observed a case in private practice, in which this eruption appeared on the third or fourth day after birth, was seated upon the arms, abdomen, and thorax, and was followed during the third week by mucous patches about the buttocks and upon the internal surface of the cheeks. At the time of conception the father was under my. care for secondary syphilis. The mother, so far as I can learn, has never manifested any syphilitic symptoms, although fear of exposing the father has prevented my making minute inquiry. The infant still lives (three months old), and its symptoms have disappeared under small doses of mercury with chalk. Notwithstanding the fact that in most cases of pemphigus neona- torum a syphilitic taint has been discovered in one or both parents, yet the mere presence of this eruption cannot, in the absence of other symptoms, be regarded as conclusive proof of the existence of hereditary syphilis, since it is possible that infants at birth may be affected with pemphigus of simple origin from which the specific form of the eruption cannot be distinguished by its outward ap- pearance. A few cases only of syphilitic pemphigus have been observed in the adult as the result of acquired syphilis, one of which is figured by Ricord in his Iconographie, PI. XXV. In this case the seat of the eruption was upon the soles of the feet, and in another case ob- served by Bassereau, it was upon the palms of the hands, showing the same predilection for these regions both in adults and infants. When occurring in the former, the prognosis is not at all of the same serious import as in the latter. Rupia.—Rupia is classified by some authors among the bullous and by others among the pustular eruptions. Strictly speaking, it 1 Iconographie, PL XLVI. RUPIA. 563 is undoubtedly entitled to the position assigned it in the present work, although in many instances the initial bulla escapes observa- tion and the eruption appears to emanate from a pustule. Unlike the preceding eruption of this group, syphilitic rupia is only met with in adults and as a symptom of acquired syphilis. Its usual mode of development is as follows: a reddish spot first appears which is somewhat tender upon pressure, and upon which the epidermis soon becomes elevated by an effusion of bloody serum; the bulla thus formed is very transitory in its duration and has usually disappeared by the third or fourth day, by which time its contents have dried into a thin scab of a greenish yellow color, and an ulcer has formed beneath. By the gradual addition and desiccation of purulent matter this scab increases in height and in breadth, and assumes a very characteristic appearance; its base is circular or oval and enchased within the underlying ulcer; it often rises above the level of the surrounding integument in the form of a cone, the sides of which are uneven and stratified by the succes- sive layers of its formation; its color is a mixture of brown and yellow, or is sometimes almost black; and it is surrounded by an areola of a dark-red or copper hue. The ulcer beneath it is deep, and its edges abrupt and sharply cut. This eruption is said to be most frequent upon the lower extremities, although in cases of syphilitic origin I have quite as often met with it upon the upper. It may occur upon any part of the integument.1 Syphilitic rupia is very persistent. Fresh scabs and ulcers appear in the vicinity of those first formed, so that the various stages of the eruption may frequently be observed upon the same person. During the reparative process, if the scabs be allowed to remain undisturbed, the ulcer granulates up from the bottom, and, when at last the scabs, having become dry and brittle, fall off, may have already attained a higher level than that of the surrounding surface. The succeeding cicatrix is of a sombre red or copper color, abruptly depressed, and indelible. Syphilitic rupia is a late symptom of constitutional infection as shown by its usual concomitants, viz., affections of the bones and periosteum, syphilitic orchitis, deep tubercles of the cellular tissue, etc. It is an indication of a very low condition of the general sys- tem, and demands the most careful attention to the hygienic condi- tion of the patient, and, in most cases, the free use of tonics. 1 Iconographie, PL XXXII. 564 SYPHILITIC AFFECTIONS OF THE SKIN. Syphilitic Pustules (Syphilitic Acne, Impetigo, and Ecthyma; Pustulo-Crustaceous Syphilitic Eruption).—The earlier writers on venereal included all eruptions upon the skin under the name of pus- tules, and made no attempt to discriminate the different forms which they assumed. Yet an examination of their writings shows that syphilitic eruptions were much more frequently pustular during the Italian epidemic and for some years afterwards than now; and this might have been expected from the known severity of syphilis at that time, since it is especially in the graver cases of this disease that the tendency to the formation of pus is most marked. Syphilitic pustules may appear upon any portion of the integu- ment. A very common seat is upon the scalp, and the question, " Have you had any scabs in the hair ?" is very frequently put to a patient by an experienced surgeon in the investigation of a sus- pected case of syphilis. Commencing upon the head, pustules often extend to the face and other parts of the integument, particularly in ana?mic constitutions and in those cases in which the disease is peculiarly virulent. In some instances the lower extremities are chiefly affected. As in several other of the syphilodermata, the anatomical seat of the eruption appears to be in the hair follicles. Syphilitic pustules may assume the form of acne, impetigo, or ecthyma, which, in respect to frequency, are in an inverse order to the one here mentioned; acne being the least and ecthyma the most frequent. Syphilitic Acne.—In this form, the pustules are of small size, generally acuminated, seated upon a prominent base, show but little tendency to spread, and remain stationary for several weeks before becoming covered with scabs, which are small, dry, and of a gray- ish or yellowish-brown color. The papule or plane surface left by the falling of the scab often takes on slight desquamation, and is of a more characteristic copper color than the preceding pustule. In some cases a superficial ulcer is formed.1 Unlike ks analogue among the common affections of the skin syphilitic acne is not limited to the superior parts of the body but may extend to the lower extremities, and may even be confined to he latter region; and this fact is of the first importance in estab- norZ of'tfT13- Then ^^ Up°n the face'back'OT ^erior po tion of he thorax, the specific often bears a close resemblance to the simple eruption for which it may readily be mistaken. It ii is Iconographie, PI. XXVII. SYPHILITIC IMPETIGO. 565 to be distinguished by the papular elevation left by the falling off of the scab, by the copper color of its later stages, and by the coex- istence of other syphilitic symptoms which generally belong to the earlier period of constitutional infection, since, in most cases, syphi- litic acne appears within a few months after contagion. Syphilitic Impetigo.—The pustules of syphilitic impetigo are flat, of variable size, and either isolated or in groups; their base is either somewhat elevated and of a coppery red color, or sunken within a prominent border of the same aspect. An important feature is the color of the scabs, which are of a grayish or greenish-yellow hue. This eruption is frequently observed upon various portions of the face, more particularly around the ala? nasi, at the commissures of the lips, and in the beard1 and eyebrows, and is also met with upon the trunk, scrotum, and the upper and lower extremities. Syphilitic impetigo, when situated upon the labial commissures or around the nasal orifices,2 presents a very characteristic appear- ance, which is not observed in any eruption of simple origin. The integument beneath is superficially ulcerated and generally vege- tates above the surrounding surface, while the summits of the granulations are covered with small yellowish scabs, and the patches tend to arrange themselves in circles or parts of circles, which are surrounded by a prominent border or copper-colored areola. At the commissures of the lips they are frequently continuous with mucous patches of the mucous membrane within the mouth. Upon other portions of the face it is sometimes difficult to distinguish syphilitic from common impetigo. When seated upon the scalp, forehead, thorax, and extremities, the pustules may be scattered or in groups, and often rest upon a hard, elevated, and dark red base; while the scabs are of a greenish- yellow color, and the integument beneath is ulcerated. As a general rule these ulcerations are deeper and more extensive the longer the time which has elapsed since contagion. The French have given the name of " pustulo-crustaceous" to a form of impetigo, which is only met with as a late symptom of constitutional syphilis. The pustules are large and arranged in circles, and, the ulcers becoming continuous by gradual exten- sion, circular patches are formed covered with yellowish scabs which are most prominent around the margin, and surrounded by an areola of a dull red color. The cicatrices are excavated, at first 1 Iconographie, PL XLV. 2 Iconographie, PL XLIL, Fig. 4. 566 SYPHILITIC AFFECTIONS OF THE SKIN. red and afterwards of a dull white color, and resemble those pro- duced by a deep burn. Syphilitic Ecthyma.—Syphilitic ecthyma, the most frequent of all the pustular syphilodermata, consists of an eruption of that form of pustules known by the name of "phlyzacious," a term applied by Willan to " pustules of a large size, raised on a hard circular base of a vivid red color, and succeeded by a thick, hard, dark-colored scab." Like ordinary ecthyma, it may affect all parts of the body and especially the lower extremities; but unlike the non-specific eruption, it is very frequent upon the hairy scalp, where it may often be observed at the same time that the trunk is covered with syphilitic roseola or papules. An eruption of ecthyma commences with the appearance of red and indurated spots upon the skin, the centre of which by the second or third day is elevated by an effusion of pus, which rapidly spreads until it covers the whole of the inflamed surface; the epidermis is soon ruptured, and the pus which escapes concretes into a broad brownish scab.1 The subsequent course of the eruption presents two varieties. In one, the tendency of the pustule and subjacent ulcer to increase in size and in depth is but slight, while in the other it is strongly marked; and hence two forms of ecthyma are admitted, viz., the superficial and the deep, the former of which is an early and the latter a late symptom of constitutional infection. In the superficial variety, the scab first formed does not materially increase in breadth or in height, and its removal exposes a super- ficial ulceration which soon heals, leaving a shallow and permanent cicatrix which is pitted like the scar of vaccinia. In the deep variety, the scab increasing in extent and in height by the constant addition of purulent matter, protrudes above the surface, is sometimes depressed at the centre, and is made up of consecutive rings; in most cases it slightly overlaps the edges of the ulcer, while in others it is set within the cavity, a portion of which may even be exposed in consequence of the scab not being sufficiently large to cover it. If the scab be removed, the ulcer is found to penetrate deeply into the tissues beneath; its edges are abrupt and its floor covered with a grayish secretion. The cica- trices which are left after the healing of the ulcers, are depressed, 1 Iconographie, PL XXVI. ter et quater. SYPHILITIC ECTHYMA. 567 at first of a dark-red color and afterwards of a dull white, never entirely disappear, but are not pitted like those of the superficial variety. In some cases the pustules of syphilitic ecthyma, although at first distinct, are collected together in groups, when they may unite and give rise to a large scabby patch, which constantly tends to extend over a still larger surface, and the outline of which exhibits the circular form so frequently seen in syphilitic eruptions. These patches, like those of impetigo, which they resemble, are known by the name of " pustulo-crustaceous." An eruption of syphilitic pustules is often preceded by the com- bination of symptoms which I have described under the head of syphilitic fever. These symptoms, however, are of short duration, but the eruption itself is very persistent, and, under the best directed treatment, may last for several months. The superficial varieties of syphilitic pustules belong to the early, and the deep to the late periods of constitutional' infection. The former are more generally diffused over the integument than the latter. Bassereau lays down the rule, that a pustular eruption occupying different parts of the body, is rarely met with at a later period than six months after contagion, unless delayed by treat- ment, and calls attention to a remark made by Gabriel Fallopius in the sixteenth century to the effect that " when the pustules in- vade the whole body, and when they are developed in the hair and beard, it is a sign that the French disease has been contracted with- in five or six months." On the other hand, the deep varieties of syphilitic pustules occupy, in most cases, but one or two regions, are much more destructive in their action, are only met with at a late period of constitutional infection, and are consequently attended by symptoms belonging to a more advanced stage of the disease than the superficial varie- ties. For instance, syphilitic orchitis, nocturnal pains in the shafts of the bones, and exostoses rarely, if ever, accompany the super- ficial, but are common with the deep forms of syphilitic pustula?. In a previous chapter, attention was called to the fact that the degree of ulcerative action attending an infecting chancre may be taken as indicative of the general condition of the system and of the probable character of the general symptoms which are likely to follow. A similar rule holds good in the syphilodermata. A tendency to the pustular forms of eruption indicates a degree of 568 SYPHILITIC AFFECTIONS OF THE SKIN. constitutional cachexia that will favor the evolution of tertiary syphilis in deep and important organs; the prognosis, therefore, in the syphilitic pustula? is decidedly unfavorable. Of 42 persons observed by Bassereau who were afflicted with deep ulcerations of the fauces, suppurating tubercles of the cellular tissue and caries of the bones, 27 had previously had a pustular syphilitic eruption. Syphilitic Tubercles.—Tubercles, like papula?, are solid eleva- tions of the derma, but differ from the latter in their larger size, the greater depth to which they involve the tissues, the later period of their development, and their marked tendency to ulceration. The name itself is an unfortunate one, since it is also applied to the pathological deposit of phthisis, to the gummy tumors of tertiary syphilis, and, very incorrectly as I shall hereafter show, to mucous patches or condylomata; but it is too commonly used to be laid aside, and I can only caution the student not to confound the various lesions to which the term is applied. Tubercles are rarely, if ever, the first manifestation upon the skin of constitutional infection. It may be laid down as a rule to which there are probably no exceptions, that they have in all cases been preceded by some one of the more superficial syphi- lodermata, as erythema or papules. They are to be ranked among the late symptoms of syphilis, and may occur ten, twenty, or even forty years after contagion. The following table exhibits the time of development of syphilitic tubercles in 54 cases observed by Bassereau:— The eruption appeared— 11 months after contagion in 1 case. 1 year " 2 years " 3 " « 4 5 6 7 9 10 12 5 cases. 3 " 5 " 6 « 7 " 3 " 2 " 3 " 2 « 2 « 13 years after contagion in 14 " " 17 " « 18 " " 20 " " 22 " " 26 " " 30 " " 40 " " 1 case. 2 cases. 1 case. 2 cases. 5 " 1 case. 1 " 1 " 1 " Total 54 cases. In many of these cases mercurials had been administered, and hence these dates do not indicate the normal period of development of tubercles when not delayed by treatment. This table, however SYPHILITIC TUBERCLES. 569 is sufficient to show that a tubercular eruption is far more tardy than the superficial syphilodermata, as erythema and papules, which are never under any circumstances observed so long after contagion as in many of the above instances. Syphilitic tubercles may be seated upon any portion of the in- tegument. It is rare for them, however, to be spread over the whole surface. They are commonly confined to one, two, or three regions, and if they involve a larger number, it is by slow and gradual progression. Their most frequent seat is upon the face, where they often attack the lips and ala? nasi, and may occasion their total destruction. Another common site is the lower ex- tremities, where they often .give rise to ulcers of long duration and very intractable. Of 70 cases observed by Bassereau— The face was involved in........26 " body « «........22 " upper extremities were involved in . . . .16 " lower " " " " .....14 " hairy scalp was involved in ...... 5 " neck was involved in ....... 8 " back of the hands was involved in . . . .1 The anatomical seat of tubercles has been carefully studied by the same author who states that, in many cases, the changes upon which they depend appear to be confined to the neighborhood of the hair follicles; while, in others, the cellular conical protuberances upon the internal surface of the derma are the primary seat of the disease, the skin becoming thinned as the tubercle is developed, and finally ulcerating and giving exit to the adventitious deposit. Again, tubercles may commence as small tumors in the sub-integu- mentary cellular tissue, become adherent to the surface, and in this case also give rise to ulcers. Syphilitic tubercles may be divided into two classes: 1. Those which terminate in desquamation or resolution; and, 2. Those which suppurate and form ulcers. Tubercles belonging to the first class are hard, shot-like bodies, occupying the whole thickness of the skin, above which they pro- ject to a variable extent.1 They are isolated or more frequently in groups, and either flat, conical, or hemispherical. Their size varies from that of a small shot to a cherry. Their color is usually i Iconographie, PL XXV., Fig. 1, and PL XXVIII. 570 SYPHILITIC AFFECTIONS OF THE SKIN. a dark red, though in a few instances, and especially in persons of a sallow complexion, it does not greatly differ from that of the normal integument. They are sometimes tense and shining, or covered with thin scales which fall off and give place to others, or surmounted by scabs which are the product of an effusion of serum beneath the epidermis without deep ulceration. When aggregated, they form groups which are generally circular, but sometimes irregular. The centre of the patch is often free, covered with thin, epidermic scales formed upon the site of tubercles which have now disappeared, and of a darker color than the healthy skin. The prominent border may be composed of distinct tubercles, which in other cases are so approximated as to* form one continuous cir- cular elevation; and the patch constantly tends to enlarge by the subsidence of the old tubercles and the development of new ones external to the first. In some instances, instead of forming wheels, tubercles are collected into irregular masses, in which, however, a tendency to a circular form is still manifest, and, if closely approximated, the general thickening of the skin beneath may elevate the patch to a considerable distance above the surrounding surface. These various forms are very slow in their progress and decline, and often persist for many years. Ulceration may commence in the second class of tubercles in several ways. It may take place beneath the thin scab formed upon tubercles which have for a time been entirely dry ; or it may attack the summits of others at a very early stage of their existence, or, again, it may commence in the interior of small tumors developed in the cellular tissue beneath the skin. In whichever way origi- nating, it often progresses until it completely destroys the tubercles, of which no traces remain except an open sore covered by a thick scab. As in the dry variety tubercles when ulcerated may be arranged in the form of wheels or circles, inclosing a sound portion of the integument and constantly enlarging by peripheral extension j1 or they may consist of elongated or spiral bands, or assume various shapes, as figures of eight, etc. In most cases there is only one ulcerated patch; in others, there are several; and in others still, the whole surface of one or more portions of the body is involved, as frequently occurs upon the face. ' Iconographie, PL XXIII. et XXIII. bis, Fig. 2. SYPHILITIC TUBERCLES. 571 The depth of the ulceration varies in different cases; when super- ficial, the scab is thin, and the subsequent cicatrix is quickly effaced; when deep, the scab is thick, of a greenish-yellow color, and either protuberant above the surface or sunken within the borders of the ulcer, and the scar is indelible. These ulcers sometimes become serpiginous and creep over a large extent of surface, healing in one direction while they advance in the opposite; causing but little detriment if superficial, but occasioning fearful ravages if they involve the whole thickness of the derma.1 Serpiginous ulcers originating in tubercles are often seen in the neighborhood of the larger joints, and also upon the back, thorax, abdomen, and neck. They may generally be distinguished from serpiginous chancres by their situation at a distance from the genital organs, by the inter- position of sound portions of the integument between the ulcers, by the greater consistency of their secretion, the thickness of the scabs, and the history of the case.8 A variety of tubercles, known as " perforating," sometimes attacks the ala? nasi, in the substance of which small tumors are formed, rapidly suppurate and burst, and give rise to an eroding ulcer which may destroy nearly the whole of the nasal organ.3 Lupus exedens, which closely resembles this form of tubercles, commonly occurs before the age of puberty, is attended by a greater degree of engorgement of the neighboring tissues, and its ravages, after many years' duration, are limited to a small extent of surface. Syphilitic tubercles have been mistaken for cancer from which they differ in their softer consistency, in the absence of lancinating pains, and in the integrity of the neighboring ganglia. The cicatrices left by this eruption, when the ulceration has been deep, are generally depressed, of a coppery-red color which subse- quently gives place to a dull white, and either smooth or traversed by bands of modular tissue. Bassereau has called attention to the numerous depressions which exist upon the general surface of the cicatrix and which mark the site of the tubercles of which the patch was originally composed. This character is not found in the scars of any eruption except those of syphilitic tubercles. In most cases, also, the cicatrices of this eruption may be recognized by their general circular outline or by the segments of circles which are apparent upon their borders. 1 Iconographie, Pis. XXXVI. and XXXVII. 2 See p. 388. ' Iconographie, PL XIX. 572 SYPHILITIC AFFECTIONS OF THE SKIN. Ulcerated syphilitic tubercles are never accompanied by the superficial syphilodermata. Their most frequent concomitants are syphilitic orchitis, affections of the periosteum and bones, and syphilitic cachexia. Ulcers.—Cullerier, the elder, and Alibert admitted still another class of syphilitic eruptions which they called " the ulcerating," but ulcers originate either in a vesicle, pustule, or tubercle, and have, therefore, been included by more modern authors among the syphilo- dermata which have already passed under our notice. It is not necessary to repeat at length the characters pertaining to syphilitic ulcerations, according as they arise from one or the other of these initial lesions. I will simply recall to the mind of the reader, that when commencing with a vesicle, ulcers are superficial and are generally scattered in large numbers over a considerable extent of surface; that those from pustules, when the eruption occurs at an early period of infection, are also numerous but deeper than the former; while in a later stage, both the ulcers of pustules and of tubercles are more limited and more destructive in their action. In many cases, the coexistence of the various stages of the eruption in the same person will facilitate the diagnosis. Ulcers of the skin may also be due to the suppuration and open- ing of deep tumors of the cellular tissue and to syphilitic affections of the periosteum and bones, but with care may be distinguished from those commencing in the skin itself. Treatment.—Little need be added to the remarks already made upon the treatment of general syphilis with reference to the special treatment of the syphilodermata. As in other syphilitic affections, our chief remedies are mercury and iodide of potassium, and the only embarrassment likely to occur is to know when to employ the one and when the other. No great difficulty, however, need be experienced upon this score, provided the fact be borne in mind that the superficial eruptions which terminate in desquamation, belong to the secondary stage of syphilis in which mercury is re- quired, and that the deeper eruptions, attended by suppuration and ulceration, belong to the stage of transition or to the tertiary period, in both of which iodine should precede or accompany mercurials in the treatment. Indeed, supposing a case of syphilitic eruption to be treatment. 573 placed in the hands of a practitioner totally incapable of assigning it its proper position upon a scientific chart of the syphilodermata, simple attention to the absence or presence of suppuration and ulceration might enable him in most cases to determine the proper course of treatment to be pursued; since he could readily recognize the broad features which distinguish the non-ulcerative and the ulcerative affections of the skin; the former class including ery- thema, papules, squama?, and vesicles, which are either entirely dry or are attended by a serous or thin sero-purulent secretion from a superficial erosion; and the latter embracing pustules and tubercles which give rise to ulcers varying in extent and depth. Pustules may, indeed, occur at an early period of infection in debilitated subjects and exhibit a marked tendency to ulcerative action, but such cases do not well support the use of mercury, so that for all practical purposes the above distinction holds good. Another indication for the choice of remedies may be found in the extent of surface covered by the eruption, which, in erythema, papules, vesicles, and the early forms of pustules, is much more extensively diffused than in late pustules and tubercles. But by far the most valuable assistance is to be derived from the character of the syphilitic symptoms which almost always accompany the syphilodermata, and which have been particularly mentioned in the preceding pages in connection with each form of eruption. It is unnecessary at present to do more than recall to mind the syphilitic fever, headache, rheumatic pains, impetigo ca- pitis, alopecia, engorgement of the cervical ganglia, and mucous patches, one or more of which usually accompany the earlier syphilodermata, and the osteocopic pains, affections of the bones and periosteum, and orchitis, which attend the later eruptions. With regard to the external treatment of the syphilodermata, a simple warm bath two or three times a week, already recom- mended in the general treatment of syphilis for the purpose of favoring cutaneous secretion, will be found to exert a beneficial influence, especially upon those eruptions which are extensively diffused over the surface, and the effect may be increased by the addition of gelatine, bran, starch, or one of the alkalies; but medi- cated baths are, I suspect, more frequently recommended in books than employed in practice, at least in this country. Baths of cor- rosive sublimate containing half an ounce of the bichloride and an 574 SYPHILITIC AFFECTIONS OF THE SKIN. ounce of muriate of ammonia to each bath, have been highly praised by Trousseau1 and others. In most cases it is not desirable to remove the scabs which cover many of the late syphilitic eruptions, since they serve to protect the sore beneath from friction and abrasion, and accomplish this purpose better than any artificial dressing. As the ulcers heal under the administration of internal remedies, the scabs fall off and expose a surface which is nearly, if not quite cicatrized. In some cases, however, as in tubercular eruptions upon the face, squama? upon the palms of the hands, and open ulcers upon various parts of the body, a regard for external appearances or the comfort of the patient requires the use of topical applications, as ointments of the red precipitate, nitrate or iodide of mercury, or iodide of sulphur; lotions containing aromatic wine, the potassio-tartrate of iron, chlorinated soda, or the compound tincture of benzoin or the emplastrum hydrargyri, or emplastrum de Vigo cum mercurio which is in much favor with the French, especially in syphilitic eruptions upon the face. An excellent treatment of sluggish syphilitic ulcers is to sprinkle their surface with iodine in powder and cover them with dry lint and a bandage. A favorite application with Ricord, is lint soaked in the following solution of iodine. R. Potassii iodidi gr. xv. Tinct. iodinii Jiss. Aquae | vj. M. I have found equal parts of glycerin and the oil of cade an ex- cellent local application to the squamous eruption upon the palms of the hands; or when there is much surrounding inflammation the following formula may be used:— R. Oil of cade gij. Glycerin £v. Solution of subacetate of lead 5j. M. 1 Therapeutique, 5eme fid., i. 229. SYPHILITIC ALOPECIA. 575 CHAPTER VIII. SYPHILITIC AFFECTIONS OF THE APPENDAGES OF THE SKIN. Alopecia.—There are two forms of alopecia dependent upon syphilis and appearing at different stages of constitutional infection. The first form is much more frequent than the second, and is, indeed, one of the most constant of the category of early symptoms which should ever be borne in mind by the surgeon who treats venereal diseases, in order that he may be able to recognize the first evidence of vitality in the syphilitic virus after the period of dormancy which follows the evolution of the chancre. No apology will be necessary to the professional reader if I add, that one can- not but admire the wonderful order and regularity in the develop- ment of even so loathsome a disease as syphilis, nor fail to take pride in being able to detect the presence of this destructive poison from so slight an indication as the unwonted falling of the hair, enlargement of the cervical ganglia, nocturnal headache, redness of the fauces, pustules upon the scalp or a few blotches upon the body. It is fortunate both for the physician and patient that he whose duty it is to treat the sad consequences of vice, can yet find interest and pleasure in his occupation. The falling out of the hair is a very early symptom of constitu- tional infection, and may take place before the appearance of any eruption upon the skin, in conjunction with those symptoms which are known under the name of syphilitic fever. It varies greatly in degree in different cases; in some it is so slight as not to attract attention unless discovered by the surgeon, who finds on passing his fingers through the hair and exerting slight traction upon it that it comes out with unusual facility; while in others the hair falls out by handfuls, especially when there is an abundant erup- tion of pustules or pityriasis upon the scalp. Nor is this symptom always confined to the head; in many cases it also affects the eye- A brows, which may become so nearly bald as to render the patient 576 APPENDAGES OF THE SKIN. conspicuous, especially if his hair be light colored. In rare instances the eyelashes and the beard fall out in a similar manner. This early form of alopecia is always amenable to treatment, and the patient may be assured that there is no danger of his becoming permanently bald. We cannot, indeed, arrest the falling out of the hair at once, but so soon as the system is brought under the influence of mercury, the tendency ceases, and the hair is repro- duced. In those persons who have taken mercurials for their infect- ing chancre, this symptom is often absent. There is another form of alopecia which is mentioned by the earlier writers on syphilis as having been extremely common in former years, but which is now very rare. It is characterized by the disappearance of every vestige of hair from the whole integu- mental surface, is only met with in the later stages of syphilis and generally in conjunction with syphilitic cachexia, and is almost always incurable. Treatment.—The early form of alopecia is speedily arrested by the constitutional treatment of the syphilitic diathesis, and there is no necessity for resorting to the use of remedies especially directed to the reproduction of the hair. To meet the wishes of patients, however, it is often desirable to prescribe some local application which may not perhaps be entirely without effect in hastening the appearance of a new growth. For this purpose pomades or washes containing a stimulant, as castor oil or tincture of cantharides, are commonly employed. The following formula? may be recom- mended :— R. Aquas Colognae 3*j. Olei ricini |j. Spiriti recti 3J. M. R. Aquae ammoniae ^j. Olei ricini §ij. " olivae Jj. " terebinthinae 3ij. " bergamii, " jasmini, aa q. s. M. The following is a very pleasant preparation :— R. Spiriti ammoniae aromat. |j. Glycerinae |ss. Tinct. cantharidis giss. Aquae rosae 3vij. M. ONYCHIA. 577 The following is known as Dupuytren's pomade:— R. Medullae ossium bovis §j. Tinct. cantharidis |j. Digest to a proper consistency and add— Plumbi acetatis 3j- Balsami Peruviani |iij. Olei caryophylli, " canellae, aa, n\,xv. M. R. Olei olivae 3*ij. Adipis gij. Hydrarg. oxidi rubri levigati 3j- Olei amygdalae 9ss. Glycerinae 3j- M. Either of the above preparations may be used once or twice a day. Fine-toothed combs and soap of every kind should be avoid- ed, and the scalp be cleaned, if required, with a solution of borax or with the yolk of an egg and warm water. In the late form of alopecia the iodide of potassium should be employed internally in conjunction with mercury. Onychia.—Syphilitic onychia is a much rarer affection than the preceding, and appears at a later period of constitutional infection. In the cases I have met it has coincided with a pustular or squa- mous eruption. The nails of the fingers are much more frequently affected than those of the toes. I have at present under my charge a man of dissipated habits who contracted syphilis six months ago, and who now has condylomata about the anus and upper and inner parts of the thighs, mucous patches within the mouth and upon the prepuce, a pustular eruption in circular patches upon the scalp and breast,, lepra upon the palms of the hands, and all of whose finger nails are affected with onychia while the nails of the toes are intact. In this affection, as most frequently observed, the integument around the base of the matrix becomes swollen, red, and tender on pressure, is detached from the nail and its epidermis exfoliates. The nail itself loses its vitality, becomes' thickened, opaque, roughened, dry, and very friable, and is often deviated from its normal direction. In a more advanced stage of the disease, ulcera- tion of the matrix takes place, and pus may be made to exude by 37 578 APPENDAGES OF THE SKIN. pressure upon the elevated border; sometimes fungous granulations spring up as in ingrowth of the nail,1 and in extreme cases the whole matrix is destroyed, the nail falls off and is not reproduced. Treatment.—Except under the circumstances just mentioned, syphilitic onychia yields to mercury and the nail resumes its normal characters. Under the administration of specific remedies it is interesting to watch the new and tender growth springing up from the matrix and pushing before it the remnants of the old nail deformed by disease. Lotions of corrosive sublimate and oint- ments of the red oxide and other preparations of mercury are recommended, but I have never found it necessary to resort to other than general treatment. Diday recommends that the patient should wear upon the affected finger a cot the extremity of which is filled with emplastrum de Vigo cum mercurio rubbed up with a sufficient quantity of olive oil to give it a semi-liquid consistency.3 Whitlow.—Syphilitic panaris may be here considered for the sake of convenience, although it is not properly included among the syphilitic affections of the appendages of the skin. Its symptoms do not materially differ from those of the common affection known under the name of whitlow or felon, for which it is usually mis- taken ; but it more frequently leaves the finger in a state of chronic inflammation and engorgement and gives rise to fistula? which are extremely difficult to heal if the cause of the disease be not recog- nized. Such mistakes are the more liable to occur because this may be the only existing symptom of constitutional infection, or its only concomitant a gummy tumor at a distance and concealed by the patient from the surgeon. Like ordinary whitlow, it arises either in the periosteum, sheaths of the tendons or cellular tissue covering the phalanges. It is usually observed in the tertiary period of the disease, and is to be treated by iodide of potassium. An interest- ing case of this affection has recently occurred at Nelaton's clin- ique.3 1 See Ricord's Iconographie, PL XLIL, Fig. 3. 8 Gaz. Med. de Lyon, No. 2, 1860. 3 Gaz. des Hop., March 3, 1860. MUCOUS PATCHES. 579 CHAPTER IX. MUCOUS PATCHES. "The name 'mucous patch' is applied to a lesion peculiar to syphilis, consisting of elevations of a more or less decided rose color, frequently rounded in form, the surface resembling a mucous membrane, and situated in the neighborhood of the outlet of mu- cous canals, especially around the genital organs and anus, upon the mucous membrane of the mouth, and sometimes upon other parts of the body, more particularly at the base of the nails and wherever the reflection of the integument upon itself forms natural folds in the skin."1 This affection is one of the earliest and most frequent secondary manifestations of syphilis, and is therefore one with which the stu- dent of venereal should be perfectly familiar; unfortunately obsta- cles have been placed in the way of acquiring a knowledge of it by the confusion which has been introduced in its classification, and in the terms which have been applied to it. Different authors, according to the views they have entertained of its nature, have described it among tubercles, pustules and papules, and have called it by the corresponding names of " mucous tubercle," " pus- tule" or "papule." But the first two of these terms are entirely inappropriate, since it does not resemble syphilitic pustules or tubercles in its time of development, its symptoms, course, or ter- mination. The name mucous papules is less objectionable, since this lesion consists in most instances of a development of the papilla? forming broad elevations above the surrounding surface; but it is not always elevated, and may even be excavated, and it is moreover so distinct in its characters from ordinary papules, and of such importance as a symptom of constitutional infection, as to entitle it to the separate name adopted by MM. Deville and Davasse, which I shall here retain. 1 Davasse and Deville, Des Plaques Muqueuses, Arch. Gen. de Med., 1845, t. ix. et x. 580 MUCOUS PATCHES. As stated in the definition given by the authors just mentioned, the seat of this lesion includes the outlet of mucous canals, and those portions of the external integument which are maintained by contact in a constant state of warmth and moisture, and are thus very nearly in the condition of mucous surfaces. Some idea of its comparative frequency in these various regions may be obtained from the following tables:— In 130 men observed by Bassereau, mucous patches were found— Around the anus Upon the tonsils " " scrotum " " lips . " " glans and prepuce " " velum palati " " tongue " " pillars of the soft palate " " internal surface of the cheeks Between the toes .... In the fold between the scrotum and thigh At the nasal orifice .... On the posterior wall of the pharynx At the base of one of the toe nails . " " meatus urinarius . In the axilla ..... Upon the gums ..... Covering the thighs in an infant three months old In 186 women observed by Davasse and Deville, mucous patches were found— 110 times 100 u 66 >« 55 a 28 it 27 ;< 18 n 17 u 11 « 11 u 5 a 2 n 2 « 2 u once. Upon 174 times it u 59 K u ii 40 II u ii nates and upper and inner parts of the thighs . 38 11 k u 19 (( ii u 8 (1 ii u 6 II u ii 5 (« ii u 5 11 ii u 3 11 Around the nails 2 11 Upoi 2 K u ii 2 II ii ii inguinal fold 2 11 u ii neck . . . p # once. u ii nipple II u u cervix uteri (I MUCOUS PATCHES. 581 It thus appears that the most frequent seat of mucous patches in men is around the anus and within the mouth, and in women upon the vnlva. It has been asserted that they are much more frequent in the latter than in the former sex, but the difference is probably not so great as has been supposed. There is certainly no more common symptom in male patients affected with syphilis. They are also present in most cases of hereditary syphilis in infants, and in consequence of the moist condition of the integument at this early age, are not confined to the regions above mentioned but may be scattered over the whole surface of the body and especially the nates and thighs. The development of mucous patches is everywhere favored by inattention to cleanliness, and in the mouth by the use of tobacco, either by smoking or chewing; in men who are habituated to this practice, they constitute one of the most persistent and troublesome symptoms we have to deal with, and in dirty prostitutes of the lower class they are equally abundant and obstinate about the genital organs. At Bellevue Hospital, in this city, I have seen some remarkable instances of mucous patches upon the walls of the vagina and cervix uteri, the consequence of syphilis and filthy habits. Mucous patches vary in appearance according to their situation. The chief points of difference are found between those seated upon the external integument and those upon membranes which are strictly mucous. The former, which are met with for the most part around the anus and genital organs in the two sexes, consist of rounded disks, either single or aggregated, of a reddish or grayish color, granu- lated and elevated to the height of about a line above the integu- ment upon which they appear to be superimposed. Their appear- ance is so peculiar, that when once seen it cannot be forgotten. Let the student who has never had the opportunity to observe them consult the admirable representation of them in Eicord's Iconographie, PI. XVII. Their mode of development is as follows: A red spot first ap- pears upon the skin, and a slight effusion takes place beneath the epidermis—sufficient to loosen it from the derma but not to raise it in the form of a vesicle or bulla; the epidermis is removed by friction or falls off, and exposes a raw surface upon which a moist, grayish pellicle is soon formed; the surface is elevated by hyper- 582 MUCOUS PATCHES. trophy of the superficial layers of the skin and gives rise to the broad, flat, wart-like disks above referred to. Another and a very singular mode of origin of mucous patches is from the surface of an infecting chancre, which, during the repar- ative process, may granulate above the surrounding integument, and become covered with a thin, translucent and grayish pellicle. This remarkable transformation of a primary into a secondary symptom has already been described in the chapter upon chancres. Numerous instances of its occurrence upon the genital organs are recorded, and I have myself met with several. Bassereau relates an interesting case in which it took place upon the lower lip.1 When originating in the manner last mentioned, mucous patches are seated upon an indurated base, but otherwise the tissues be- neath them are found on pressure to retain their normal suppleness. Contrary to the statements of some authors, they never present the copper color of other syphilitic eruptions, but are either of a reddish or grayish white color. If the patient happen to be jaundiced, the pellicle covering them may be tinged with yellow. They are usually smeared with a very offensive muciform secretion, which is peculiarly unpleasant when the patches are seated in the neighbor- hood of the genitals, and I have repeatedly known the odor to be so strong as to pervade the room. In a few exceptional instances the patches are dry. Mucous patches readily become ulcerated. When exposed to friction against the clothes or the opposed integument, the pellicle covering the patch is removed, and a red, superficial, but depressed ulceration takes the place of the elevated disk. Such is the origin of the raw surfaces frequently seen upon the sides and front of the scrotum in syphilitic patients. Ulcerated mucous patches upon the margin of the anus closely resemble ordinary anal fissures, from which they may be distin- guished by their more prominent and rounded edges, and by the grayish pellicle which is generally visible upon the sides of the cleft. When situated between the toes, their odor is particularly disgust- ing, and they often project upon the dorsum of the foot in the form of a crescent at the base of the interdigital sulci. Ulcerated and fissured mucous patches upon the margin of the anus, between the toes, or elsewhere, are called rhagades. 1 Op. cit., p. 326, MUCOUS PATCHES. 583 Condylomata upon the vulva are generally elevated and of a red- dish color, as is well represented in Bicord's Iconographie, PI. XX. Those that I have seen within the vagina and upon the cervix uteri, have more closely resembled mucous patches upon the external in- tegument than those situated upon other mucous membranes, as, for instance, within the buccal cavity. Mucous patches upon the geni- tal organs in both sexes sometimes give rise to a discharge resem- bling gonorrhoea from the neighboring mucous membrane, which is not unfrequently observed about the time that early secondary symptoms appear, or when a relapse takes place in the constitutional disease. ... \ / Unlike most syphilitiMeruptidhs mucous patches are frequently attended by severe pruritu* especially when seated upon the scrotum or perineum, and when proWr attention is not paid to cleanliness or the parts have become warm and moist from exercise or pro- longed contact in bed. The unquestionably contagious character of these lesions has been dwelt upon in another chapter.1 Mucous patches within the buccal cavity present a somewhat different appearance from those now described. Their most char- acteristic feature is the grayish-white color, appearing as if they had been pencilled over with a crayon of nitrate of silver, which has given them the name of " opaline patches." They are more irregular in their outline than condylomata, and unlike the latter are not, as a general rule, perceptibly elevated above the surface. In some cases, the adventitious deposit which gives them their grayish color and which is with difficulty removed, is confined to the irregular margin of the patch, while the centre remains sound; and when presenting this appearance they have been compared to the track of a snail.8 The most frequent seat of this form of mucous patches is upon the internal surface of the lips and cheeks, upon the sides and dorsum of the tongue, upon the gums, tonsils, and soft palate. They rarely extend beyond the pillars of the fauces, although occasionally, as in two instances in Bassereau's table already quoted, they are seen upon the walls of the pharynx. A frequent situation is at the angle of the mouth, where they are often intersected by cracks and fissures, the sides of which present the characteristic grayish color of this lesion, and where they are 1 See page 482. * Iconographie, PL XX., bis. 584 MUCOUS PATCHES. continuous with small patches of impetigo upon the external integu- ment. Upon the dorsum of the tongue, their base is sometimes hard, indurated, and fissured; or the pellicle which at first covers them may be rubbed off by the food, leaving a slightly depressed surface resembling an aphthous ulceration; or, again, they may granulate above the surface and form vegetations. When seated upon the tonsils, mucous patches are peculiarly exposed to irritation and ulcer- ation from friction of the food in deglutition, and ulcers are formed, attended by considerable inflammation and swelling of the surround- ing parts, and in which the characters of the original lesion are entirely lost. Deglutition is very much impeded, and the surround- ing inflammation may extend to the Eustachian tube and produce partial deafness. Bassereau states that mucous patches may react upon the neigh- boring lymphatic ganglia, in the same manner as syphilitic erup- tions situated upon the scalp, but only in case their development is attended by acute inflammation. Thus the submaxillary glands are frequently swollen from sympathy with mucous patches upon the fauces; and the inguinal glands may be enlarged in conse- quence of the presence of condylomata upon the scrotum, but the effect upon the latter is less readily perceived because they are gen- erally indurated from their anatomical connection with the primary sore. In two cases observed by Bassereau, in which the chancre was situated at a distance from the genital organs, the inguinal glands were enlarged in consequence of mucous patches in the last mentioned situation. This effect upon the ganglia is, however, ex- ceptional, and always consists of mere engorgement and never of induration. The following tables from the same author exhibit the period of development of this lesion after contagion when no treatment had been instituted, and also when mercury had been given for the primary sore:— In the former case, mucous patches appeared— On the 20th day after contagion in " " 29th " " " » From 1 to 2 months after contagion ii 2 " 3 " " " " 3 " 4 " » « u 4 u 5 u u it « 5 « 6 « d ii 1 u 25 instances 5 " 7 u 5 n oit>> t iy p 122 • L'Union Medicale, 1854. No. 137. Virchow says that the affection described by Cullener is only simple ulceration of the intestinal follicles. (Syphilis Cons.i- tutionnelle, p. 162.) 6 Gaz. des Hop., 1857, No. 66. SYPHILITIC STRICTURE OF THE RECTUM. 601 enteritis in an adult coinciding with an eruption of roseola upon the integument. None of these cases, however, can be regarded as entirely con- clusive, although they are sufficient to induce the practitioner, when ordinary remedies fail to afford relief in obstinate affections of the intestinal canal occurring in syphilitic subjects, to make a cautious trial of mercurials. Syphilitic Stricture of the Eectum.—Rectal stricture is sometimes of undoubted venereal origin; although, as shown by M. Gosselin, its predominance in the female sex, its existence in cases free from syphilitic taint, the difference in the pathological changes from those usually produced by syphilis, and the inefficacy of specific remedies, prove that it is not due to infection of the consti- tution with the syphilitic virus; and that hence the name "syphilitic stricture" is not, strictly speaking, correct. The exact mechanism of its production is somewhat obscure. Gosselin, who has especi- ally investigated the subject in an admirable paper in the Archives Generales de Medecine,1 attributes it to a peculiar modification in the vitality of tissues bathed by the chancrous virus, the same which gives rise to hypertrophy of the prepuce and labia in men and women affected with primary sores, and to simple vegetations in the subjects of gonorrhoea. Still it is very questionable whether there is anything so "peculiar" in this effect of the chancrous virus that it may not be produced by the secretion of gonorrhoea or any irritant of a simple character; but however this may be, it is sufficient for our present purpose to know that venereal stricture of the rec- tum is due to the extension of inflammation from the anus and perineum, and is more common in women because these parts, from their anatomical position, are more exposed than in men to contact with irritant discharges from the genital organs. I propose briefly to state the symptoms of this affection as deduced from twelve cases observed by M. Gosselin, and the pathological changes found in three post-mortem examinations by the same surgeon. In several instances, the patients were not aware of the existence of a stricture, and simply complained of a frequent desire to go to stool, which was followed by a discharge of pus and sanguinolent mucus. Constipation, and difficult and painful defecation were 1 Dec. 1854. 602 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. present in but a few cases; the majority, especially when the disease was of long standing, suffered from habitual diarrhoea. An important symptom was the quantity of pus which was discharged from the rectum, either with or without fecal matter at stool, or involuntarily during the day. In addition, most of the patients lost flesh and strength, and suffered from various dyspeptic symp- toms. In nearly all, hypertrophied and prominent folds of the integument were found upon the margin of the anus, which were attributed by Gosselin to the same chronic inflammation which produced the stricture, and the contraction of the gut was invaria- bly situated at a short distance from the anus. In describing the post-mortem appearances, Gosselin lays con- siderable stress upon the anatomical division of the rectum into three portions, viz: the inferior portion, measuring about an inch and a half in length and corresponding to the external and internal sphincter; the middle or dilated portion; and the superior portion, which is narrower than the preceding, but is not separated from it by any well defined line of demarcation. Venereal stricture is situated at the juncture of the lower and middle portions, encroach- ing somewhat upon the latter; or, in other words, is about an inch and a half or two inches from the margin of the anus, and does not appear to vary its position like strictures dependent upon other causes. The stricture is composed of an indurated and inextensible ad- ventitious deposit in the substance of the mucous membrane and in the submucous cellular tissue. It is never impermeable, nor so contracted as entirely to prevent the exit of fecal matter. The muscular tissue surrounding the contracted portion is somewhat hypertrophied. There is no evidence of any deposit similar to that found in gummy tumors. The lining membrane of the middle or dilated portion of the rectum above the stricture is denuded of its epithelium and glan- dular layer, giving rise to an extensive and continuous erosion for about four or five inches above the contraction, and the muscular tissue surrounding this portion is hypertrophied. This ulcerated surface is the chief source from which is derived the pus that is mingled with the stools and flows away involuntarily. Gosselin believes that so extended an erosion is peculiar to this class of strictures. In two of Gosselin's cases there could be little doubt of the vene- AFFECTIONS OF THE NASAL PASSAGES. 603 real origin of the stricture, which was developed under the obser- vation of 'the surgeon while the patients were under treatment for obstinate chancres of the anus, one of which arose from the inocu- lation of matter proceeding from a chancre upon the vulva. The remaining cases were first seen after the stricture had formed, but in nearly all traces of the previous existence of primary sores were found. Gosselin is unwilling to attribute this affection to unnatural practices, nor has he been able to trace its origin to gonorrhoea of the rectum, which is, moreover, a very rare disease. Mercurials and iodide of potassium are found to have no effect whatever in relieving venereal stricture of the rectum. At the outset of the disease, dilatation either alone or combined with inci- sions may effect a cure; at a later period, they are, in most cases, only palliative. The twelve patients, upon whom these observations were founded, were all inmates of the Lourcine Hospital of Paris, in the year 1854. Two of them died in 1857 of pulmonary phthisis, and the post- mortem appearances did not materially differ from those in the three cases above described. A third, who had been kept under observation, was still maintained in a tolerable state of health by repeated dilatation and incision of the stricture and the adminis- tration of tonics.1 Two cases in confirmation of those of M. Gosselin have been reported, one by Mr. Holmes Coote,2 and the other before the Ana- tomical Society of Paris.3 Syphilitic Affections of the Nasal Passages.—In the order of frequency of syphilitic manifestations, the nasal passages proba- bly come next to the buccal cavity, although the former are less exposed than the latter to observation, and, in many instances, their lesions consequently pass unnoticed. The pituitary mem- brane may be the seat of erythema, mucous patches and super- ficial ulcerations, which obstruct the nasal passages and give rise to a muco-purulent secretion and other symptoms resembling those of an ordinary catarrh, from which they differ in their greater persistency, and in their disappearance upon the administration of mercurials. Sometimes an ulcer can be seen just within the nasal 1 Gaz. des Hop., Aug. 22, 1857. * Med. Times and Gaz.. Jan. 27, 1855. 3 Bulletin de la Soc. Anat. de Paris, 2d sfirie, t. iv., 1859, p. 100. 604 syphilitic affections of mucous membranes. orifice, surrounded by a swollen condition of the mucous mem- brane, and rendering the ala? nasi tender upon pressure; and plugs of inspissated mucus, mixed with blood and pus, are from time to time discharged from the deeper recesses of the organ. In a more advanced stage of the syphilitic diathesis, ulcers of a deeper description appear, which originate in tubercles devel- oped beneath the mucous membrane and gradually involve the cartilaginous and osseous textures; or the latter structures may be first attacked and the pituitary membrane become implicated secondarily. Dryness and obstruction of the nasal passages are the first symptoms complained of by the patient, but suppuration soon takes place, giving rise to an exceedingly fetid discharge of bloody pus and mucus, hard and dark-colored scabs, and fragments of necrosed bone; the voice assumes a nasal sound; the sense of smell may be lost; the patient, breathes chiefly if not entirely through the habitually open mouth; the disease is exceedingly persistent, and finally leaves the nose flattened, or its bridge sunken from the partial destruction of its osseous and cartilaginous support. The remaining portions of the ossa nasi become thickened and eburnated, and are often separated superiorly so as to form a longi- tudinal furrow running along the dorsum of the nose. According to Virchow,' this tendency to eburnation and thickening of the osseous tissue is not confined to the part first affected, but may extend to the bones composing the base of the skull. The earlier syphilitic affections of the nasal passages readily yield to the internal administration of mercurials, and rarely re- quire topical applications. In tertiary affections of the same organ, iodide of potassium, preparations of iron, the mineral acids, cod- * liver oil, and other tonics must frequently be employed either alternately or in combination, and for a long period, in order to afford permanent relief to the disgusting and distressing symptoms. The most efficacious local treatment consists in mercurial fumiga- tions, which may be administered by means of the ordinary mercu- rial vapor bath, provided the general health of the patient be not too much reduced; but a more convenient method is to evaporate a sufficient quantity of calomel, the bisulphuret or binoxide of mer- cury from a metallic plate heated over a spirit lamp, directing the fumes into the nostrils by means of a tunnel of paper or other 1 La Syphilis Constitutionnelle, p. 64. SYPHILITIC aphonia. 605 convenient material. Injections of black wash, diluted chlorinated soda (one part to twelve or twenty of water), and weak solutions of nitrate of silver or chloride of zinc may also be of service. Syphilitic Affections of the Larynx and Trachea.—The effects of syphilis upon the air-passages are chiefly confined to a late period of constitutional infection, and consist in ulceration of the mucous membrane and suppurative inflammation of the carti- lages. Syphilitic Aphonia.—Diday has described a singular affection of the larynx, independent of any appreciable lesion and accompanying early secondary manifestations, to which he has given the name of syphilitic aphonia. Its symptoms are of such a peculiar character, that it is not commonly noticed except in public singers, since the pronunciation is clear and distinct so long as a conversational tone is maintained, but as soon as the patient attempts to sound the higher notes of the musical scale, his voice fails him and he can scarcely emit an audible sound. This diminution in the compass and flexibility of the voice is the only indication of the disease. There are no symptoms of coryza, angina, or bronchitis, no cough, dyspnoea, pain, or difficulty in swallowing, nor general febrile ex- citement. Diday states that he has met with twenty cases of this affection, all of which occurred at an early period after the develop- ment of the infecting chancre; and in five, of which he possesses accurate notes, the average interval was four months. The pathol- ogy of the affection is obscure. It is evident that it cannot be attributed to the sloughing form of ulceration which is known to affect the mucous membrane of the larynx in the later stages of syphilis. A more probable cause might appear to be the presence of mucous patches, but these lesions are rarely met with posterior to the fauces, and they would be attended with some degree of pain or uncomfortable sensations in the region of the larynx. Diday suggests that it may be due to paralysis of those muscles which govern the power of vibration in the borders of the rima glottidis. He admits, however, that this explanation is a mere supposition, which he adopts for the want of a better. I must confess that if Diday's cases had been reported by one less known as an accurate observer, I should be inclined to attribute them to laryngeal catarrh, the symptoms of which had not been recognized; no such suspicion, however, is admissible under the circumstances, but I think that 606 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. the pathology of the affection must be determined by future ob- servation. Syphilitic aphonia generally begins to improve on the second or third day after commencing mercurial treatment, and disappears in the course of a week.1 Syphilitic laryngitis, unlike the affection just mentioned, is always a late symptom of constitutional infection, occurring many months and generally many years after contagion. It is, in most cases, accompanied by tertiary manifestations, and even when isolated has always been preceded by other syphilitic symptoms, and frequently by sloughing ulcers of the fauces. This disease may consist in an ulceration of the mucous mem- brane, or in inflammation of the perichondrium surrounding the laryngeal cartilages. In the former case, it may have extended from an ulcer of the pharynx, or have originated in the larynx; and it often involves the internal surface of the epiglottis, and the greater portion of the lining membrane of the laryngeal cavity. According to Virchow2 it is always accompanied by inflammation of the neigh- boring perichondrium. The latter affection, however, may exist alone without ulceration of the mucous membrane, and an abscess form within the perichondrium denuding and destroying the cartilage, as is observed between the periosteum and bone in syphilitic peri- ostitis. The greater portion of the cartilage may become necrosed and separated in the form of a sequestrum, as in a case figured by Ricord.3 The mucous membrane, even when not ulcerated, is usu- ally more or less cedematous. The existence of an abscess or in- flammatory deposit without the laryngeal cavity explains the enlargement of the throat which is sometimes visible externally, and the prominence of which is increased by the emaciation of the patient. At the commencement of the disease, the voice is husky, and respiration difficult; slight pain is felt in the region of the larynx ; and the patient hawks up a small quantity of purulent matter mixed with blood, and sometimes containing small sloughs; at a later stage, the voice is entirely lost or can be heard only in a whisper; the larynx may be seen on external examination to be increased in size; the patient becomes very much emaciated, and 1 Gaz. Med. de Lyon, No. 2, 1860. 1 La Syphilis Constitutionnelle, p. 149. 3 Iconographie, PI. XXX. SYPHILITIC LARYNGITIS. 607 death may ensue from exhaustion or asphyxia. These symptoms do not materially differ from those of laryngeal phthisis, and the differential diagnosis may in some cases be attended with difficulty. The latter disease, however, is always accompanied by a deposit of tubercles in the lungs, and auscultation will therefore enable us to decide as to the nature of the affection, even when this is not evi- dent from the history of the case and the concomitant symptoms. The post-mortem appearances of syphilitic disease of the larynx and air-passages are thus described by Dr. Wilks: " In the tuber- culous disease of these organs, apart from the small amount of adventitious scrofulous deposit, the affection is characterized by the extensive ulceration, whereas, in the syphilitic form the peculiarity is the thickening and induration owing to a formation of fibrous tissue. The difficulty is in distinguishing between a syphilitic and a simple inflammatory form of disease; but I believe the majority of cases of chronic laryngitis which we meet with are syphilitic, and the more likely is this to be the case when there is a large amount of fibrous deposit present. The disposition in constitu- tional syphilis is to the production of lymph, which may subse- quently become a tough fibrous tissue; this you see in periosteal nodes, as well as in the same formations in other parts; and thus in the larynx you may find sometimes, perhaps, nothing more than a mass of fibrous tissue developed in the glottis, and almost closing it; in other cases you find, with this extreme thickening, also the epiglottis thickened and hardened; or this condition may extend down the larynx as far as the trachea; or the whole organ may be indurated throughout, and even sometimes the cellular tissue ex- ternally with the adjacent small lymphatic glands all matted to- gether, and implicated in the process. With this induration there is generally more or less destruction of the parts, and in most cases, no doubt, the ulcerative process has accompanied the indura- tion and contraction: and thus the inner surface has either lost its mucous membrane, or presents a cicatriform appearance. Some- times, if the ulceration is considerable, the whole of the inner surface of the larynx presents a shaggy or flocculent aspect, and occasionally the ulceration is continuous over the glottis, with an ulcer of the pharynx; in such a case the question may arise as to the original site of the disease; but, as both these parts may be in- dependently affected, it is possible that the disease in both has pro- gressed simultaneously. Other parts of the air-passages may be 60S SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. affected as well as the larynx, as you see in the specimen I now show you, where the lower part of the trachea is very much thick- ened, and the surface ulcerated; and in the preparation I just now showed you, of contracted bronchus arising from an ulcer, the nature of the disease was clear, in the fact of the patient dying of syphilitic laryngitis: the contracted trachea also had the same origin. As I before mentioned, in some of these cases of ulcera- tion of the trachea the rings are laid bare, as you will see in these specimens; and which sometimes become detached during life, if the patient recovers."' Syphilitic ulceration of the trachea, which is described by Dr. Wilks from preparations in Guy's Hospital Museum, has been noticed in a number of reported cases, in some of which the affec- tion was confined to the trachea and in others implicated also the larynx. Thus Virchow2 cites the case of Marguerite Rudloff} who died of stricture of the larynx following syphilitic ulceration, and in whom cicatrices were found in the trachea and bronchia with stricture of the latter. It is an interesting fact that stricture of the air-passages conse- quent upon the cicatrization of a syphilitic ulcer may cause death from dyspnoea, so that specific remedies may in reality hasten a fatal termination just so far as they exert a beneficial influence upon the local disease. Two interesting cases of this description are given in the Annuaire de la Syphilis (annde 1858, p. 324). In the first, reported by Moissenet, the stricture was situated just above the bifurcation of the trachea. The lining membrane at this point pre- sented a honeycomb appearance, and the cartilages were more or less changed in their structure and destroyed; indeed, four of the rings had entirely disappeared and were replaced by flexible tissue; hence, in addi- tion to the diminution in the calibre of the tube, its walls collapsed at each act of inspiration and added to the difficulty in the ingress of the air. The patient had been taking mercurials and iodide of potassium which only aggravated her symptoms. Tracheotomy was performed without benefit, since the larynx was unaffected and the obstruction was below the artificial opening. Death was caused by asphyxia. The following is a summary of the second case reported by M. Demarquay:— 1 Pathological Anatomy, p. 204. 2 La Syphilis Constitutionnelle, p. 151. SYPHILITIC LARYNGITIS. 609 The patient, aged 36, entered a maison de sanU, Oct. 25, 1858, with all the symptoms of oedema of the glottis. He seemed to be threatened with suffocation; his respiration was noisy and painful; he had had a cough for two months with slight expectoration ; his sputa resembled those of laryngeal phthisis; and he had lost much flesh. For.a fortnight his symptoms had been very intense. The lungs were found to be sound; and as the patient had had chancres twelve years before, followed six years afterwards by ulceration and perforation of the soft palate, iodide of potassium was ordered. Under this treatment he continued to improve for a month; but on Nov. 25th he was suddenly seized with such extreme dyspnoea that M. Demarquay thought it best to perform tracheotomy. The operation was of no benefit and death soon ensued. At the autopsy, the larynx was found to be perfectly healthy, with the exception of a small cicatrix between the two arytenoid cartilages; but the trachea was found to be abruptly contracted opposite its eleventh ring, at which point its circumference measured only 28 millimetres. This stricture involved the left side of the trachea and was formed of cicatricial tissue in which six rings of the tube were twisted on themselves and fractured. Below the stricture the bronchia were dilated, and their longitudinal muscular fibres hypertrophied. The lungs were healthy, and free from tubercles.1 The bronchia may also be the seat of syphilitic ulceration and consequent stricture. In the case of Marguerite Rudloff, reported by Virchow, " the right bronchus was contracted at its bifurcation and above that point; a section of it presented the form of a triangle ; its diameter measured a quarter of an inch, while that of the left bronchus measured half an inch. The left bronchus was contracted to a still greater extent near its bifurcation, but only for the distance of a quarter of an inch, and was adherent at this point to the normal oesophagus through the inter- vention of a thick and tendinous mass of tissue. The right bronchus was the seat of thickening and contraction which extended for a short distance into its branches, which farther on were reddened upon their internal surface and dilated. Several larger dilatations of the bronchia were found in the inferior lobe of the lung which was otherwise healthy; and at these points the pulmonary tubes were filled with mucus and sur- rounded by condensed tissue which extended as far as the pleura." Virchow concludes from this and another case of which he gives an analysis, that " we must admit the existence of syphilitic ulcera- ' Bulletin de la Soc. Anat. de Paris, 2e serie, t. ii. p. 484. 39 610 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. tion and stricture of the bronchia similar to the same lesions of the larynx, and must also concede that syphilitic bronchitis may give rise to chronic pneumonia, in the same manner as laryngeal ulcera- tions cause extensive induration of the cellular tissue of the neck. I have often seen in constitutional syphilis, limited star-shaped cicatrices of the pleura and pleurisies, in consequence of the above mentioned changes."1 Treatment.—The prognosis in syphilitic ulcerations of the air- passages is exceedingly unfavorable. The iodide of potassium, mercurials, nourishing diet and tonics may, in some cases, afford relief, while in others they prove inefficacious, or, in a few in- stances, as already remarked, may hasten a fatal termination by inducing cicatrization of the ulcer and consequent contraction and stricture. Carmichael believed that the ulcerative process was maintained by the transit of the air, and that the best method of cure was the early performance of tracheotomy. These views have not, however, been confirmed by recent surgeons, who resort to this operation only in cases of impending suffocation, and even then, since the stricture may be seated below the artificial opening, if for no other reason, the prospect of affording relief is very dubious. Op. cit., p. 154. SYPHILITIC AFFECTIONS OF THE EYES. 611 CHAPTER XII. SYPHILITIC AFFECTIONS OF THE EYES. A large number of tissues enter into the composition of the orbit and its contents, and syphilitic affections of this region are correspondingly numerous; but a minute description of all of them would be inconsistent with the limits of this work; and I shall therefore merely allude to several of them and dwell chiefly upon those which are the most common and most likely to fall under the care of the general practitioner. Affections of the Bones of the Orbit.—Syphilitic nodes may be met with upon either of the four walls of the orbit. They are most frequent near the anterior opening of the socket, but may occur at a greater or less depth within its cavity and cause protru- sion of the eyeball and loss of vision consequent upon stretching of the optic nerve. The following cases are reported by Mr. Poland:—l Case 1. John M----, aet. 41, a large, bony, well-developed man, be- came an out-patient at Moorfields, suffering from an extensive swelling of the bone at the upper part of the orbit, encroaching upon the eyeball so as to displace it downwards and forwards. The history of the case, as well as the present marks of old mischief, at once indicated the nature of the growth. From his statement, it appeared that about ten years ago he had un- deniable syphilitic inoculation ; hardened chancre and a non-suppurating bubo, followed by secondary symptoms of a rather protracted form. He underwent mercurial treatment, both internally and by ointment, and with benefit; ultimately he became free from all symptoms, and since that time at intervals he has had occasional attacks of rheumatism, which have been relieved by iodide of potassium, and on more than one occasion he has 1 On Protrusion of the Eyeball, Ophthalmic Hospital Reports, vol. ii. p. 223. 612 syphilitic affections of the eyes. had nodes on the tibia, which were relieved by blisters. The present swelling on the frontal bone had been in existence for nearly six weeks, and, within the last few days, had increased most rapidly in size; it was perfectly firm and hard, but very tender and painful, and seemed to extend towards the orbit, instead of taking the usual course over the forehead, and had already encroached upon the eyeball, slightly displacing it down- wards and forwards. There were no cerebral symptoms whatever. The man was ordered to take three grains of the iodide of potassium three times a day, and to rub an ointment of the same on the swelling morning and night. By persevering with this treatment for three months the swelling entirely disappeared. Case 2. The second case was that of a woman nearly six feet in height and of immense bony development, who came under Mr. Poland's care at Moorfields, having a large node growing from the inner wall of the orbit; it was perfectly solid to the touch, but pushed the eye outwards and forwards, and had caused tension of the optic nerve, so that there was loss of sight, dilated fixed pupil, and perfect immobility of the eye. She soon afterwards had severe cerebral symptoms, and died suddenly in a comatose condition. There was no examination of the body. I have never met with exophthalmos dependent upon this cause during five years' connection with the N. Y. Eye Infirmary. The bones of the orbit, and most frequently the frontal bone, may be the seat of caries, originating in syphilis and occasioning abscess and sinuses of the lids. Affections of the Lachrymal Passages.—Syphilis not un- frequently gives rise to changes in the lachrymal passages, causing obstruction to the flow of tears, epiphora and lachrymal abscess and fistula. Since these passages are not exposed to direct observa- tion, the exact nature of the changes in their walls is not always apparent. In a few instances, the disease appears to be confined to the mucous membrane and submucous tissue, and to consist in catarrhal inflammation, consequent oedema, and ulceration; in the majority of cases, however, it commences in the bony wall or peri- osteum, and the mucous membrane is affected secondarily • changes which correspond to those met with in other mucous membranes contiguous to bony tissue. The character of the coexistent syphi- litic symptoms may afford some idea of the changes in the tear passages, which, however, can only be accurately determined by direct exploration. J affections of the lachrymal passages. 613 The symptoms are sufficiently obvious. The tears meeting with obstruction to their transit through the lachrymal passages, collect upon the conjunctival surface; if profuse, they flow over upon the cheek, especially when the patient is exposed to the wind, and the eye is evidently more moist than its fellow, whence the name " watery eye" applied to this disease. Soon, pressure over the lachrymal sac causes a reflux into the eye of the lachrymal secretion mixed with more or less purulent matter, or the same result takes place spontaneously; the conjunctiva, especially that of the lower lid and inferior portion of the globe, is maintained in a constant state of irritation and inflammation, and the puncta are abnormally red, swollen, and prominent. In extreme cases an abscess forms in the lachrymal sac or neighboring cellular tissue, opens and gives rise to one or more fistula?. Much may be done for the relief and permanent removal of ob- structions of the lachrymal passages by the persevering and long continued use of specific remedies. The bichloride of mercury and iodide of potassium were for many years exclusively employed with very satisfactory results at the New York Eye Infirmary where this affection is very common. Many cases, however, refuse to yield to internal remedies alone, and in all a cure may be ex- pedited by a resort to the improved local treatment for which ophthalmic surgery is so largely indebted to Mr. Bowman of the Moorfields Ophthalmic Hospital.1 Mr. Bowman's treatment consists in slitting up the canaliculi as far as the caruncle, and afterwards dilating the passage into the nose by means of graduated probes as we would a stricture of the urethra. The first part of the above procedure is often sufficient to afford great relief to the patient by opening a free communication between the conjunctiva and sac, and by preventing collections of matter in the latter or facilitating their evacuation. One or both canaliculi having been slit up, an opportunity is afforded to explore the nasal passages with a full-sized probe (about one-twentieth of an inch in diameter), and to ascertain the nature of the obstruction. If this be due to swelling of the mucous and submucous tissues alone, the passage of a probe repeated every two or three days for 1 See Mr. Bowman's papers in the Medical and Chirurgical Transactions, 1851, and in the Ophthalmic Hospital Reports, for Oct. 1857 ; also Remarks on Diseases of the Lachrymal Passages by the author in the Report of the N. Y. Eye Infirmary, N. Y. Journal of Med., July, 1859. 614 syphilitic affections of the eyes. a few weeks, and retained on each occasion for about half an hour, will in most cases suffice to re-establish the patency of the canal; but when denuded bone can be felt, showing that the disease is seated in the periosteal or osseous tissues, Mr. Bowman's method will rarely prove successful, and it becomes necessary either to resort to obliteration of the sac and canaliculi (which should always be included) by the actual cautery, or to wait for the slow elimina- tion of the necrosed portions of bone under the internal adminis- tration of iodide of potassium. The old-fashioned style is rapidly going into disuse and has already been entirely abandoned at the Moorfields and New York Eye Infirmary. The danger and incon- venience attending its employment far more than counterbalance any benefit that can be derived from it. Syphilitic Affections of the Eyelids.—These may be pri- mary or secondary. All chancres that have been observed upon the eyelids, have been of the infecting species. The induration of the base of the sore is well marked and persistent, and the accom- panying indurated bubo is seated in the ganglion in front of the ear. A case of this kind occurring at the New York Eye Infir- mary has been referred to in the chapter upon chancres. The external surface of the lids, like other portions of the integument, may be the seat of the various syphilitic eruptions. Secondary ulcers are almost always situated near the free border, encroaching upon the mucous membrane or upon the skin, and sometimes, as in a number of cases collected by Mackenzie,1 causing complete destruction of the lid. I have seen but one case in a lad aged 19, affected with syphilitic disease of the lachrymal passages and nodes upon the tibia, and who had several small excavated ulcers upon the mucous membrane of the lower lid bordering upon its free margin. His disease could be traced to an infecting chan- cre contracted three years previous, and disappeared under iodide of potassium and mercurials. These ulcerations may be mistaken for ophthalmia tarsi, and epithelial cancer, or, when situated near the inner canthus, for disease of the lachrymal passages. Syphilitic eruptions of the eyelids are more frequent in infants affected with hereditary syphilis, than in adults. The external surface of the lids is the seat of an eruption of pustules, which ' Diseases of the Eye, Phil, ed., 1855, p. 160. AFFECTIONS OF THE CORNEA. 615 run into each other, break and leave the skin excoriated and red.1 The conjunctiva of the lid and the globe may become involved through .extension of the inflammation, and the cornea destroyed by infiltration of pus. This affection may be distinguished from ophthalmia neonatorum by its later development—the former appearing about the third day and the latter several weeks after birth—and by the presence of the eruption upon the external sur- face of the lids to which the conjunctivitis is only secondary. Affections of the Conjunctiva.—If we except the ulcera- tions of the margins of the lids already described as sometimes encroaching upon the mucous membrane of the internal surface, the conjunctiva is very rarely the seat of syphilitic manifestations. Infants tainted with hereditary syphilis are, indeed, more fre- quently than others the subjects of ophthalmia neonatorum; to which they are peculiarly exposed from their general cachectic condition and the frequency of vaginal discharges in their syphi- litic mothers; but there is no direct connection between their hereditary taint and the purulent inflammation of the conjunctiva, which usually makes its appearance before the development of constitutional symptoms. Mucous patches, so common upon other mucous membranes, are never met with upon the conjunctiva; this membrane, however, ac- cording to Desmarres,8 is sometimes the seat of syphilitic tubercles coexisting with a similar eruption upon the skin. This author relates the case of a patient affected with syphilitic iritis, in whom one of the so-called condylomata of the iris, situated near its external mar- gin, penetrated the sclerotic and formed a protuberance beneath the conjunctiva, which, moreover, was studded on every side with small, indolent, hard and oblong tumors, exactly similar to an eruption of syphilitic tubercles upon various portions of the integument. The disease disappeared under mercurial treatment. Affections of the Cornea.—Mr. Jonathan Hutchinson3 has expressed the opinion founded upon a lengthy and ably conducted series of observations, that the peculiar inflammation of the cornea, 1 Figured by Devergie, Clinique de la Maladie Syphilitique, PL 37. * Traite" des Maladies des Yeux, t. ii. p. 216. 8 Ophthalmic Hospital Reports, vol. i. p. 229. 616 SYPHILITIC AFFECTIONS OF THE EYES. met with for the most part between the ages of five and twenty and known by the name of "strumous corneitis,"1 is always due to hereditary syphilis. In his attempt to establish this point Mr. Hutchinson has attached no little importance to certain peculiarities in the form, size, and color of the permanent incisor teeth, which he regards as diagnostic of inherited syphilitic taint, and which he states are all but invariably coexistent with strumous keratitis. In describing this condition Mr. Hutchinson says: " As diagnostic of hereditary syphilis, various peculiarities are often presented by the others, especially the canines, but the upper central incisors are Fig. 34. "The teeth converge towards each other, are very short, have a vertical notch or cleft in their free edges, and are also very narrow from side to side at their edges, not being so wide there as at their necks." the test teeth. When first cut these teeth are usually short, narrow from side to side at their edges and very thin. After awhile a crescentic portion from their edge breaks away, leaving a broad, shallow, vertical notch which is permanent for some years, but be- tween twenty and thirty usually becomes obliterated by the pre- mature wearing down of the tooth. The two teeth often converge, Fig. 35. and sometimes they stand widely apart. In certain instances in which the notching is either wholly .absent or but slightly marked, there is still a peculiar color ('a dirty brownish hue resembling that of bad size'2), and a narrow squareness of form, which are easily recognized by the practised eye.'" Diday4 adduces a single 1 The name " Keratitis " is much preferable to " Corneitis." 2 Hutchinson, on the Means of Recognizing the Subjects of Inherited Syphilis in Adult Life, Medical Times and Gaz., Sept. 11, 1858, p. 265. 3 Ophthalmic Hosp. Reports, vol. ii. p. 96. « Gaz. Hebdom., Feb. 4, 1860. SYPHILITIC IRITIS. 617 case in confirmation of Mr. Hutchinson's observations upon stru- mous corneitis and notching of the teeth as symptomatic of heredi- tary syphilis. In justice to the importance of this subject, and to Mr. Hutchin- son's laborious researches, no decided opinion for or against his statements would be warrantable, unless based upon an equally thorough series of investigations, which I have not as yet found time to undertake, although I hope soon to be able so to do at the New York Eye Infirmary, than which no better field is anywhere afforded. I may be permitted, however, to give my own impres- sions, which are shared by my colleagues at the Infirmary, that the peculiarity of the teeth, above described, is a symptom of general cachexia, which may be occasioned by other causes than syphilis, and that strumous keratitis is observed in subjects in whom there can be no suspicion of inherited taint; although I can fully confirm Mr. Hutchinson's statement, that the most efficacious treatment of this disease, in the majority of cases, is by means of mild mercurials and iodide of potassium, assisted by nourishing diet, fresh air, and tonics. Syphilitic Iritis.—Syphilitic iritis, endangering, as it does, the integrity of one of the most important organs of the human frame, should be familiar to every student of venereal, that he may early be able to recognize and treat it. A knowledge of its symptoms may, I think, be best imparted by a concise description, in which its prominent features, whereon the diagnosis must be based, shall be alone included, omitting the more minute details which are chiefly of interest to the ophthalmologist, and which are apt to confuse the mind of one who has not made a special study of the eye. Let me premise by saying that we have no certain means of distinguishing syphilitic iritis from that dependent upon injury, scrofula, or other causes; although there are certain symptoms, presently to be described, which, when observed, render the former origin probable. Moreover, the majority of cases of iritis are doubt- less due to syphilitic taint,1 so that the existence of this disease 1 My friend, Dr. Henry D. Noyes, of the Infirmary, informs me that, according to statistics collected by Prof. Graefe, and reported by him in his lectures, about sixty per cent, of all cases of iritis occur in persons affected with syphilis. 618 SYPHILITIC AFFECTIONS OF THE EYES. should always excite suspicion, and lead the surgeon to make a thorough examination of the present condition and past history of the patient. Two forms of iritis are admitted. The first, which is the most common and most worthy of our attention, is to be ranked among the secondary symptoms of syphi- lis. Without being able to furnish any statistics from which the exact time of its development may be determined, yet I have often been struck with the fact that, when no mercury had been adminis- tered, this occurred somewhere about six months after contagion. In a number of instances, iritis has been the first general symptom which has induced patients to seek surgical advice, but careful inquiry has never failed to show that other symptoms, as alopecia, engorgement of the cervical ganglia, mucous patches, erythema, or papules, had preceded it, although regarded at the time as of no importance. The most prominent symptoms of this disease are the follow- ing:— Injection of the conjunctival and sclerotic vessels, giving the eye a red appearance. But unnatural redness is observed in simple conjunctivitis; and how shall the two be distinguished? In the first place, by depressing the lower lid, and, at the same time, tell- ing the patient to look upwards; whereby the inferior palpebral fold will be exposed. In most cases of conjunctivitis, the greatest amount of injection will be found remote from the cornea; while in iritis the contrary is the case; the redness is almost entirely con- fined to a circle round the cornea, called the "sclerotic zone," while the more distant portions of the white of the eye remain clear. If the eye has been congested by the injudicious application of poul- tices, alum curds, etc., this difference will be less, or not at all, apparent. Again, observe the character of the injection: some of the conjunctival vessels are distended, and may be recognized by their brick-red color, large size, tortuous course (chiefly over the recti muscles), and their mobility, if the conjunctiva, by means of slight pressure with the finger external to the lid, be made to slide over the sclerotica; but beneath these brick-red vessels a second layer is discovered on close examination, composed of others radi- ating from the margin of the cornea, much finer than the preceding, straight, and of a pinkish hue, and which are seen to remain sta- tionary through the meshes of the sliding network of conjunctival SYPHILITIC IRITIS. 619 vessels. It is these vessels which constitute the sclerotic zone, met with not only in iritis, but in other internal inflammations of the eye. Next observe the condition of the iris and pupil and compare them with those of the opposite and sound eye. The affected iris is seen to have lost its natural brilliancy; its minute texture is less apparent; its surface covered over with a thin layer of fibrin; and its color changed. In persons with blue eyes it assumes a yellowish green hue; in others, the change is less marked but may generally be detected. Close the two eyes with the thumb of each hand, the fingers resting for support upon the temples, and alter- nately open one and then the other; and the iris of the affected eye will be found to be sluggish in its motions or quite immovable. At a later stage of the disease one or more yellowish or brownish elevations may begin to appear upon the surface of the iris, and generally, though not always, upon its inner ring near the margin of the pupil. These " tubercles," as they are called, gradually in- crease in size and sometimes become organized and covered with a minute network of vessels. If seated near the external border of the iris they may cause projection of the cornea or sclerotica. Graefe states that they are composed of fibrinous exudation, gran- ular amorphous matter and pus-corpuscles.1 Virchow2 believes that they are dependent upon a deposit of syphilitic tubercle in the substance of the iris, but this opinion cannot be received without further proof. They are very much more frequent in syphilitic than in iritis from other causes,3 but are not exclusively confined to the former, hence their presence affords a strong probability though not an absolute certainty of syphilitic taint. At an early stage of the disease, the pupil assumes a dull ap- pearance, and is less clear and bright than natural, owing to com- mencing changes in the anterior capsule of the lens; it may also be somewhat irregular. This irregularity of outline, due to. adhe- sions between its margin and the capsule of the lens, becomes more marked as the disease progresses, and is especially evident if the pupil be dilated by belladonna, when its margin is found to be scalloped owing to its being attached at some points and drawn out • Notes of Graefe's Lectures, for which I am indebted to Dr. Henry D. Noyes. 2 La Syphilis Constitutionnelle, p. 146. s Of sixty cases of iritic tuhercles collected by Graefe, in only two was there no proof of syphilitic taint. Notes of Graefe's Lectures. 620 SYPHILITIC AFFECTIONS OF THE EYES. in others. In some cases the adhesions become continuous around the whole circumference, and the capsule of the lens is covered with a layer of lymph which completely blocks up the pupil. When syphilitic iritis is early and successfully treated, the ins resumes its normal mobility and color, and the eye is restored to its original integrity. But in weak and cachectic subjects and in the absence of appropriate treatment, the changes which take place are more or less permanent. The tubercles are absorbed but the iris never regains its original color and consistency; it is thinned and friable; and its adhesions to the capsule, unless stretched or broken by the persevering use of mydriatics, permanently impede the motions of the pupil. As a general rule, the pain and photo- phobia in syphilitic iritis are much less than in the other forms of the disease. The patient may merely complain of a sense of fulness and uneasiness in the globe and shrink from exposure to a strong light only. In other cases, severe pain is felt in the ball of the eye and in the temporal and supra-orbital regions, and the least ray of light causes the most intense suffering; the variations between these two extremes are numerous. There is almost invariably some dimness of vision which is due not only to the changes in the capsule of the lens, but also to those in the deeper structures of the eye which are always involved to a greater or less extent. Iritis usually presents such marked symptoms that it is easily recognized by any competent person; and yet every ophthalmic surgeon must have met with not unfrequent instances in which through carelessness or ignorance it has been mistaken for simple conjunctivitis and treated solely with collyria of nitrate of silver, sulphate of zinc, etc. A few cases, however, are met with in which the most experienced surgeon may for a day or two fail to make a diagnosis. This generally occurs at the commencement of the dis- ease, before any marked changes have taken place in the iris, and especially when the conjunctival vessels have been congested by the application of poultices. I have seen a number of such cases at the N. Y. Eye Infirmary, in some of which attention has been expressly called to the obscurity of the symptoms and the necessity of waiting a day or two before deciding as to the nature of the dis- ease ; while in others it has been determined not from the appear- ance of the eye itself, but from the discovery of some syphilitic symptom, as a mucous patch, a copper-colored eruption, or an enlarged post-cervical gland. I would repeat, however, that such SYPHILITIC IRITIS. 621 cases are very rare, and that the obscurity is almost invariably due to improper applications to the eye. I have already remarked that the diagnosis of syphilitic iritis, although rendered highly probable by the absence of severe pain and photophobia, and the presence of tubercles upon the iris, can only be satisfactorily established by the history of the case or the coexistence of undoubted syphilitic symptoms. I would also add that the presence of any general eruption upon the body leaves scarcely room to doubt that a coexisting iritis is of spe- cific origin, since this disease, when due to other causes, is very rarely accompanied by affections of the skin. The practical surgeon when called to treat a case of iritis, almost instinctively turns to the arms, chest, and abdomen, to look for traces of one of the syphilodermata. The second form of iritis, to which I have referred, is met with as a symptom of tertiary syphilis, and differs from the preceding chiefly by the insidious manner in which it attacks the eye, and by its greater persistency. There is almost a complete absence of pain and photophobia; the iris becomes infiltrated and covered with lymph, and has a peculiar swollen and velvety appearance; nu- merous adhesions take place between its pupillary margin and the capsule of the lens; and the irregular pupil is blocked up with an effusion of lymph, upon which small, black, uveal deposits may often be detected. Both eyes are generally attacked in succession; the disease is exceedingly persistent, and with difficulty controlled by treatment; and the danger of complete loss of sight from ob- struction of the pupil is very great. The deeper structures of the eye appear to be implicated to a less extent than in the acute form. Among the absurdities of medical belief that have had their day is to be reckoned the idea that mercury may give rise to iritis—a disease which is often met with when no specific remedy has been employed, and which can in no way be better controlled than by the judicious use of mercurials; indeed, the surgeon rarely has an opportunity of witnessing a more remarkable effect of treatment than is seen in the absorption of lymph, the disappearance of the abnormal injection, and the restoration of the iris to its original condition, which take place under the administration of mercury in acute syphilitic iritis. It is hardly necessary to say that an agent of so much good is capable of doing a great amount of harm, and that I am here speaking of its use and not of its abuse. 622 SYPHILITIC AFFECTIONS OF THE EYES. The plan of treatment of the acute form of iritis which I have found almost uniformly successful, has, for its objects— 1. To bring the system under the influence of mercurials as speedily as possible, without injury to the general health, and with- out inducing salivation. 2. In a depressed state of the system, to combine tonics with mercurials, or to employ the former in connection with iodide of potassium instead of the latter. 3. To keep the pupil constantly dilated by means of atropine or belladonna, and thus prevent adhesions between the iris and capsule of the lens. 4. To relieve pain and regulate the general hygienic management of the case. The subjects of these different heads will be somewhat briefly considered in view of the fact that most of them have been included in what has been said of the general treatment of syphilis. In persons of a fair state of health, no form of mercurial is pref- erable to the ordinary pill of calomel and opium (one grain of the former to a quarter or half a grain of the latter) administered three times a day—an hour after meals. When the general condition of the system is depressed, a tonic should be combined with the mer- curial ; and the following formulae are most frequently employed at the N. Y. Eye Infirmary, where the patients are, for the most part, of the poorer class, and under unfavorable hygienic influ- ences :— $. Hydrargyri cum creta gr. ij. Quiniae sulphat. gr. j. M. et ft. plv. I£. Hydrargyri cum creta. gr. ij. Quiniae sulphatis gr. j. Pulveris Doveri gr. iij. M. et ft. plv. The latter formula containing Dover's powder is to be preferred when the pain is severe. The frequency of the administration of these powders is to be determined by the strength and general condition of the patient. Under ordinary circumstances, one may be given three times a day; or, when the system is much depressed one morning and night, with one or two grains of quinine in addi- tion twice during the day; and when thus guarded by quinine, mercury may be employed in nearly every case of this disease It SYPHILITIC IRITIS. 623 is well to prolong the use of this remedy until evidence of its action upon the mouth is perceptible, but not to continue it until salivation is produced. So soon as the gums are decidedly affected, the mer- curial should be suspended, and chlorate of potash employed, while at the same time the tonic may be continued. It is a singular fact, that the opposite eye will sometimes be at- tacked while the patient is taking mercury for the one first affected, and, in rare instances, even during the existence of ptyalism. It will be observed that the above mode of employing mercury in combination with quinine, as practised for many years at the New York Eye Infirmary, is widely different from the exclusive use of this mineral, which has been recommended by some authors. It would be out of place in the present work to enter into a discus- sion of the comparative merits of the two methods, and I must, therefore, content myself with expressing a strong preference for the one here proposed; merely adding, that it is equally as true of iritis, as of other syphilitic manifestations, that the administration of mercury, without regard to the condition of the patient, is quite as likely to do harm as to do good. My friend, Dr. Henry W. Williams, of Boston, has adduced sixty- four cases of iritis, dependent upon various causes, to show that the treatment of this disease may be successfully conducted without mercury, by means of quinine, iodide of potassium, narcotics, and mydriatics. There appears to be no good reason why we should lay aside so valuable an agent as mercury, provided it be not abused. In a large number of cases of iritis, treated by my colleagues and myself, at the Infirmary, I have never seen any unfavorable influence upon the general health; and repeated trials of Dr. Williams's method by Dr. C. R. Agnew and myself, have convinced us both that the results are less satisfactory than when mercury is employed. In two instances, permanent impairment of vision ensued, which we had reason to believe might have been prevented by the use of mercurials; and in all the duration of the disease was considerably prolonged. It is of the first importance in the treatment of iritis to maintain the pupil in a constant state of dilatation, so as to remove the iris as far as possible from the convex surface of the lens, and prevent adhesions or closure of the pupil with lymph. For this purpose, instillations of a solution of atropine are far preferable to extract of belladonna smeared upon the brow. In addition to its power of 621 SYPHILITIC AFFECTIONS OF THE EYES. dilating the pupil, atropine is a most valuable sedative—a rare combination in the same remedy. Two grains to the ounce of distilled water, first dissolved in a few drops of dilute acetic acid, or, better still, in a little alcohol, is the formula which I com- monly employ. This solution is best applied to the inner canthus by means of a camel's hair brush; in default of which, the pa- tient's head may be thrown back, and a small portion of the fluid be poured upon the concavity upon the side of the nose, when some of it may readily be made to flow between the lids. If the case be seen at the outset, before the motions of the iris are im- peded by an infiltration of lymph, two or three times a day will be sufficiently often to use the drops. In the acute stage of iritis, some authors advise us entirely to abstain from the use of atropine and belladonna, which have but little power of influencing the pupil after effusion has taken place, and which, it is said, may "irritate and tease the iris, and cause pain."1 My own experience leads me to believe that these fears are groundless. Instead of aggravating, I believe that atropine greatly relieves the pain and irritation, and although its immediate action upon the pupil is not perceptible, yet it gradually stretches or breaks down the adhesions already formed, and thus assists the iris in recovering its dilatability; hence I am in the habit of even increasing the frequency of the instilla- tions, during the acute stage, to three or possibly four times a day. Care should be taken, however, that the atropine, some of which gains the pharynx through the lachrymal and nasal passages, does not produce its physiological effects upon the general system. Venesection is never required in syphilitic iritis, and local deple- tion by means of cups and leeches is advisable in only a few cases in robust subjects. After the acute stage has passed, counter- irritation is best effected by painting the brow with the strong tincture of iodine. It is highly important that the patient should obtain sleep, for which purpose ten grains of Dover's powder may be given at bed- time, and repeated if necessary. In many cases, however, frictions upon the brow and temple at bedtime of mercurial ointment, with the addition of powdered opium (ung. hydrarg. 3j, plv. opii 3j) will suffice to allay pain and procure sleep. In this, as in nearly all affections of the eye, the surgeon has to i Critchett, Lectures on Diseases of the Eye, London Lancet, Am. ed., March, 1855, p. 216. INFANTILE IRITIS. 625 contend with the deeply-rooted prejudices of the masses in favor of poultices of bread and milk, tea leaves, alum curds, raw oysters, pieces of pork, et id genus omne. Not only should all such vile applications be put far away, but the eye should not be tied up with handkerchiefs or cloths in any manner. In women, the best protection against the strong light is a veil; in men, a pasteboard shade will answer the same purpose. In unfavorable weather, or in unusually severe cases of iritis, the patient should be confined to the house, or even to his room, which should be shaded but not darkened. In most cases, however, when the weather is fair, it is desirable that the patient should pass a portion of the day out of doors, in the early morning or evening, if the intolerance of light be excessive, and with the eyes protected in the manner above directed. Photophobia and irritability of the eye will be aggravated by confinement to a dark room. The diet must be proportioned to the general condition of the system. Robust subjects should take but a small quantity of light food; while the cachectic require an abundant supply of nourish- ment and, it may be, stimulants. Proper attention should also be paid to the digestive organs, and a daily evacuation of the bowels secured. The chronic form of iritis met with in tertiary syphilis most fre- quently occurs in persons whose constitution is enfeebled, and by whom mercury is poorly tolerated; but when properly guarded by tonics, this mineral may still, in many cases, be used with marked benefit; in others we are obliged to resort to iodide of potassium, until by every available means the general health is restored. Mercurial inunction may often be employed, when mercury by the mouth cannot be borne. I must refer the reader to works upon ophthalmic surgery for a description of the operations intended for the relief of closure of the pupil, the effect of iritis. Infantile Iritis.—An extremely interesting form of iritis is met with in infants affected with hereditary syphilis. It is a rare disease, but probably exists in many instances in which it is overlooked. All the cases hitherto reported are included in the following table, prepared by Mr. Jonathan Hutchinson; and the conclusions deduci- ble from them are from the pen of the same author.1 ' Medical Times and Gaz., July 14, 1860. 40 TABULAR STATEMENT OF TWENTY-ONE CASES OF INFANTILE IRITIS. NAME, HOSPITAL, REFERENCE, ETC. AGE. Jane M. ; Mr. Law- rence. Sex not stated ; Maun- sell and Evanson. "A child ;" Dr. Jacob. 4 Mary O. ; Mr. Walker. Mary Ann W. ; Mr. Dixon; the Ophthal- mic Hospital. William J. J.; the Ophthalmic Hospital; Mr. Dixon. 7 Harriet H.; the Hospi tal for Diseases of the Skin; (the writer's own notes.) 16 months 11 months. A few months. 10 Emily C ; St. Bartho- lomew's ; Mr. Wor- maid. Christopher T. ; Hospi- tal for Diseases of the Skin; (the writer's own notes.) Sarah P. ; St. Bartho- lomew's ; Mr. Wor- mald; (the writer's own notes.) PARENTS' HI8TORT. The mother had contracted syphilis three months be fore her confinement. Its father had at the time a tubercular syphilide. No details. No details. 9 weeks. Both parents denied hav- ing had syphilis. The mother had had sores, followed by rash, a few weeks before her confine- ment. 8 months, 3 months. 8 months. 5 months. Mother covered with a se condary syphilitic rash. Child illegitimate and first-born. The mother denied all his- tory ; father not seen. Mother under treatment for a syphilitic rash. A first-born child. The mother had lost five infants with suspicious symptoms, and this was her only living child. INTERVAL BETWEEN PROBABLE SYPHILIS IN PARENTS AND BIRTH OF CHILD. 3 months. Probably short No details. No details. Not known. 2 months(?). A few months. Not known. A few months. Not known (proba- bly six years). SYMPTOMS PRESENT AT THE TIME IN THE CHILD. Vaginal discharge and condylomata at the anus. No details given. No details. The child had unmistakable symptoms when un- der notice. A copper-colored rash, of four months' dura- tion. Scaly, copper-colored eruption ; loss of eye- lashes ; peeling of cu- ticle ; sore mouth. A dusky, red eruption. Emaciation; cachexia; ulcerated condylo- mata. Snuffles; emaciation; sore mouth ; syphili- tic psoriasis. Had been attending for 4 months on account of a syphilitic rash, which was disappear- ing. Syphilitic psoriasis; condylomata; ema- ciation. WHICH EYE AFFECTED. The left only. In one eye only. No note. The right only. Both eyes. The right first; subse- quently the left. The right first, and two months later the left. The left only. One eye only. The right only. TREATMENT AND RESULT. Complete recovery of the eye under mercurial treatment. No details given. No treatment had been adopt- ed, and the pupil was closed by adhesions. Both rash and iritis were cured by mercurial treat- ment. Under the use of mercurials every trace of the effused lymph was removed from both eyes. Under mercurial treatment the left eye wholly cleared ; the pupil of the right was left occluded. Complete recovery of both eyes under mercurial treat- ment continued for several months. The patient was lost sight of before the case was com plete. The iris cleared perfectly un der mercurial treatment. The pupil was wholly oc eluded; no treatment had been adopted for three months. The first recorded case of infantile iritis. This appears to have been the only exam- ple of infantile iritis witnessed by the au- thors quoted. Dr. Jacob did not see the patient until three years after the attack. Mr. Walker states that he had seen several, but this is the only case of which he gives details. The treatment was not commenced until the disease had existed three weeks. In this case the child was at the date of the iritis, "healthy-look- ing, well-grown, and lively." Previous mercurial treatment did not prevent the iritis. OS to OS Ui *| a i—< a M a H l-H o O H M 03 TABULAR STATEMENT OF TWENTY-ONE CASES OF INFANTILE IRITIS— Continued. NAME, HOSPITAL, REFERENCE, ETC. Alice K. C.; the Oph- thalmic Hospital; Mr. Critchett. 2 months. Anna I.. ; the Ophthal- 3 months. mic Hospital; Mr. Critchett. Emily W. ; the Oph- thalmic Hospital; Mr. Critchett. A girl; St. Bartholo- mew's; Mr.Wormald. James C.; Ophthalmic Hospital; Mr. Crit- chett. Wm. John J. ;■ Oph- thalmic Hospital; Mr. Critchett. James W.; Ophthalmic Hospital; Mr. Mac- murdo; Mr. Moon's notes. A girl; the Ophthalmic Hospital; Mr. Dixon. A girl; theOphthnlinic Hospital; Mr. Hulke. Emma D.; Ophthalmic Hospital; Mr. Dixon. Mary L. ; the Ophthal- mic Hospital; Mr. Dixon. 16 months. 2 months. 9 weeks. 14 months. 4 months. 7 months. parents' history. Her mother had borne 8, 6 of whom were still-born, and one died with suspi- cious symptoms. The pa- tient was the only living one. Two previous infants had died ; the mother showed suspicious sores at the angles of the mouth. All history denied; but four infants had died with suspicious symp- toms. The mother confessed to having had syphilis. No notes. Mother suffering from sus- picious symptoms, but not aware of primary sores. Father known to have had syphilis. Both parents had had sy- philis. Both parents had suffered from primary syphilis four months before the infant's birth. 4 months. JThe father had had syphi- lis fourteen months before the infant's birth. 7 weeks. No notes. INTERVAL BETWEEN PROBABLE SYPHILIS IN PARENTS AND BIRTH OF CHILD. Not known (proba- bly seven years, or eight years). Not known (proba- bly two or three years). Not known (proba- bly several years). Probably only a few months, but uncertain. Not known. Not known (proba- bly a few months). Not known. 11 months. 4 months. 14 months. Not known. SYMPTOMS PRESENT AT THE TIME IN THE CHILD. Emaciation and ca- chexia ; syphilitic psoriasis; tinea tarsi; psoriasis palmaris. Cachexia and emacia- tion ; fissures at oral angles; psoriasis of arms and hands. Emaciation and ca- chexia ; had had sore mouth and anus. No details. Snuffles; scaly rash ; ulcers at anus. Snuffles; ulcerated con- dylomata at anus; syphilitic eczema. Cachexia; an eruption. Condylomata at anus. Cachexia and emacia- tion ; hydrocephalus; snuffles. Snuffles ; sore tongue; copper-colored psoria- sis; psoriasis at anus Copper-tinted psoria- sis ; snuffles; separa- tion of the nails. WHICH EYE AFFECTED. Both. Bight eye only. Bight eye. Left first; the right 8 months af- terwards. Both. Left only. Both. Right only. Right only. Both. TREATMENT AND RESULT. The result was not known, owing to the patient's irreg- ularity of attendance. Mercurial treatment; no re- cord of result. The pupil was occluded by dense, yellow lymph, of two months' duration, when the mercurial treatment was begun; great improvement followed. The lymph which had been abundant, was absorbed under mercurial treatment, but left the left pupil closed. The right eye recovered un- der mercurial treatment, but the left pupil was occluded. Recovered under mercurial treatment. The right eye improved un- der mercurial treatment, but the left had probably been destroyed. Both pupils were almost closed by iritis, which had occurred two months before, and had not been treated. The right pupil was closed by red, organized lymph. The inflammation had not been treated, and the pupil was wholly closed. Mercurial treatment was ear- ly adopted, and both eyes child was well-grown. perfectly recovered. In the right eye there appeared to be deep- seated effusion of lymph, probably cho- roidal. The child looked as if in excellent health. In this instance the 628 SYPHILITIC AFFECTIONS OF THE EYES. Mr. Hutchinson deduces the following conclusions from the above series of cases:— 1. That the subjects of infantile iritis are much more frequently of the female than the male sex. 2. That syphilitic infants are most liable to suffer from iritis at about the age of five months. 3. That syphilitic iritis in infants is often symmetrical, but quite as frequently not so. 4. That iritis, as it occurs in infants, is seldom complicated, and is attended by but few of the more severe symptoms which charac- terize the disease in the adult. Haziness of the cornea and photo- phobia, which are common in adults, are rare in infants, in whom there is also but little pain and sclerotic injection. 5. Notwithstanding the ill-characterized phenomena of acute inflammation, the effusion of lymph is usually very free, and the danger of occlusion of the pupil great. 6. Mercurial treatment is most signally efficacious in curing the disease, and, if recent, in procuring the complete absorption of the effused lymph. 7. Mercurial treatment previously adopted does not prevent the occurrence of this form of iritis. 8. The subjects of infantile iritis, though often puny and cachec- tic, are also often apparently in good health. 9. Infants suffering from iritis almost always show one or another of the well-recognized symptoms of hereditary taint. 10. Most of those who suffer from syphilitic iritis are infants born within a short period of the date of the primary disease in their parents. This accords with what is observed in the iritis of adults, which, in a great majority of instances, is a secondary, and not a tertiary symptom. I have seen only one instance of this affection in an infant at the Infirmary, who was not brought a second time, and whose case I was therefore unable to follow out. I have at present in charge a case of double chronic iritis in a boy aged 10, affected also with engorgement of the cervical ganglia, who, as reported by his father, was said, by the attending physician (Dr. G. L. Bedford), to have contracted syphilis from his wet-nurse. I may mention incidentally, that his teeth are generally misshapen, and that one of his upper incisors is completely perforated by a small hole about one-third of its length from its lower margin. RETINITIS AND CHOROIDITIS. 629 Retinitis and Choroiditis.—The subjective symptoms of these two affections are often so slightly marked at their commence- ment as to attract but little attention either from the patient or surgeon, and irreparable mischief may be done before their gravity is fully appreciated. I have repeatedly met with cases of constitu- tional infection in which some slight complaint from the patient has led to an ophthalmoscopic examination of the eye disclosing the existence of a disease which threatened the loss of sight, but which was subsequently arrested by appropriate treatment. The symptoms of retinitis and choroiditis of syphilitic origin do not differ from those of the same affections dependent upon other causes. In most cases, the patient first perceives a fog or mist before the sight, attended perhaps by a sensation of fulness in the globe, muscae and frontal headache or hemicrania; the excessive photophobia formerly insisted on as a symptom of retinitis is rarely present; the obscuration of vision gradually progresses until finally the capability of distinguishing between light and darkness alone remains, or the eye becomes entirely blind. These subjective symptoms cannot enable us to distinguish between retinitis and choroiditis, which have only quite recently been recognized by the use of the ophthalmoscope, which has rendered the examination of the deeper structures of the eye nearly as easy as that of the ex- ternal. In order to explain the ophthalmoscopic appearances of retinitis, it is necessary to premise, that in a state of health, the retina, which is an expansion of the optic nerve, is perfectly transparent and enables us to see through it the abrupt margin of the sclerotica, forming the boundary of the optic disk—the whitish circle visible upon ophthalmoscopic examination at the fundus of the eye. Now the natural effect of inflammation upon this transparent membrane is to give it increased vascularity, and cause effusion into its sub- stance and render it opaque. Hence one of the earliest signs of retinitis is increased redness, which may commence either upon the optic nerve-entrance imparting to it a pinkish hue, or peripherally in the retina; the vessels, both arteries and veins, which emerge from the optic disk to be distributed to the retina are also abnor- mally enlarged and injected; and at certain points of their course they are lost to view, owing to the opacity of the retinal tissue which covers them. Their rupture may also give rise to small patches of ecchymosis. Again, effusion into the substance of the 630 SYPHILITIC AFFECTIONS OF THE EYES. retina first impairs its transparency, and produces the appearance of a fog or haze in the fundus of the eye, and finally entirely con- ceals the entrance of the optic nerve, the site of which can only be determined by the convergence of the dilated veins. The ob- scurity of the deeper structures may also be increased by transuda- tion into the vitreous humor. The ophthalmoscopic appearances of choroiditis are very numer- ous, but are nearly all dependent upon various degrees of atrophy of the choroid, permitting the white sclerotic to be seen through the thinned portions. At an early stage of the disease, when the atrophy is confined to the internal and pigmentary layers of the choroid, a condition known as "maceration of the pigment of the choroid" is seen; the coloring matter is distributed irregularly, thinned in some portions and aggregated in others, giving the fundus of the eye a mottled or watered appearance, as if sprinkled with ink. Again, the atrophy may be confined to circumscribed patches, of an almost pearly white color and in striking contrast with the general pinkish hue of the fundus of the eye; or it may be general, in which case the internal chamber of the organ of sight reflects an unusual amount of light. Deposits of lymph in the substance of the choroid may also give rise to light-colored patches, similar to those produced by atrophy; but the former may be re- cognized from the fact that they conceal the choroidal and retinal vessels, which in the latter may be seen to cross the patch. Exudation from the choroidal vessels may produce sub-retinal effusions, which are generally limited to one portion of the fundus and prevent vision in the opposite direction; for instance, if the effusion be situated externally, the patient can see outwards but not inwards; if inferiorly, he can see downwards but not upwards. These effusions present a very characteristic appearance before the ophthalmoscope and resemble a large semi-transparent bleb or bulla, encroaching upon the vitreous and oscillating to and fro. The retinal vessels may be seen leaving the attached retina and ascend- ing upon the surface of the detached portion. The use of the ophthalmoscope has as yet been so little extended, that it is not to be expected that the above symptoms can always be recognized by the general practitioner. The important facts to be borne in mind are these: that the instrument referred to has demonstrated the existence of deep-seated changes in the eve pro- duced by constitutional infection and threatening the loss of sight; PARALYSIS OF THE MOTOR NERVES OF THE EYE. 631 and hence that any impairment of vision in syphilitic subjects, although unattended by symptoms of external inflammation, should at once put the surgeon upon his guard and lead him to resort to specific remedies. I have met with several cases of syphilitic retinitis occurring at various intervals after iritis. The wife of the patient referred to upon page 370, suffered from this disease fifteen months after her attack of iritis, and at a time when no other syphilitic symptoms were present. In this case the disease was promptly removed by mercurials; and the prognosis is generally favorable in otherwise healthy persons, provided specific remedies be employed in time. Indeed, with respect to the success attending appropriate treatment, syphilitic choroiditis and retinitis resemble syphilitic iritis. Syphilitic Amaurosis.—Before the invention of the ophthal- moscope most cases of choroiditis and retinitis were included under the name of amaurosis, which is now properly limited to a loss of vision dependent upon disease of the optic nerve or brain, without appreciable lesion of the tunics of the eye. In the amaurosis of syphilitic subjects, the use of the ophthal- moscope can sometimes discover nothing abnormal in the condition of the fundus of the eye; while in other cases, the optic nerve is found to be atrophied, as shown by its diminution of volume, its cupped surface, its peculiarly white and opaque color, and the small size of the central vessels—especially the arteries. When this condition exists the prognosis is very unfavorable, and but little effect can be expected from treatment. Paralysis of the Motor Nerves of the Eye.—It is a frequent remark of my esteemed friend Dr. Abram Du Bois, who, from his long attention to diseases of the eye both in private practice and at the New York Eye Infirmary, is eminently qualified to judge, that a large proportion of cases of paralysis of the motor nerves of the eye are due to syphilis; and this statement is fully confirmed by my own more limited experience. Graefe1 also attributes this class of affections to constitutional taint "in nearly half of all the cases met with." In most instances, it is the third pair, or motor oculi, that is 1 Syphilitic Affections of the Eye, Deutsche Elinik, 1858, No. 21. 632 syphilitic affections of the eyes. affected; next in order of frequency comes the sixth pair, or abdu- cens;1 and finally the fourth pair, or patheticus. My limited space compels me to refer the reader to treatises upon diseases of the eye for a description of the symptoms of these affec- tions.8 I will merely remark, that the surgeon should carefully avoid confounding paralysis of the sixth pair with converging stra- bismus. The two may readily be distinguished by the fact that, in the former, the patient is unable, under any circumstances, to turn the eye outwards; while, in the latter, if the straight eye be covered, the squinting eye resumes its normal direction. Atten- tion to this point will enable the surgeon to avoid an error which I have known to be committed, viz., that of resorting to division of the internal rectus, which can be of no use whatever while the ex- ternal rectus is paralyzed. The pathology of paralysis of the motor nerves of the eye is often obscure. Dixon3 relates two highly interesting cases, in which examination after death revealed the existence of tumors (supposed to consist of syphilitic tubercle) in the substance of the nerve. The paralysis is rarely due to disease of the bony passages, or their lin- ing membrane, traversed by the nerve, but has been traced upon post-mortem examination to softening of the nervous or cerebral tissue. Virchow4 quotes a number of cases dependent upon the last-mentioned cause. These affections of the motor nerves are generally met with in the tertiary stage of syphilis, and in most cases yield to iodide of potassium; indeed the facility with which they are affected by treatment, would seem to preclude the idea that they are neces- sarily dependent upon serious organic changes either in the nerve or brain. 1 Dr. Beyram has related three interesting cases of paralysis of the sixth pair due to syphilis, L'Union Medicale, Feb. 23, 1860. 1 See an able article, by Dr. Wells, giving an account of Graefe's researches upon paralytic affections of the eye, Ophthalmic Hospital Reports, vol. ii. p. 44. * Med. Times and Gaz., Oct. 23, 1858. * Syphilis Constitutionnelle, p. 129 et seq. syphilitic affections of the ear. 633 CHAPTER XIII. SYPHILITIC AFFECTIONS OF THE EAR. Patients not unfrequently complain of deafness suddenly su- pervening in the course of general syphilis, and evidently de- pendent upon the constitutional taint, since it coincides with well- marked syphilitic manifestations, and yields to specific remedies. In most of these cases, as ordinarily met with in practice, the dis- ease consists in inflammation of the tympanal membrane, as is evinced by the abnormal redness and vascularity of the drum, if an examination be made of the external auditory canal. For this purpose a tubular speculum (either Mr. Wilde's or Mr. Toynbee's) is far preferable to a bivalve instrument, and the ear should be exposed to the direct rays of the sun. As a general rule, the ac- companying pain is less than in acute myringitis of simple origin, and in some instances is entirely absent; but in others it is very severe, radiating over the side of the head, and increased by cough- ing, sneezing, swallowing, blowing the nose, pressure in front of the meatus, and the motions of the jaw. There is no abnormal discharge from the external ear. If the disease be allowed to go on unchecked, lymph may be effused between the lamellae of the drum, producing permanent impairment of hearing. Mr. Wilde, of Dublin, in his able work upon diseases of the ear,1 was the first to call attention to this affection, and to show that the deafness arising in the course of constitutional syphilis is, in most cases, dependent upon myringitis, and not, as was commonly sup- posed, upon obstruction of the Eustachian tube from inflammation or ulceration of the fauces. A number of cases have been observed by my colleagues and myself, at the New York Eye Infirmary, and I have met with others in private practice, in which the truth of Mr. Wilde's statement has been fully confirmed, and in which the 1 Practical Observations on Aural Surgery, etc., Phil., 1853, p. 252. 634 syphilitic affections of the ear. pathology of the disease could not be mistaken. I feel obliged to dissent, however, from this author's assertion that syphilitic myrin- gitis is "unaccompanied by local pain," which, although generally less than in simple acute myringitis, was quite severe in several of the cases referred to—a point which has also been confirmed by my friend, Dr. C. R. Agnew. The character of the co-existing' symptoms, and the amenability of the disease to mercury, indicate that syphilitic myringitis should be ranked among secondary lesions; indeed, its position in the syphilitic scale may be regarded as nearly identical with that of the secondary form of iritis, with which it possesses several points of analogy. The treatment of this affection consists in the active employment of mercurials internally, together with opiates, if required for the relief of pain; and in the external application of leeches in front of the tragus, or within the meatus auditorius, followed by poultices or hot fomentations. When the acute inflammation has been sub- dued, if any effusion of lymph be visible in the substance of the drum, or if the function of the organ be not completely restored, the administration of iodide of potassium, and blisters behind the ear, should be resorted to. In addition to the manner now described, the ear may be indi- rectly implicated by secondary ulcerations of the meatus, by the extension of phagedenic ulcers of the pharynx to the Eustachian tube and tympanum, and by ostitis or caries of various portions of the temporal bone; but these affections are rare, and their full description would exceed the limits of the present work. Most of the cases reported by authors, may be found collected in the work of M. Gustave Lagneau, fils, upon syphilitic affections of the nervous system.1 9 1 Maladies Syphiliticus du Systeme Nerveux, Paris, 1860, p. 295. syphilitic orchitis. 635 CHAPTER XIV. SYPHILITIC ORCHITIS. A disease of the testicle, dependent upon constitutional syphilis, was recognized by Astruc,1 who speaks of its indolent character, and contrasts it with the acute inflammation of gonorrhoeal testicle; it was unknown to Hunter, but was noticed by Bell,2 and, more recently, has been described by Sir Astley Cooper,3 B^rard,4 Vel- peau,5 and others; but our present knowledge of this affection is chiefly due to Ricord, who has given a most faithful description of its symptoms, pathology, and treatment, under the name of syphi- litic albuginitis. Syphilitic sarcocele, orchitis, or albuginitis, as it is variously termed, is one of the so-called transition symptoms of syphilis, on the confines between secondary and tertiary lesions, but more closely allied to the latter than the former. When the constitu- tional disease runs a rapid course, it may sometimes occur as early as the fourth or fifth month after contagion, while secondary symp- toms are still present; but, in the majority of cases, it does not appear until several years after the primary sore, and is accom- panied by well-marked tertiary manifestations in the fauces, perios- teum, or bones; or, in some instances, it stands alone as the only evidence that the patient is still affected with the syphilitic dia- thesis. The statement that " it may appear at the same time with primary chancre," or, in other words, that an infecting chancre and syphilitic orchitis, due to the same contagion, may be developed contemporaneously, is too absurd to require refutation. 1 Book III., chap. iv. 2 Treatise on Gonorrhoea Virulenta and Lues Venerea, vol. ii. p. 128. 3 Structure and Diseases of the Testis. * Des divers Engorgements du Testicule, Paris, 1834. 6 Dictiounaire de Med. 636 SYPHILITIC ORCHITIS. Symptoms.—In most cases, syphilitic orchitis attacks both testi- cles either at the same time or consecutively. Its symptoms are deserving of special attention, since it may readily be confounded with other affections of the testis which require extirpation. The records of surgery show that many testicles have been removed for what is now known to be an essentially curable disease. One of the most characteristic features of this affection is the almost entire absence of pain attending it and the great insensi- bility to pressure; so much so, that whenever a testicle becomes. enlarged without any of the ordinary signs of inflammation in a person who has once had constitutional syphilis, there is strong reason to suspect that the disease is due to syphilitic taint. In exceptional instances, a dull pain is felt about the loins, but gen- erally the only uncomfortable sensation is a feeling of weight in the affected organ, which is worse towards evening after the patient has been upon his feet during the day, but which does not undergo the nocturnal exacerbation so common to syphilitic pains situated in the periosteum and bones. Moreover as the disease progresses, the testicle appears to lose even its normal sensibility, and may be roughly handled without causing the slightest uneasiness. Another important feature is the entire absence of morbid changes in the scrotum, vas deferens, and epididymis. The healthy condition of the cord and of the covering of the testicle is evident throughout the whole course of the disease; the same fact may be established relative to the epididymis at the commencement, and still holds good at a later period, although, when the swelling at- tains a considerable size, it is sometimes impossible to distinguish the different portions of the organ. The body of the testicle, which is always the part affected, is somewhat increased in size but never to the same extent as in en- cephaloid disease of the same organ; and it rarely exceeds twice its normal diameter. Ricord was in the habit of saying at his lectures, "Whenever you meet with a tumor of the testis as large as your fist, and find that the swelling is not in a great measure due to effusion, you need not suspect syphilis." In most cases, a small portion of the apparent swelling is dependent upon hydro- cele; since in nearly every instance of syphilitic orchitis, there is a slight effusion into the tunica vaginalis. When the amount of fluid is considerable, it may be necessary to evacuate it by punc- ture with a broad needle before a satisfactory examination can be symptoms. 637 made; but in most cases, we may by firm pressure sufficiently dis- place the fluid to reach the body of the testicle and determine its condition by palpation. At an early stage of the disease, the tes- ticle is found to contain one or more distinct masses of induration, which may form slight projections upon the surface, of the size of the head of a pin, pea, or even an almond, but which are never so prominent as to change the general contour of the organ. These projections are due to an effusion of plastic material, of the same nature as gummy tumors, upon the surface of the tunica albuginea. As the disease progresses, the distinct masses of induration coalesce and form a hard resistant tumor, which still preserves to a great extent the normal shape of the testicle. The course of this affection is exceedingly slow and chronic, fre- quently lasting for several years. The sexual desires are not changed, unless the disease has made great progress in both testi- cles. When recognized at a sufficiently early period, syphilitic orchitis may almost invariably be arrested and the organ restored to its original integrity. If left to itself it most frequently terminates in obliteration of the seminiferous tubes, and complete or partial atrophy corresponding to the extent of the adventitious deposit; or, again, the parenchyma of the gland may degenerate into fibrous, cartilaginous, or even osseous tissue. Ricord has laid down the law that suppuration never takes place in uncomplicated syphilitic orchi- tis, and has shown that many supposed cases to the contrary were really instances of tubercular disease of the testis or gummy tumors of the cellular tissue of the scrotum. This law has generally been admitted as correct, and has not until recently been called in ques- tion ; but Rollet1 has reported an unquestionable instance of this disease in which the substance of the testicle protruded through an ulceration of the scrotum, and the tunicas vaginalis and albuginea, giving rise to the condition known as fungus of the testicle; and also quotes a similar case, witnessed by himself, from Jarjavay, and refers to another described by Curling.' Victor de Meric3 has reported still another instance of fungus of the testicle dependent upon syphilis; and I would also call the reader's attention to the case of orchitis, attended by suppuration, in an infant affected with 1 Annuaire de la Syphilis, annee 1848, p. 90. 2 On the Testis, 2d ed., p. 277. s London Lancet, Am. ed., May, 1859. 638 SYPHILITIC ORCHITIS. hereditary syphilis, which has been reported upon page 465. It would appear, therefore, that Ricord's law is not without exception. Diagnosis.—Syphilitic orchitis may be confounded with gonor- rhceal epididymitis, with cancer, tubercular disease of the testis, or chronic orchitis. Gonorrhceal inflammation of the testis is an acute disease, at- tended with severe pain, difficulty of motion, redness, heat, and tension of the scrotum; chiefly attacking the epididymis; often complicated with inflammation of the vas deferens; preceded or accompanied by a discharge from the urethra; and yielding to simple treatment. The induration left by an acute attack of swelled testicle may be recognized by the previous history of the case and by being limited to the epididymis. In cancer of the testicle, which is generally of the encephaloid variety, the pain is slight at the commencement, but increases with the progress of the disease and becomes very severe and lancina- ting ; the tumor is very irregular, grows with great rapidity, and often attains an immense size; and the cord and neighboring ganglia are frequently involved. " If you remove a cancerous tes- ticle, the disease almost always returns in the cord; in a second attack of syphilitic orchitis, the opposite testicle is affected."1 Tubercular disease of the testis occurs about the age of puberty rather than in adult life, and in subjects presenting evidences of a strumous diathesis. The adventitious deposit first takes place in the epididymis, or in the centre and not in the external portions of the testis as in syphilitic orchitis; as the disease progresses, slight protuberances may be formed upon the surface as in the last men- tioned disease, but they soon contract adhesions with the tunica vaginalis and scrotum, suppurate and ulcerate. Moreover, evi- dences of tubercular deposit may often be detected in the vesiculae seminales by examination with the finger per anum, or in the cord and inguinal ganglia. Great diversity of opinion exists, especially between English and French surgeons, relative to the frequency, nature, and symptoms of chronic orchitis. Mr. Curling, who may be taken as the repre- sentative of English views, regards this affection as quite common and dependent upon a deposit, generally in circumscribed masses! ' Ddpcyteen, Le ons Orales de Clinique Chirurgicale, 2d ed., t. iv. p. 236. TREATMENT. 639 of a peculiar yellow homogeneous substance in the body of the testicle, which frequently terminates in suppuration and benion fungus of the testis. Among the French, Nekton maintains, justly, I think, that this description applies to true tubercular testis, and that Curling has also included under the head of chronic orchitis many cases of syphilitic albuginitis. He believes, with the gen- erality of French surgeons, that chronic orchitis is an exceedingly rare affection; that it is due to plastic inflammatory infiltration, bearing no resemblance to tubercle, in the substance of the epididy- mis and body of the testicle, not circumscribed in well-defined masses, often very persistent, but capable of absorption without suppuration; that it often originates in irritation about the deeper portions of the urethra, and sometimes gives rise to a very peculiar condition of the sperm, which is of a reddish color, resembling thin currant jelly.1 It is unnecessary to enter more minutely into the details of the differential diagnosis between syphilitic orchitis and the above mentioned diseases. If attention be paid to their prominent fea- tures as now described, especially when assisted by a knowledge of the history of the case and a careful search for coexisting syphi- litic symptoms or traces of their previous existence, the surgeon will not often be left in doubt. If any uncertainty exist, the pa- tient should always have the benefit of a trial of specific remedies before resorting to operative procedures. Treatment.—In the treatment of this disease, Ricord relies almost exclusively upon iodide of potassium, administered in doses of from five to thirty grains three times a day. It would appear that Ricord is here somewhat inconsistent with his own doctrines, since he else- where recommends a mixed treatment consisting both of iodide of potassium and mercury in the transition symptoms of syphilis, among which he ranks syphilitic orchitis. In my own practice, I have been dissatisfied with the iodide of potassium alone and have obtained much more favorable results from its combination with mercury. For instance, in a case recently under my care, the pa- tient had been taking ten grains of the iodide three times a day during two months for a tubercular syphilitic eruption, when my attention was first called to the affection of the testicle, which had 1 Gaz. des HSp., No. 14, 1857. 640 syphilitic orchitis. either appeared or certainly had not improved during the treat- ment. The dose of the remedy was gradually increased to twenty grains three times a day without affecting the orchitis, which speedily improved after substituting half a grain of the protiodide of mercury for the iodide of potassium taken at noon, and con- tinuing the latter remedy morning and night. In many cases, and especially in broken-down constitutions, it is better to employ mercurial inunction upon the inner portions of the thighs and axillae together with the iodide of potassium and tonics internally. Diday expresses himself very decidedly in favor of a mixed treatment. He says: "The treatment of this affection is of impor- tance both as an element of diagnosis and as a means of recovery. I do not share the exclusive confidence of certain specialists in the employment of iodide of potassium alone in this disease. I grant it is an excellent remedy, and perhaps the best, if only one is to be used; but some credit, I think, should be reserved for mer- cury. Can we forget or deny the success which was obtained by Sir Astley Cooper and Dupuytren at a time when this metal alone had the responsibility as well as the honor of curing ? And does not syphilitic chronology, in assigning to this lesion a position mid- way between secondary and tertiary symptoms, indicate that the most successful treatment will be one of a mixed character ? In my own practice, experience has confirmed these anticipations. I confess that if it were necessary to choose between mercury and iodine, I would give up the former rather than the latter; but I am very positive that their simultaneous use is often indispensable. The association of these remedies is almost always sufficient, but careful observation of recent cases occurring in my practice would seem to warrant the conclusion that mercury acts better at the com- mencement of treatment and iodine afterwards; that the former possesses a decided superiority during two or three weeks, after which time it is powerless compared with the efficacy which the latter now acquires. If I were asked for an explanation of this peculiarity, the truth of which has been demonstrated by experi- ence, I should say that mercury, by virtue of its anti-plastic pro- perty, is of service in rendering soluble the intertubular deposit so that it is more readily absorbed; and that iodine afterwards comes in to better advantage as a true specific, with its anti-syphilitic and anti-tertiary property, and stimulates the process of absorption."1 1 Nouvelles Doctrines sur la Syphilis, p. 499. TREATMENT. 641 The experience of the surgeons of the New York Hospital, as reported by my friend Dr. Thos. M. Markoe,1 has been similar, and decidedly against the exclusive employment of iodide of potassium. Local treatment is of secondary importance, and, in most in- stances, may be entirely dispensed with, except that the testicles should be relieved of their own weight by a suspensory bandage. Judging from the case reported by Rollet, even a fungoid growth of the testicle projecting through an ulceration of the scrotum, will disappear and cicatrization take place under the use of con- stitutional remedies alone. The local treatment commonly recom- mended, and which perhaps in a few cases may be employed with advantage, consists in daily mercurial inunction upon the scrotum, or compression by means of straps of adhesive plaster as in swelled testicle from gonorrhoea. The effusion into the tunica vaginalis is in most cases soon absorbed under general treatment, but if exces- sive, may be evacuated by means of a lancet or broad needle. The danger of wounding the swollen testis is too great to admit of the use of a trocar as in the ordinary method of tapping for hydrocele. 1 New York Medical Times, March, 1855, p. 204. 41 642 AFFECTIONS of the muscles and tendons. CHAPTER XV. SYPHILITIC AFFECTIONS OF THE MUSCLES AND TENDONS. Syphilitic affections of the muscles, although noticed by As- truc,1 attracted but little attention until investigated during the present century, more especially by Boyer,8 Ricord,3 Bouisson,4 and Notta.5 These affections may be enumerated as muscular pains, muscular contractions, and muscular gummata or tumors. Muscular Pains.—Muscular pains dependent upon syphilis have already been described6 as frequently accompanying the earliest outbreak of general symptoms; affecting by preference the neighborhood of the joints; often involving the fibrous as well as the muscular tissues; fleeting and changing in their character; re- lieved by pressure; and, in most cases, unattended by swelling, heat, or redness. In the tertiary period of syphilis, also, patients often complain of pains in the extremities, but these are depend- ent upon changes in the periosteum or bones, or upon deposits of syphilitic tubercle in the muscles, and are therefore to be regarded as merely symptomatic of lesions described in this and other chapters. Muscular Contraction.—This singular effect of constitutional syphilis consists in a diminution in the length of one or more muscles, interfering with motion, but without the existence of other 1 A Treatise of Venereal Diseases, etc., translated from the Latin, London, 1754, vol. ii. p. 15. 2 Traite pratique de la Syphilis, Paris, 1836. s Notes to Hunter, 2d Am. ed., 1859, p 458. * Gaz. Med. de Puis, 1846, p 211. 6 Mem sur la Retraction Muscul. Syph., Arch. Gen. de M6d., Dec. 1850, 4e se>ie, t. xxiv. p. 413. « See p. 547. muscular contraction. 643 changes appreciable upon external examination. The muscles most frequently affected are the flexors of the upper extremity, and especially the biceps. Notta met with six cases, in two of which the disease was confined to the biceps; in two others, to the biceps and supinator longus; and in the remaining case to the flexors of the fingers. The biceps has been affected with the same frequency in the cases reported by other observers. The contraction comes on insidiously, and the first symptom noticed by the patient is an inability to extend the limb. On ex- amining the affected muscle, no change is perceptible either in its size or texture; its power of contraction is normal; and there is simply a diminution in length, as shown by its tension when the limb is forcibly extended. In neither of Notta's six cases was the fleshy portion of the muscle sensitive to pressure; but in five, pain was excited by pressing upon one or both of the tendinous inser- tions, and by forced extension. The contraction increases, slowly in most cases, but rapidly in some, up to a certain point, when it remains stationary. In five cases in which the biceps was affected, the angle formed by the arm and forearm, when the latter was ex- tended to the utmost, measured 160°, 135°, 135°, 130°, and 90°, respectively. In another case, the ring and little fingers were com- pletely flexed upon the palm of the hand. Under the name of "chronic syphilitic tetanus," Deville' has re- ported a case in which a large number of muscles were involved, and death ensued from contraction of the muscles of the pharynx, which was impassable to a probang. Notta coincides with Deville in regarding the disease as syphilitic. In none of Notta's cases had the patients ever suffered from rheumatism, which, therefore, could have had no part in producing the muscular contraction; but all presented unquestionable syphi- litic symptoms, which, in three, belonged to the tertiary; in two to the secondary; and in one to both the secondary and tertiary pe- riods. So far, therefore, as it is admissible to judge from so small a range of statistics, it may be concluded that muscular contrac- tion, like syphilitic orchitis, belongs to the period of transition intervening between pure secondary and tertiary manifestations. The treatment of this affection consists in the combined adminis- tration of mercurials and the iodide of potassium. By these means Bulletin de la Soc. Anatomique, 1845, p. 276. 644 AFFECTIONS OF THE MUSCLES AND TENDONS. Notta succeeded in effecting a perfect cure in four cases; in a fifth the relief was only partial; and in the sixth treatment had no effect whatever. As is true of other syphilitic symptoms, the disease is likely to return if treatment be suspended too soon. The pathology of syphilitic contraction of the muscles is obscure. Virchow ascribes it to "callous degeneration of the muscular tissue; an alteration analogous to that produced by rheumatic inflammation, either simple or traumatic. In the interspaces between the muscu- lar fasciculi, a conjunctive tissue is developed, which hardens and produces atrophy, and finally the destruction, of the primitive muscular fibrils."1 Muscular Tumors.—Our knowledge of syphilitic tumors of the muscles, tendons, and aponeuroses is due in a great measure to the labors of M. Bouisson, late Prof, of Surgery at Montpellier. These tumors consist of the same gummy material which has been described in a previous portion of this work. Indeed we have already referred to deposits of this nature in the muscles when speaking of syphilitic affections of the mouth and air passages; since tubercles of the tongue are frequently seated in the muscular as well as in the cellular tissue; and many of the sloughing ulcers of the velum palati, pharynx and larynx, commence as gummy tumors of the neighboring muscles, the mucous membrane being involved secondarily. Mention has also been made of similar tumors in the lips, which have sometimes been mistaken for epi- thelial cancer. In addition to the muscles of the regions here mentioned, gummy tumors have been met with in the glutaeus maximus, trapezius, sterno-cleido-mastoideus, vastus externus, pec- toralis major, and some others; and in the walls of the heart by Ricord,2 Lebert,3 and Virchow.4 " Syphilitic tumors of the tendons appear to depend upon circum- scribed hypertrophy of the normal fibrous tissue, together with an effusion of serous and plastic material. They are the seat of more or less pain, which is increased by the action of the corresponding muscle. If the tendon be examined after death, it is found to have preserved its normal color or to be but very slightly injected; but 1 La Syphilis Constitutionnelle, p. 105. 2 Iconographie, PI. XXIX. 3 Traite d'Anatomie Pathologique, t. i. PI. LXVIII., Fig. 5. 4 La Syphilis Constitutionnelle, p. 108. MUSCULAR TUMORS. 645 it is swollen either from thickening of its fibres, or the deposition of an albuminous and semi-solid material within its substance. In old cases not terminating in suppuration, ossification may take place and involve the whole extent of the tendon, as in one instance I have met with in the psoas parvus; in other cases it is limited to the part of the tendon first affected, and gives rise to a kind of sesamoid bone. "Syphilitic tumors of the tendons are sometimes situated near their surface and sometimes at their centre. The former are the more common. In this case the swelling is more perceptible and forms an abrupt projection in the course of the tendon; and if suppuration takes place, the continuity of the fibrous cord is re- spected. But the disease may be limited to the central portion, in which case the normal fibres of the tendon are separated by the adventitious deposit, and the tumor assumes an ovoid or fusiform shape." Of syphilitic tumors in the muscles Bouisson says: "It is difficult to determine whether the earliest changes take place in the muscu lar fibrils or in the intervening cellular tissue; although analogy would lead us to believe that it is the fibro-cellular element connect- ing the fleshy fibres or serving as their sheath, which is first in- volved. But in advanced cases—no matter what the mode of termination, whether by suppuration or induration—all the ana- tomical elements appear to be affected; and, according to the pro- gress of the morbid action, the muscular fibres are either surrounded by a material of new formation or are softened and destroyed, or, again, are transformed into indurated, sub-cartilaginous or even osseous tissue. Such at least are the different stages I have met with in these tumors. " In the first stage, the muscle is the seat of a local and circum- scribed swelling, of greater consistency than oedema. Upon a cut surface of the diseased tissue we can recognize decolorized muscu- lar fasciculi in the midst of a plastic effusion of a grayish color. " In the second stage, the adventitious deposit softens, and, if the attendant inflammation continues of a chronic character, is trans- formed into a viscid, stringy liquid, resembling a solution of gum. If, on the contrary, acute inflammation sets in, or if the tumor has been attended from the outset with constant pain and an increase of temperature, pus is formed in the centre of the muscle, the fibres are softened and destroyed, and more or less disorganization 646 AFFECTIONS OF THE MUSCLES AND TENDONS. takes place. I suspect that many intra-pelvic abscesses, and many cases of destructive inflammation of the psoas and iliacus muscle are really syphilitic phlegmasiae of the muscles of this region. I have frequently observed complications of this kind in syphilitic subjects; and I recently called the attention of my students to a patient at the hospital, who was seized with chronic inflammation of the psoas and iliacus muscles on the left side. A tumor of con- siderable size formed in the pelvis, and pointed near Poupart's ligament. On being opened an enormous quantity of pus escaped. The patient was subjected to specific treatment, and completely recovered. " In the third stage, those syphilitic tumors of the muscles which do not suppurate, become indurated. Like periostoses, they pass through successive stages of organization, and from being firm, become sub-cartilaginous, cartilaginous, and osseous. This final transformation, from its peculiarity and persistency, has especially attracted the attention of pathologists. I have seen a very remark- able example of it in the museum of the Faculty of Medicine at Strasbourg—an osseous mass of very considerable size developed in the substance of the quadratus femoris. Ossifications of the muscles and their tendons have frequently been observed in syphi- litic persons with exostoses on various parts of the body. In the collection of my colleague, Prof. Dubrueil, is the skeleton of an Arab who was affected with syphilis, and in whom, besides nu- merous exostoses, there was ossification of a large number of mus- cles at the points of their insertion."1 These tumors vary in size from that of a filbert to an orange. They are most easily detected when the muscle is relaxed, and their independence of the subjacent bone can then be best estab- lished. They excite little or no pain unless the muscle be put upon the stretch, and their chief inconvenience is due to their inter- ference with motion. They are almost always accompanied by other syphilitic manifestations, as nodes, exostoses, tubercles of the cellular tissue, or ulcerations of the fauces; and their treatment is that of the advanced stages of the disease, viz., by means of the iodide of potassium and tonics, either associated with, or followed by, mercurials. 1 Bouisson, op. cit. AFFECTIONS OF THE NERVOUS SYSTEM. 647 CHAPTER XVI. SYPHILITIC AFFECTIONS OF THE NERVOUS SYSTEM. Among the affections of the nervous system, which, with greater or less probability, have been ascribed to syphilis, are the various forms of paralysis, apoplexy, epilepsy, mental derangement, dis- orders of sensibility, defective memory and intelligence, and the neuralgias. These affections may proceed— A. From caries, necrosis, or exostosis of the bones of the head or spinal column, involving the nervous centres, or the nerves them- selves secondarily. B. From lesions of the meninges of the brain and medullary canal; the most frequent of which are gummy tumors springing from the dura mater, and encroaching upon the cerebrum, cerebel- lum, or spinal marrow. C From gummy tumors developed in the substance of the brain, or in the course of the cranial nerves. D. In some instances, when post-mortem examination reveals no organic lesions to account for the nervous symptoms, but in which it is probable that such previously existed, but have since disap- peared either spontaneously, or, more frequently, as the effect of treatment. Ricord1 reports a case of hemiplegia and mental de- rangement in a syphilitic subject, at whose post-mortem nothing abnormal was found in the brain or bones of the head, and similar instances are mentioned by other observers. Syphilitic affections of the nervous system present no pathogno- monic symptoms by which their specific character may be recog- nized ; and, except in those instances in which manifest lesions of the bones of the skull, face, or spine, clearly indicate the etiology of the disease, the diagnosis can only be established by the history 1 Iconographie, PI. XXXIX. 648 AFFECTIONS OF THE NERVOUS SYSTEM. of the case, the concomitant symptoms, and the effect of treat- ment.1 The two following cases of syphilitic epilepsy have occurred in my own practice. Case 1. Mr H., aat. 36, applied to me October 22, 1856, for a super- ficial erosion, with slightly indurated base upon the internal surface of the prepuce, and a pleiad of indurated ganglia in each groin. He was told that he had constitutional syphilis, and was immediately put upon the use of mercurials, under which the sore speedily healed, and the glands lost much of their hardness. Although the mouth was kept tender for several weeks, and treatment was continued until the first of April, yet a papular eruption made its ap- pearance May 21, accompanied by mucous patches on the tonsils, and pustules upon the scalp and beneath the whiskers. Treatment was again resumed, but as soon as his symptoms had been dissipated, Mr. H. became irregular in taking his medicine, and had another relapse the following August. He now became convinced of the necessity of pursuing treat- ment faithfully for a long period, and expressed himself willing to follow any directions which I should give him. I determined to pursue the course recommended by Ricord,a and give my patient mercurials for six months, keeping him constantly upon the verge of salivation, and afterwards iodide of potassium in full doses for three months. Mr. H. faithfully obeyed my directions, aud maintained his general health and strength to a remarkable degree under the depress- ing influence of mercurials, which were continued in as full doses as could be borne without producing salivation until the middle of February. The iodide of potassium was now commenced, and gradually increased from fifteen to forty-five grains a day, but was suspended about the middle of April, a month before the appointed time; however, as the mercurial treatment had been pursued so thoroughly, this was regarded as of slight importance. On May 2d of the same year (1858), only a fortnight after suspending this active course of treatment, Mr. H. again applied to me, complaining of frontal headache, which was not, so far as I could learn, nocturnal in 1 When the reader is informed that M. Lagneau, fils, has written a closely-printed volume of 528 pages, octavo, upon syphilitio affections of the nervous system, he will appreciate the impossibility of my doing justice to this subject within the limits of the present work. For farther details, I would refer to the work in ques- tion, which comprises all that is now known upon the subject, and includes most of the cases published by various authors. 2 See page 520. AFFECTIONS OF THE NERVOUS SYSTEM. 649 its character, and which I attributed to excessive attention to his busi- ness, and late hours. His bowels were also quite costive. On the evening of May 5th, Mr. H. assisted in putting out a fire at the house of a neighbor, and on the following day, while at his office, was suddenly seized with an epileptic fit, which was followed by five others before night. I saw him in several of them, and found that they pre- sented the ordinary characters of epilepsy, viz., loss of consciousness, con- vulsive action, foaming at the mouth, biting the tongue, etc., followed by stupor for a short period afterwards. He recovered sufficiently from this attack in three or four days to re- sume his business, and was feeling quite well again, with the exception of some continuance of the headache, and a tendency to constipation, when on the 28th of the same month he sprained his ankle, which obliged him to keep his bed; and on the following day (29th) he was again seized with epilepsy, and had, as before, six fits before night. He did not recover from this as from his previous attack, but was left in an exceedingly ex- cited, and, at times, almost maniacal condition. For a few moments he would converse rationally and connectedly, and then suddenly cry out at the top of his voice, and talk in the most incoherent manner; his memory also left him in a great measure, and, at times, he did not appear to recog- nize his friends around him. It should be here stated that Mr. H. was a man of abstemious habits, and, although of a naturally nervous tempera- ment, had never before suffered from any cerebral affection. The question now arose in my mind whether his symptoms were due to his syphilitic taint, but was answered in the negative, on the ground that he had but just completed so thorough a course of anti-syphilitic treat- ment; and I feared in his present condition to resort again to mercurials. I, therefore, directed him to be kept quiet and away from business, and to take a daily ride in a carriage; introduced a seton in the back of his neck; and prescribed valerianate of zinc, combined with extract of hyos- cyaraus internally, together with cathartics, when required. This treat- ment, however, had but little effect; the seton gave him so much annoy- ance, and appeared to increase his irritability to such a degree, that I was compelled to withdraw it; his fits did not return, although he was several times threatened with them; but his almost insane condition continued with but little amelioration until June 17th, when I sent him into the country for a change of air and scene. Here he somewhat improved, although almost imperceptibly; he was still troubled with headache, and was at times very excitable. About the middle of August, an eruption of syphilitic psoriasis appeared upon his legs and body, and led me at once to doubt the correctness of my previous conclusion as to the nature of his complaint, and to regard it as syphilitic. I immediately commenced the use of protiodide of mer- 650 AFFECTIONS OF THE NERVOUS SYSTEM. cury and iodide of potassium, under which the improvement in his cere- bral symptoms was as gratifying as it was astonishing, and my patient returned to his business before the end of August, with his mental faculties completely restored. Since that time he has been actively engaged in his profession, and constantly in good health, except on two occasions, when he has had a slight return of his syphilitic eruption, which is always preceded by mental depression and nervous excitability. Mercury acts like a charm under these circumstances, dissipates the eruption, and restores his health and spirits. This case is, in many respects, a very peculiar one. The decided benefit which has always been derived from mercurials, and yet the frequent re- lapses which have taken place, are quite unusual. Various preparations of mercury, and different modes of its administration, among others mer- curial fumigation, have been tried without affording permanent relief. The pathology of the nervous affection is also obscure, since the symp- toms have always been those of the secondary stage of syphilis, and not such as would indicate lesions of the fibrous and osseous tissues. The facility with which they have yielded to remedies would lead one to sus- pect effusion within the ventricles, or at the base of the brain. It should be remarked that the urine has been repeatedly examined and found to be normal; and there has been no evidence of disease in the kidneys or other organs. Case 2. Mr. W., aet. 38, a gentleman by birth, and a man of fine con- stitution, but sadly addicted to drink, applied to me June 14, 1860, for an erythematous eruption upon the abdomen, and mucous patches upon the tongue, the result of contagion three months before. He still bore an indurated mass in the site of the chancre in the furrow at the base of the glans, and the inguinal glands were also indurated. The eruption disappeared within a fortnight under the use of the protiodide of mercury, and I urged him to continue treatment for some time longer. This he promised to do, but I lost sight of him, and afterwards learned that he gave up taking his medicine within a few days after his last visit. I next saw him at his house, October 14th, after he had been on a debauch for three weeks, during which time he had not been home, and had slept in a bar-room. He was now one of the most disgusting and yet pitiable objects I ever saw. His hair, which was naturally black when I last saw him, had turned to an iron gray; his head was covered with a pustulo- crustaceous eruption, arranged in circles, or segments of circles; there was a large patch of the same eruption over the sternum; the post-cervical glands were very much engorged; the internal surface of his lower lip was covered with opaline patches, and his voice indicated ulceration of the AFFECTIONS OF THE NERVOUS SYSTEM. 651 fauces; the palms of his hands presented copper-colored rings of elevated and scaly integument; all of his finger nails without exception were ulce- rated around their bases; and the buttocks and upper and inner portions of his thighs were profusely scattered over with condylomata, the secre- tion from which filled the room with its offensive odor. During this and the two following days, my patient had six or eight epileptiform seizures, characterized by loss of consciousness, convulsive action, and foaming at the mouth; in the intervals of which he was per- fectly rational, and exhibited no more nervous agitation than is commonly observed after a debauch. The treatment adopted consisted in mercurial inunction externally, and the internal administration of quinine and sedatives, together with a nou- rishing diet; and by the first of December, Mr. W. left for the South, entirely relieved of his syphilitic symptoms. 652 AFFECTIONS OF THE PERIOSTEUM AND BONES. CHAPTER XVII. SYPHILITIC AFFECTIONS OF THE PERIOSTEUM AND BONES. These affections are among the latest manifestations of the syphi- litic diathesis, and may be regarded as types of tertiary syphilis. They do not necessarily occur in every case of syphilis, even if left to itself without treatment; since the disease often wears itself out before arriving at the tertiary period; while, still more frequently, it is arrested by appropriate remedies administered during the pri- mary or secondary stage. The idea, which is sometimes advanced, that these affections are due to mercury, even when judiciously employed, is entirely without foundation. This mineral is gener- ally necessary in conjunction with the iodide of potassium to effect their permanent removal, and can never favor the evolution of tertiary syphilis, unless pushed to the detriment of the general health. In the time of their development tertiary follow secondary lesions, or coincide with the later forms of the latter. The absolute inter- val which has elapsed since contagion, at the time of their appear- ance, varies very much in different cases, and chiefly depends upon individual peculiarities, the mode of life of the patient, and the treatment to which he has been subjected. It often amounts to many years, and, according to Ricord's rule, which is undoubtedly correct, is rarely, if ever, less than six months. We meet with some instances in which syphilis appears to skip over its secondary, and manifest itself only in its primary and ter- tiary forms. A man has an infecting chancre, and after several years of apparent health is attacked with tertiary symptoms, as, for instance, osteocopic pains, ostitis, or tubercles of the deep cellu- lar tissue. In such cases, either the patient was subjected to mer- curial treatment for his primary sore, which has prevented secon- dary, but has not been sufficient to avert tertiary manifestations; OSTEOCOPIC PAINS. 653 or he has had secondary symptoms of so slight a character as not to attract attention. As I have shown at length in a previous chapter, the general symptoms of syphilis, in the absence of specific treatment, always appear within six, and generally within three months after infection. In many cases the morbid processes which syphilis sets up in the periosteum and bones, appear to be the same as those induced by other causes. Thus, we find inflammation of the periosteum and of the subjacent layer of bone, terminating in an effusion of sero- albuminous or purulent matter—in other words, forming an ab- scess, which finally opens externally through thinning and ulcera- tion of the integument. In like manner, syphilis often gives rise to ostitis, terminating in suppuration, caries, and necrosis, which cannot be distinguished from the effects of non-specific causes of inflammation. In many instances, however, syphilitic affections of these tissues exhibit the same marked tendency to the effusion of plastic material, which has been noticed when speaking of tertiary ulcerations of the air passages. Thus the adventitious deposit of nodes is often transformed into true bony tissue (epiphysary exos- toses); and syphilitic ostitis frequently gives rise to outgrowths springing from the bone itself (parenchymatous exostosis); or it may result in general hypertrophy (hyperostosis). Again, when attacking the periosteum and bones, syphilis sometimes causes a deposition of the same material, known as syphilitic tubercle, which is found in the gummata of other regions. Whether these various changes are to be regarded as distinct, or as stages of one and the same process, cannot, in the present state of our knowledge, be fully determined. Osteocopic Pains.—The pains in the bones, belonging to ter> tiary syphilis, differ from those observed in connection with early secondary symptoms, in being confined to certain regions, and in not changing their locality like the latter. Their favorite seat is in those bones which approach nearest the surface, as the tibia, ulna, clavicle, sternum, and cranium; but no portion of the skele- ton is exempt from them. In most cases they are increased, but in others are uninfluenced by pressure. A striking peculiarity of these pains is their marked nocturnal character. They are gener- ally absent or are scarcely felt during the day, but return at night with great severity after the patient retires to bed, and only abate 654 AFFECTIONS OF THE PERIOSTEUM AND BONES. towards morning. This nocturnal exacerbation is attributed to the warmth of the bedclothes by Ricord, who states that in bakers, who are obliged by their occupation to turn day into night, the pains are chiefly diurnal. This explanation, however, does not appear to hold good in all cases, for in some they return at a cer- tain hour in the evening, whether the patient has or has not retired; and, in a few instances, they are equally as severe during the day as at night. In most cases tertiary osteocopic pains are merely symptomatic of commencing changes in the periosteum or bones, which, in the absence of appropriate treatment, are usually mani- fest within a few months. In other instances, however, they per- sist for a long period without the appearance of any appreciable organic lesion; although, even then, it may be questioned whether the deeper portions of the bones, or the lining membrane of the medullary canal, be not affected. Osteocopic pains yield with great facility to the internal admin- istration of iodide of potassium, but are very prone to relapse. In most cases, their permanent removal can only be effected by care- ful attention to the general health and the judicious employment of mercurials. Patients have frequently been under my care, who for years have been obliged to resort to iodide of potassium every few months for the relief of tertiary pains, which have ceased to return after a mercurial course, administered either by the mouth, by fumigation, or inunction. Mercurial inunction is especially adapted to these cases. Nodes.—In the formation of nodes, inflammation of the super- ficial portion of the subjacent bone, as well as of the periosteum itself, doubtless has a share; although the adventitious deposit which constitutes the swelling is chiefly effused from the latter tissue. These tumors exhibit a preference for those regions already mentioned as the favorite seat of osteocopic pains. They are most frequent upon the internal surface of the tibia and upon the bones of the head; but are also seen upon the clavicle, sternum, ribs, radius, ulna, etc., and similar changes may take place beneath the lining membrane of the medullary canal in the long bones, and between the dura mater and the bones of the skull. When seated upon the superficial bones, nodes appear as ill- defined tumors, adherent to the osseous tissue beneath, generally tender upon pressure, giving rise to severe nocturnal pain, and un- NODES. 655 attended, at least at their commencement, by redness of the integu- ment which is movable over them, and only becomes involved, if at all, in the subsequent progress of the tumor. If an opportunity be offered to examine their internal structure, the periosteum is found to be injected and thickened by infiltration into its substance, and elevated above the bone by an effusion of fluid. In some cases, the effusion consists of pus, which after a time finds exit through ulceration of the integument and exposes the bone, which often becomes carious or exfoliates. In other instances, the effusion consists of a yellowish, gelatinous fluid, containing an abundance of fat-corpuscles as seen under the microscope, and inclosed in a loose network of cellular tissue. This variety, which generally undergoes resolution, resembles the gummy deposits which take place in the cellular tissue, in the mus- cles and many of the viscera, and has been denominated " gummy periostosis." Ricord1 has reported and figured a case of perios- tosis upon the internal surface of the tibia, in which there was a deposit of gummy material in the corresponding portion of the medullary cavity of the bone and in the substance of the neigh- boring tibialis posticus muscle, together with simple hypertrophy of this part of the shaft of the tibia. In a third variety, which is the most common, the tumor is hard and firm; the nocturnal pain is especially severe; and the contained fluid, which is of a plastic character, acquires greater consistency and often gives rise to an exostosis, at first separated from the bone by cartilaginous tissue, which finally undergoes ossification. These epiphysary exostoses, as they are called, are generally of small size, sometimes thin and flat, and sometimes hemispherical or pedunculated. "At an early period of their existence, they consist of cellular tissue, containing a well-developed network of vessels. They acquire greater consistency with time, and finally present an eburnated texture. Arrived at this point, resolution is no longer possible; the tumor remains stationary, and treatment has no other effect than to quiet the osteocopic pains. If resolu- tion be attained at an earlier period, their surface, which before was smooth, becomes irregular, indicating partial absorption. Some- times this absorption continues after the whole of the tumor has 1 Iconographie, PI. XXVIII. bis. 656 AFFECTIONS OF THE PERIOSTEUM AND BONES. disappeared, so that local atrophy of the bone succeeds the exos tosis."' In other instances, syphilitic exostosis is not preceded by periostosis, but is the result of ostitis terminating in hypertrophy of the normal bony tissue, in which case it is denominated paren- chymatous exostosis. An exostosis situated externally rarely occasions sufficient in- convenience or deformity to necessitate its removal by an operation unless under peculiar circumstances, as was the case with a violin- ist from whose metacarpal bone a tumor of this nature, which had interfered with the exercise of his profession, was removed by Ricord. But exostoses may also spring from the internal surface of the cranial bones and give rise to symptoms of the most serious char- acter, as convulsions and the various forms of paralysis. The frontal bone is by far the most frequently affected in this manner. Lagneau, in his able work2 upon Syphilitic Affections of the Nervous System, has been able to collect but three cases of exostosis spring- ing from the parietal, and one from the sphenoid bone; he appears to have met with none in the occipital or temporal. These intra- cranial exostoses vary very much in size. Saltzman3 reports a case in which the tumor occupied the internal surface of one of the parietal bones, commencing at two fingers' breadth from the sagittal suture and extending to the coronal suture in front and the temporal below; the patient died with symptoms of apoplexy. Within the cranium4 of Clermont-Ferrand, deposited in the Du- puytren Museum, are two exostoses, one of which is as large as an orange. In general, however, these tumors are much smaller, and often multiple. They also vary in density, some presenting a hard, eburnated texture, while others are cellular. Most of them spring directly from the surface of the bone (parenchymatous exostoses); indeed, the existence of epiphysary exostoses within the cranium has been denied, but Vidal4 gives a representation of a specimen in the Dupuytren Museum, in which the tumor is separated from the normal tissue by a distinct line of demarcation. 1 NIlaton, Pathologie Chirurgicale, t. ii. p. 16. 2 Maladies Syphilitiques du Systeme Nerveux, par Guptave Lagneau Fils Paris, 1860, p. 45. ' * Acta Phys. Med. Academic Ces.-Leop. Carol. Nature Curiosorum Ephemerides ■ Norimbergae, 1730, t. ii. p. 222, obs. 99 (as quoted by Lagneau, fils, op. cit., p. 361)! ♦ Figured by Vidal, Pathologie Externe, 2e edition, t. iii. p. Ill 1846 6 Op. cit., t. iii. p. 116. CARIES AND NECROSIS. 657 Syphilitic exostosis of the vertebrae, either external or within the spinal canal, is rare; but Lagneau1 has adduced several in- stances reported by Cloquet and Berard, Godelier, Piorry, and Minich. The treatment above recommended for osteocopic pains is equally applicable to nodes, which generally yield with great facility to iodide of potassium; although a subsequent course of mercury is necessary to secure immunity for the future. The best local treatment is the one so highly extolled by Ricord, consisting in the repeated application of blisters which may be dressed with an ointment containing morphine or powdered opium. As a general rule, the swelling should not be opened, even if fluctuation be evi- dent, since resolution may almost always be obtained by the means indicated, and exposure of the bone is frequently followed by caries or necrosis of its superficial layer. Caries and Necrosis.—Syphilitic caries and necrosis may arise— A. From ulceration of the soft parts in the neighborhood of the affected portions of bone. The ulcerative process involves the periosteum or perichondrium, and the bone or cartilage, deprived of its vascular supply, loses its vitality. This is the usual mode of origin of caries and necrosis of the hard palate, the bones of the nose, and the thyroid cartilage; more rarely the superficial bones, as the clavicle, sternum, cranium, and the internal surface of the tibia, are similarly affected consecutively to ulceration of the in- tegument. B. From the suppuration and opening of nodes, whereby the bone is laid bare, and its vascular supply cut off. C From suppurative inflammation of the osseous tissue inde- pendently of any affection of external parts. Caries and necrosis are not confined to any portion of the skele- ton, but are most frequent in the superficial bones. Although they generally attack the shafts of the long bones, yet they occasionally involve the neighborhood of the joints, where they cannot be dis- tinguished from the effects of scrofula except by the history of the case and the concomitant symptoms. Inflammation of the cranial bones resulting in caries and necro- 42 1 Op. cit., p. 193. 653 AFFECTIONS OF THE PERIOSTEUM AND BONES. sis usually commences in the external, but sometimes in the inter- nal table, and attacks the frontal far more frequently than either of the others. More or less of one of the tables may exfoliate, leaving the diploe and opposite layer intact. In a case observed by Du- puytren,1 two-thirds of the internal table of the skull were necrosed; and in another, reported by Pe'trequin,2 the whole external table of the frontal bone exfoliated. More frequently, although the exter- nal table is involved to the greater extent, the diploe and internal table are perforated at one or more points, laying bare the dura mater, which, when the opening is large, may protrude externally, either preserving its normal character, or assuming a highly vas- cular and fungous appearance. When the disease commences in the internal table of the skull, the inflammatory products and portions of necrosed bone some- times find exit through perforation of the external parts; or, in other instances, accumulate between the bone and dura mater, cause compression of the brain, or give rise to encephalo-meningitis and disorganization of the cerebral substance. Moreover, in nearly every case of syphilitic disease of the cranial bones, the dura mater, upon its internal or cerebral aspect, presents thin layers of fibri- nous or hemorrhagic deposit, which are easily detached from the surface.3 Virchow4 states that necrosis produced by syphilis may be dis- tinguished from that due to other causes by the sequestrum, which is perforated with large holes and presents a worm-eaten appear- ance. "In syphilitic necrosis, the surface of the sequestrum is pierced with large holes, which unite internally and lead to the suspicion that they have been due to a deposition of gummy mate- rial; the surrounding tissue, whether necrosed or not, is often dense and eburnated, presenting a strong contrast to the above." The same author5 has described among the syphilitic affections of the bones a form of caries without suppuration, to which he gives the name of "dry caries," or "inflammatory atrophy of the cortical substance of the bone," and which he believes is due to the compression exercised by deposits of gummy material. 1 Clinique de l'Hotel Dieu ; Transactions Medicales, par MM. Forget et Sandras, Paris, 1832, t. x. p. 269 (quoted by Lagneau, op. cit., p. 403). * Oaz. Med. de Paris, 1836, t. iv. p. 643. » Virchow, Syphilis Constitutionnelle, p. 50. * Op. cit., p. 49. s 0p. cit., p. 37. CARIES AND NECROSIS. 659 Extreme fragility of the bones has often been noticed in persons affected with tertiary syphilis. A patient who was under my care a few years since for syphilitic necrosis of the bones of the head, fractured his thigh while simply turning in bed. Death ensued from exhaustion in the course of a few weeks, but no opportunity was offered for a post-mortem examination. It is unnecessary to repeat the directions already given for the constitutional treatment of tertiary syphilis, which includes that of syphilitic affections of the bones. In commencing ostitis, valuable assistance may be derived from the local application of blisters, which, as recommended by Ricord, may be dressed with mercurial ointment. " When suppuration or caries occurs, especially of the bones of the face which are so often necrosed in these cases, we should never fail to remove them as soon as they can be separated from the sound parts. We must recollect that caries engenders caries; that when the organic tissue of a bone has been destroyed by suppura- tion or has lost its vitality, it cannot be regenerated by any consti- tutional or local treatment whatsoever; and that its debris should never be left to spontaneous evolution, since they are foreign bodies, maintaining and extending suppuration, which, by involv- ing important parts, may occasion the most serious symptoms, or even result in death.'" 1 Ricord, Notes to Hunter, 2d Am. ed., 1859, p. 507. 660 CONGENITAL SYPHILIS. CHAPTER XVIII. CONGENITAL SYPHILIS. Syphilis acquired during intra-uterine life is variously desig- nated as congenital, hereditary, or infantile. The first of these terms appears to me the most appropriate, since it includes those cases in which the disease is derived from one or both parents at the time of conception, and also those in which it is communicated to the foetus through the mother during gestation; while it excludes those instances in which it is contracted during or after delivery, and in which syphilis pursues essentially the same course as in adults. Etiology.—Congenital syphilis may be derived from both parents; from the mother alone; from the father alone. In either case it is not necessary that the parent or parents, in whom the disease originates, should present syphilitic manifestations; the existence of the syphilitic diathesis is alone sufficient; and nu- merous cases have been reported of persons in whom the disease has been latent for many years, and who have yet had syphilitic children. When both parents are tainted with syphilis, and provided they have not been subjected to general treatment, the disease is almost certain to appear in their offspring. When one or both parents have received appropriate treatment, or when only one is affected with syphilis, the child may yet be born healthy. When the foetus is infected through the mother alone, the latter may have contracted the disease either before or after impregnation. Syphilis contracted by the mother prior to conception is sufficient to give rise to the disease in a child by a perfectly healthy father. Thus, a widow who has been infected by her first husband, may marry a healthy man and give birth to syphilitic children; or a woman who has contracted the disease by nursing a syphilitic ETIOLOGY. 661 infant, may be delivered of tainted offspring whose father is un- affected. An infant may also be born syphilitic in consequence of disease contracted by the mother subsequent to conception. Numerous instances of this kind are reported, and I have already mentioned one occurring in my own practice, in which the disease was com- municated by a husband to his wife as late as the end of the fifth month of gestation.1 It is generally admitted, however, that the danger to the foetus is much less during the latter months of preg- nancy than at an earlier period; and Diday2 concludes, from an analysis of eleven cases, that syphilis contracted by the mother after the completion of the seventh month has never produced the dis- ease in the foetus. As suggested by the same author, if this fact should be confirmed by farther observation, it would prove of con- siderable practical importance, in enabling us, when syphilis is contracted by a woman during the eighth or ninth month of preg- nancy, to dispense with mercurial treatment until after delivery; and also to intrust a child born under these circumstances to a wet nurse without danger of infection to the latter. Again, syphilis in the father may occasion the same disease in the foetus without previous infection of the mother. In most cases of hereditary syphilis, primarily due to disease in the father, we find that the mother has also been infected either before or during ges- tation ; but a number of instances have been reported in which the latter has continued perfectly healthy for a long period after deli- very, and in which the disease in the offspring must have been derived from the former alone. For a father to transmit syphilis to his child, it is not necessary that he should present upon his person, at the time of impregnation, the slightest syphilitic manifes- tation. He may have recently contracted an infecting chancre, and be passing through the period of incubation of secondary symptoms; or the disease may have been subdued by treatment, and many years have subsequently been passed in apparent health. The ex- istence of the diathesis, even if it be latent, either in the father or mother, may engender syphilis in the offspring. It has been supposed by some authors, if a man affected with syphilis has connection with a pregnant woman, that his semen may be absorbed, and conveyed directly to the foetus causing its 1 See page 371. 2 De la Syphilis des Nouveau-n6s, p. 48. 662 CONGENITAL SYPHILIS. infection, without communicating the disease to the mother. So extraordinary an occurrence cannot be admitted unless sustained by indubitable evidence; and I am, therefore, surprised that it is regarded with favor by Diday, especially as he has been able to adduce but one exceedingly lame fact, reported by Albers, in its support. The analogy drawn by Diday and Lawrence from the occurrence of smallpox in the foetus, while the mother remains ex- empt, is very far from conclusive, since the poison of variola is volatile, and is readily absorbed through the sound mucous mem- brane of the respiratory organs; whereas the syphilitic virus is communicated only by contact, and never, so far as we know, with- out causing ulceration at its point of entrance. Evidently, the transmission of disease, and of mental and physical characteristics, from the father to the ovum, at the time of impregnation, does not warrant our assuming, in the entire absence of evidence, the impro- bable supposition that the same may be communicated to the foetus, at any period of gestation, by a man who has connection with the mother. If this were so, the proof of paternity would, in many cases, be of an extremely doubtful character. Although syphilis acquired after leaving the womb of the mother is not properly included under the head of congenital or hereditary syphilis, yet a few remarks upon this subject will not be out of place at the present time. After its exit from the uterus, the infant is evidently exposed to the same sources of contagion as adults, with the exception of voluntary sexual congress. In its passage into the external world, its cutaneous surface is very thoroughly protected by a sebaceous coating which commonly prevents inocu- lation from any syphilitic lesion upon the genital organs of the mother; and although contagion in this manner is by no means impossible, or even improbable, yet, according to Diday, no un- questionable instance has ever been reported. At a subsequent period, infants most frequently contract syphilis from wet-nurses, themselves affected with the disease, who bear either a primary or secondary lesion upon the breast. In most cases of contagion from a nurse to a nursling, the sore upon the breast of the former is an infecting chancre, accompanied by indu- ration of the axillary ganglia, and originally derived from a mucous patch upon the mouth of some child, whom she has previously nursed; in other cases, the secretion of a secondary lesion is the source of contagion. The reader is referred to page 488 of the TRANSMISSIBILITY. 663 present work for a fuller account of the phenomena of secondary contagion. Although it is not improbable that the milk may have some influence in the transmission of syphilis to infants at the breast, yet no conclusive facts have hitherto been reported by which this method of contagion can be established beyond a doubt. Transmissibility.—We have seen that an ovum, healthy at the time of conception, may become infected during the greater portion of the period of gestation in consequence of the mother contracting syphilis. This influence, as existing between mother and child, is mutual; and a foetus contaminated with syphilis by its father may communicate the same disease to a mother, who was unaffected at the time of impregnation. Infection of a mother through the me- dium of a foetus was, according to Mr. Hutchinson, first noticed by Gardien (Traite des Accouchements) in 1824, and is admitted by most recent writers upon venereal, among whom may be mentioned Ricord, Diday, Depaul, Acton, Harvey, Tyler Smith, and Balfour; it is by no means, however, to be regarded as a necessary conse- quence of the contamination of the ovum by a diseased father; and, as in thirteen cases reported by Victor De Me'ric,1 a mother may give birth to a syphilitic child, and yet never present the slightest evidence that she herself is affected. The contagiousness of secon- dary lesions, which is now established beyond question, will pro- bably explain many cases in which a wife becomes infected in the absence of primary sores in her husband, and which have hitherto been considered, especially by the advocates of Ricord's earlier views, as instances of the communication of the disease through the foetus. In consequence of the frequency of mucous patches upon the buccal mucous membrane and the intimate contact between the mouth and breast in the act of nursing, instances of the communi- cation of secondary syphilis by an infant affected with hereditary syphilis are far more numerous than those by adults. In France, where children are often sent to a wet-nurse in the rural districts, syphilis is thus not unfrequently conveyed to villages where it was previously unknown, and, spreading from one person to another, finally affects a large number of individuals. The fre- Lettsomian Lectures, p. 65. 664 CONGENITAL SYPHILIS. quency of instances of this kind induced Diday, in his able work upon Infantile Syphilis, to admit that hereditary syphilis possesses a peculiar virulence and powers of contagion greater than those of acquired syphilis; a distinction which he has abandoned since the contagiousness of secondary manifestations in general has been conclusively demonstrated. To the liability of contagion from the lesions of hereditary syphi- lis, there is an important exception which first attracted the attention of the acute mind of Abraham Colles, of Dublin; it is this, that although the disease is frequently communicated by an infant to a wet-nurse, yet a mother has never been known to be infected from nursing her own offspring. This fact, singular as it may at first appear, is, in most cases, susceptible of ready explanation; it is, indeed, merely an exemplification of the "unicit6" of the syphilitic diathesis; for whenever the mother has already been contaminated, either directly by the father or indirectly through the foetus in utero, she is thereby protected from a second infection; and even when she presents no evidence of a syphilitic taint, she must have been exposed to it during gestation, and her immunity is to be ascribed to a constitutional inaptitude to contract the disease; in other words, the mother has undergone before delivery the greatest amount of exposure to which the foetus can subject her, and which, if capable of infecting her system at all, has already done so before the birth of the child. Abortion.—Syphilis is so frequent a cause of the premature expulsion of the foetus, that repeated abortions form a valuable element of diagnosis in the investigation of suspected cases of this disease in married life. It has sometimes been supposed that the cause of the abortion in these cases was not a syphilitic taint, but the mercurial treatment to which the mother was subjected. This opinion, however, is erroneous. The careful administration of mer- cury to a pregnant woman affected with syphilis affords the surest protection to her child; and it is very rare for this mineral to pro- duce abortion unless given injudiciously and in such a manner as to irritate the stomach or intestines. When both parents are affected with syphilis at the time of con- ception, and the mother does not receive appropriate treatment in the early months of pregnancy, the foetus will rarely be carried to the full term of gestation. When only one parent is affected, it is PERIOD OF DEVELOPMENT. 665 reasonable to suppose, with Diday, that the influence of the mother, from whom the foetus derives its nutrition, will be greater than that of the father; although the contrary is maintained by Prieur, Lloyd, Wade, and Maisonneuve and Montanier. In most cases of abortion from syphilis the general health of the mother is in a very fair condition, so that the death and expulsion of the foetus cannot be ascribed to a deficient supply of nourishment. In many cases it is sufficiently accounted for by the changes which are found upon post-mortem examination to have taken place in the thymus gland, lungs, and liver, and which will hereafter en- gage our attention. The researches of Dr. Robert Barnes have led him to believe that in some instances the immediate cause of the abortion consists in fatty degeneration of the maternal and foetal structures of the placenta, the result of defective nutrition. "In a placenta affected with fatty degeneration, the lobes of the placenta are altered in appearance, some of them being of a yellow, fatty color, brittle, and exsanguine; the rest presenting their ordinary characters. Examined more minutely, the tufts are found to be glistening, hard, and tallowy, and not expanding when placed under water, as is the case with the villi of healthy placentae. Under the microscope, the villi are found to be studded with spherules and droplets of fatty matter and oil. The fatty material is found prin- cipally in the cells of the villi, and in the coats of the bloodvessels of the villi. When the fatty degeneration of the vessels exists to any extent, the vessels do not carry red globules. The villi and the vascular loops affected with degeneration are knobbed and mis- shapen in appearance."l Abortion from syphilis is most frequent about the sixth month of gestation, but is by no means confined to this period. Ricord states his impression that abortion takes place earlier when the germ of the disease has been derived from the father alone.8 Period of Development.—In most cases, an infant affected with congenital syphilis does not present at birth any of the ordi- nary manifestations of the disease as they are commonly met with in the subjects of acquired syphilis, but is in an apparently healthy 1 Tyler Smith, London Lancet, Am. ed., July, 1856, p. 4. 2 Discussion before the Soc. de Chirurgie, Session of May 31, 1854; Gaz. des Hop., 1854, p. 296. 666 CONGENITAL SYPHILIS. or even robust condition; and when any traces of the inherited taint are manifest at this time, they usually consist of an eruption of pemphigus, or of lesions of the internal organs, rarely met with in adults. But although this is the general, it is by no means an invariable rule. Sir Astley Cooper has observed several cases of a copper-colored eruption upon the palms of the hands, soles of the feet, and buttocks, at birth; Gilbert one of flat brownish-red pustules (condylomata) scattered over the back, buttocks, and thighs, and another of a similar eruption around the nates, both infants living but a few days; Guerard one of "tawny-colored spots which every one would recognize as syphilitic;" Landman one of copper-colored stains upon the body and condylomata upon the labia majora. Simon has reported the case of a woman affected with syphilis who repeatedly aborted about the seventh or eighth month, and in each instance the foetus, which was born dead, bore evident traces of syphilis; Deville one of numerous and well- marked mucous patches upon different parts of the body; and Bouchut one of an infant, born at seven and a half months, who presented mucous patches and pustules of a brownish-red or copper- color upon the legs and arms, together with ulceration of the labia minora and onyxis upon all the fingers and toes. Cullerier, in ten years' service at the Hopital de l'Ourcine, Paris, met with only two cases of syphilitic eruptions at birth, one of roseola and the other of mucous patches about the anus.1 Victor de Menc states that out of forty-six cases of hereditary syphilis which have been under his care, and in which the children were born alive, in only two did the infants present at birth distinct symptoms of syphilis. We conclude that, with the exception of an eruption of pemphigus and specific changes in the viscera, syphilitic lesions manifest at birth, although sometimes met with, are quite infrequent. In the very great majority of cases, the symptoms of congenital syphilis make their appearance within the first few months after birth; and this fact is of great importance, since, when the parents are the subjects of syphilis, and manifest anxiety as to the future of their offspring, exemption during the period referred to renders it highly probable that the child has escaped contamination. Of 158 cases collected by Diday from various sources, the disease showed itself— 1 Emile Vidal, De la Syphilis Congemtale, These, Paris, 1860, p. 8. LATE DEVELOPMENT. 667 Before the completion of one month after birth in Before the completion of two months in Before the completion of three months in At four months in..... At five months in ..... At six months in ..... At eight months in..... At one year in ..... At two years in ..... It appears from this table that the greater proportion of out- breaks of constitutional syphilis in tainted infants occur within the first three months after birth; and that when this period is passed in safety, there is not much probability that any symptoms of the kind will manifest themselves.1 Other authors have arrived at similar conclusions. Trousseau states that, as a general rule, congenital syphilis appears within the first month; sometimes during the second, third, or fourth; rarely as late as the fifth; and that he has met with but one instance as late as the seventh month.2 According to Cullerier, it is rare for infants affected with hereditary syphilis to pass six months without the disease appearing; he has, however, witnessed its development in the eighth, ninth, and tenth month, but never after a year from birth. So far as known facts enable us to judge, Diday concludes that there is no relation between the period of development, the charac- ter and progress of congenital syphilis, and its particular mode of origin; in other words, that the evolution and nature of the symp- toms will be essentially the same, whether the infant has derived the germ of the disease at the time of conception or during preg- nancy. Late Development of Congenital Syphilis.—We have seen that congenital syphilis almost invariably shows itself within a year, and, in the immense majority of cases, within three months after birth, and that the exceptional cases thus far mentioned do not greatly exceed the former limit. But an important question here arises, viz., whether the period of its latency may be indefinitely prolonged, and a child carry the germ of the disease undeveloped in its system until puberty or even adult life before it betrays itself by external manifestations? The solution of this question is sur- rounded by many difficulties, since it requires that the syphilitic 45 15 1 Diday, op. cit. 2 Union Medicale, 1S57, p. 182. 663 CONGENITAL SYPHILIS. nature of the symptoms, the absence of direct contagion, and the previous infection of the parents should be clearly established. Many of the facts reported fail to satisfy these conditions; yet others render an answer in the affirmative highly probable. Diday quotes the following cases:— A washerwoman of Orleans, of bad constitution, but tolerably healthy up to that period, married in 1824. She was delivered at the full time of a male child, which wasted rapidly, and sank on the seventeenth day, with small white pimples around the nails. At the end of a year she bad a second child, now more than two years old, and healthy. A short time after having weaned it, she observed three swellings de- velope themselves upon her own body, one on the left clavicle, the second at the inner edge of the right sterno-cleido-mastoideus muscle, and the third near the elbow on the same side. The first soon suppurated, and the orifice was converted into a large ulceration. This woman, when the disease had existed five months, came into the hospital. At the spot indicated, an ulcer with red, abrupt edges, and a grayish base, was observed. She had, farther, a painful node on the left tibia. No trace of primary venereal affection could be discovered on the genital organs of this woman. She asserted that she had never had con- nection with any one but her husband, who, by his own account, had never had syphilis before marriage, and had always been healthy since. But she knew that her father had several times communicated the venereal disease to her mother, and that the latter had been suffering from it when she herself was born. Mercurial treatment rapidly effected the cure of the ulcer.1 We find also in Rosen the case of a young girl of eleven, fresh as a rose, in whom hereditary syphilis manifested itself in the form of swelling and suppuration of the glands of the neck and of the nose, of caries of the palate, and of corroding ulcers of the face.8 The work of Cazenave3 on syphilitic affections contains two cases of disease called by him hereditary syphilis, occurring in two girls, one of nine years old, the other of eighteen, in the latter of whom the symptoms had first shown themselves at the age of ten. They had tubercular and serpiginous eruptions, which had produced serious effects. It was impos- sible to discover any trace of primary lesions, the existence of which was, moreover, rendered very improbable by the age at which the secondary phenomena had appeared. The first was cured by the administration of the protiodide of mercury. 1 Gibert, Journ. Univ. des Sciences Med., t. Iv. p. 100. 2 Maladies des Eufants, p. 843. 3 Traitg des Syphilides, p. 542. LATE DEVELOPMENT. 669 Trousseau has related the history of a young girl of nineteen, in whom he himself observed, in 1826, a chancre (?) in the posterior part of the throat. She had had, at six years of age, exostoses on the legs, and during the six following years nocturnal pains, which did not cease until the appear- ance of the menses, and afterwards returned. There was probably, says Trousseau, hereditary or acquired syphilis at the moment of her birth. These symptoms were cured by anti-syphilitic treatment. Sperino1 saw a child born of a mother who died of syphilis ; this child, previously healthy, though puny and scrofulous, was attacked by ulceration of the palate at the age of eleven years. Treated only with antiphlogistic and anti-scrofulous remedies, the ulcer continued to extend, and, after having destroyed the soft palate, it perforated the hard palate. These changes had required two years for their completion. When Spe- rino saw this child, at the age of thirteen, it was pale, emaciated, had purulent expectoration, almost incessant cough and fever, with evening exacerbations. He believed at first in the existence of pulmonary tuber- cles, but auscultation showed that none existed. The syphilitic character of the lesion having been diagnosed, syphilization was commenced. But in spite of the evident amelioration which ensued, fresh ulcers having ap- peared in the throat after four months of this treatment, recourse was had to iodide of potassium, which, given to the extent of 630 grains, completed the cure. Ricord does not hesitate to admit the late development of con- genital syphilis, which he would attribute to the effect of treatment administered to the mother during pregnancy; and he inquires, with much plausibility, why specific remedies, which are capable of retarding the evolution of general symptoms in the adult, may not similarly affect the foetus in utero.2 Fournier3 gives a brief summary of two cases, occurring in patients aged eighteen and twen- ty-five, who presented nearly the same symptoms, viz., a gummy tumor of the velum palati and an ulcerated tubercle on the poste- rior wall of the pharynx, which, in the absence of any evidence of direct contagion, were ascribed by Ricord to hereditary taint; and the latter surgeon states that he has "seen subjects in whom hereditary syphilis did not manifest itself before the age of forty."A In this connection I would refer the reader to Mr. Hutchinson's > La Sifilizzazione Studiata qual Mezzo, etc., 1853, p. 454. * Discussion on Hereditary Syphilis before the Soc. de Chirurg., Session of May 31, 1854. 3 De la Contagion Syphilitique, p. 11. 4 Discussion before the Academie Imperiale de Medecine, Session of Oct. 8,1853. 670 CONGENITAL SYPHILIS. views of the syphilitic nature of "strumous keratitis," so-called, and notching of the permanent incisor teeth, already mentioned in the chapter upon syphilitic affections of the eyes.1 Symptoms.—Many of the symptoms of congenital are identical with those of acquired syphilis, and do not require special descrip- tion at this time; I shall, therefore, dwell chiefly upon those which are peculiar to the subjects of an inherited taint. General Aspect of Syphilitic Infants.—-Infants affected with con- genital syphilis do not, as a general rule, present any peculiarity of appearance at birth, but, soon after the evolution of general symptoms, they almost always waste away and assume a withered aspect similar to that observed in the aged, and which has been denominated " miniature decrepitude." The skin loses the smooth- ness and freshness of early life, and is wrinkled and sallow; the cheeks and eyes are sunken; the borders of the mouth are thrown into radiated folds, as if drawn together with a purse-string; the palms of the hands and soles of the feet are dry, wrinkled, and often chapped; and the general aspect of the child is one of pre- mature old age. In many cases, the skin assumes a peculiar bistre tint, which is regarded as quite characteristic of congenital syphilis by Trousseau, who describes it as follows: "The bistre tint is rarely absent, though it varies in extent, in intensity, and in the time of its appearance. Sometimes it occupies nearly the whole surface of the skin, but even then is most decided in its seat of election; at other times it is confined to the face, certain portions of which are most apt to be affected. As a general rule, it is less marked the more widely it is diffused. Its favorite seat is upon the lower portion of the forehead, the nose, the eyelids, and the most promi- nent portions of the cheeks. The deeper parts, as the internal angle of the orbit, the hollow of the cheeks, and the depression which separates the lower lip from the chin, are alrnost always exempt, but no invariable limits can be assigned to it."2 Coryza.—This is one of the earliest and most frequent manifesta- tions of congenital syphilis, and, in a few instances, is the only symptom present. It commences with a thin serous discharge from the nostrils, the margins of which are observed to be reddened, 1 See p. 616. 1 Arch. Gen. de Med., 4e serie, t. xv. p. 159, 1847. SKIN AND MUCOUS MEMBRANES. 671 and covered with small pustules, mucous patches, or fissures. As the disease progresses, the discharge becomes purulent and sanious; the nasal passages are obstructed by the desiccation of matter and the formation of scabs; respiration is attended with a peculiar snuffling, which is very characteristic of this affection; and the impossibility of breathing freely through the nose seriously inter- feres with or altogether prevents suction at the breast; thus the nutrition of the child is impaired, and death sometimes occurs from inanition. In severe cases, the osseous and cartilaginous tissues are attacked; small fragments of necrosed bone come away with the discharge, and the septum nasi may be perforated, or the nose sunken. The disease sometimes involves the throat and larynx, and renders the voice hoarse or almost inaudible. Syphi- litic coryza commences in the mucous membrane, which, as shown by Diday, is the seat of mucous patches or pustules similar to those found upon other mucous surfaces. These are succeeded by ulcer- ations which involve the bones and cartilages secondarily. Affections of the Skin and Mucous Membranes.—A still more frequent and characteristic symptom of congenital syphilis, and one which is very rarely wanting, is an eruption of mucous patches. In infants, as well as in adults, the favorite seat of this eruption is in the neighborhood of the outlets of mucous canals, and especially in the vicinity of the anus; but, owing to the general moisture of the integument at this early age, mucous patches are often much more extended than in adults, and may occur upon any part of the surface. They are most frequent upon the nates, scrotum, vulva, thighs, around the umbilicus, in the axillee, behind the ears, and upon the labial commissures; they are also seen upon the hairy scalp, where they are never met with in adults. They are gener- ally distinct upon the thighs and trunk, but are often confluent in the genito-crural fold and around the margin of the anus, and in the latter situation frequently become ulcerated, and give rise to rhagades or fissures which radiate from the anal orifice. They exhale a very offensive and characteristic odor, especially if atten- tion to cleanliness be neglected. When seated upon a mucous surface, these patches present an opaline appearance, as if pencilled over with a crayon of nitrate of silver. They are rare upon the tongue, but frequent upon the in- ternal surface of the lips and cheeks, at the base of the gums, and upon the fauces, and in these situations are a common source of 672 CONGENITAL SYPHILIS. contagion from the infant to the nurse. Whether seated upon the skin or mucous membranes, the appearance of this eruption does not materially differ from that already described in a previous chapter. Syphilitic erythema is rare in the subjects of congenital syphilis, although a number of cases have been reported. Bassereau men- tions an instance, in which red spots appeared upon the brow and cheeks the third day after birth, and presented the copper color and slight elevation peculiar to the papular form of syphilitic erythema. Syphilitic coryza appeared upon the fourth day, and the infant died at the end of a fortnight.1 Pemphigus, unlike other syphilitic eruptions, is frequently present at birth. It is characterized by large vesicles, filled with yellowish serum often mixed with blood, and resting upon violet-colored or bluish patches of integument. Its favorite seat is upon the palms of the hands and soles of the feet, although it sometimes occurs elsewhere. In most cases, some of the vesicles have been ruptured previous to the birth of the child, and the underlying skin is found to be reddened and superficially eroded, or, in some instances, more or less deeply ulcerated. The prognosis is exceedingly unfavora- ble, since death ensues in the great majority of cases. In other instances, syphilitic pemphigus does not make its appearance until a few hours or days after birth, and, if the child survives, the erup- tion usually disappears within three weeks. There has been no little discussion whether the pemphigoid eruption of infants is to be regarded as the immediate result of syphilis, or as the conse- quence of the general cachexia produced by the inherited taint; this question, however, is of minor importance, since the eruption is rarely, if ever, met with in the offspring of other than syphilitic parents. Other syphilitic eruptions occurring in the subjects of congenital syphilis are pustules (syphilitic impetigo and ecthyma), and deep tubercles of the cellular tissue. Syphilitic papulae and squama?, and the non-ulcerated form of tubercles, are rare at this age. Onychia.—Syphilitic onychia is sometimes observed in infants, but is rarer than in adults. Suppuration of the Thymus Gland.—Paul Dubois,2 in 1850, first called attention to certain pathological changes which are found Op. cit., p. 541. 2 Gaz. Med. de Paris, 1850, p. 392. CHANGES IN THE LUNGS. 673 in the thymus glands of infants who are born dead, or who die a few days after birth from inherited syphilis. Externally, the gland appears to be normal in size, color, and consistency; but if an incision be made into its substance, pressure will cause to exude from the cut surface a few drops of yellowish fluid, which, under the microscope, is found to consist of pus. In the cases observed by Dubois, the purulent matter was uniformly diffused throughout the glandular tissue; but Depaul,1 Weber,2 and Hecker3 have met with abscesses of the thymus. The thymus gland natu- rally contains a whitish, viscid fluid, which may, with a little care, be distinguished from the suppuration dependent upon syphilis. Of five cases of this lesion observed by Dubois and Depaul, an eruption of pemphigus was present in four; and in the same number the syphilitic antecedents of the parents were clearly estab- lished. Virchow4 mentions a case reported by Lehmann, in which tuberosities of the conjunctive tissue, which had undergone fatty degeneration, were found in the thymus gland, the dura mater, and the liver, but the history of the parents could not be ascertained with certainty. Changes in the Lungs.—In 1851, Depaul called the attention of the profession to peculiar masses of induration which he found in the lungs of infants affected with congenital syphilis. Specimens of this lesion furnished by Depaul were submitted by the Anatomi- cal Society of Paris to Lebert for examination, who reported upon them as follows: " There is no trace of pus in the masses of indu- ration. The tissue presents a peculiar yellow color, and is elastic and resistant. In the midst of a network of the normal pulmonary tissue we find, mingled with fibro-plastic elements, a soft, pulpy, diffused substance, containing small cells, which differ from those of cancer and of tubercle, and which resemble in every respect those seen in syphilitic gummata. These specimens may, therefore, be regarded as an early stage of pulmonary gummata, which first appear as indurated masses, and afterwards assume a yellowish and pulpy appearance, and finally soften so as to resemble puru- lent infiltration or abscesses."4 In his Treatise upon Pathological i Gaz. Med. de Paris, 1851. 2 Beitrage zur Path. Anat. der Neugeboren. Kiel, 1852, vol. ii. p. 75. » Verhandl. der Berliner Gesells. fur Geburtshulfe, vol. viii. p. 117. * La Syphilis Constitutionnelle, p. 158. s Bulletin de la Soc. Anatomique, 185;', p. 23. 48 674 CONGENITAL SYPHILIS. A natomy, Lebert gives a plate of one of these masses of induration, which he compares to certain changes produced by pneumonia.1 Virchow thus describes the results of his post-mortem investi- gations: "At Wiirzburg, where hereditary syphilis is very com- mon, I have found a large number of children die in consequence of a peculiar form of broncho-pneumonia. Microscopical examina- tion has shown the existence of a dry and resistant substance, very analogous to tubercular infiltration, which was inclosed in the pul- monary alveoli and consisted of cells pressed against each other, and for the most part puriform. The larger portion of this sub- stance speedily underwent fatty metamorphosis, and remained in the pulmonary vesicles in the form of granular detritus. But I have also observed this lesion independent of any direct connection with syphilis. In children who were simply atrophied, I have found in many cases quite an abundant infiltration around the bronchi, where they penetrate into the pulmonary lobules, together with granular collections and abscesses, perfectly resembling what is called tubercle, and also distributed in the lungs. At present, it is difficult to determine how we are to recognize the syphilitic character of such pneumonias; and I forbear from expressing an opinion upon certain cicatricial and caseous lesions, some of which are very probably due to sj-philis.""1 Changes in the Liver. — Of the various changes in the viscera which have been ascribed to syphilis, there is the least doubt re- specting those occurring in the liver, which were first noticed by Gubler in 1848.3 Diday's description of this lesion is so clear and complete, that I shall avail myself of it. " When the lesion has reached its maximum, the liver is sensibly hypertrophied, globular, and hard. It is resistant to pressure, and even when torn by the fingers its surface receives no indentation from them. The elasticity of the organ is such, that if a wedge- shaped piece taken from its thin edge be pressed, it escapes like a cherry-stone, and rebounds from the ground. When cut into, it creaks slightly under the scalpel. The distinct nature of its two substances has completely vanished. On a uniform yellowish ground, a more or less close layer of small, white, opaque grains is seen, having the appearance of grains of semola, with delicate arborescences, formed of empty bloodvessels. On pressure no blood 1 Traite d'Anatomie Pathologique, PI. XIII., Figs. 3 and 4 2 Op. cit., p. 156. 3 Gaz. des Hop., 1848. CHANGES IN THE LIVER. 675 is forced out, but only a slightly yellow serum, which is derived from the albumen. Gubler has only three times seen the change carried to this extent. It is most frequently much less marked. Thus, the tissue of the organ is firm, without having that extreme hardness and yellow color which might admit of comparison to some kinds of flint. The interior of the organ presents rather an indefinite color, shaded with yellow or brownish-red, more or less diluted; but in no part is the parenchyma quite healthy in appear- ance. "Again, the change may be found in circumscribed parts only. Gubler has seen it confined to the left lobe, to the thin edge of the right lobe, and to the lobulus Spigelii. He ascertained by injections that, in the indurated tissue, the vascular network is almost imper- meable ; that the capillary vessels are obliterated, and that even the calibre of the larger vessels is considerably diminished. Micro- scopical examination enabled him to discover the cause of this dis- position by revealing in the altered tissue of the organ, in every degree of change, the presence of fibro-plastic matter, sometimes in considerable, sometimes in enormous quantity. In the portions intervening between the diseased parts, the cells of the hepatic parenchyma maintain all the characteristics of their normal condi- tion. The physical consequences of the deposit of these elements are an increase in the volume of the liver, the compression of the cells of the acini, the obliteration of the vessels, and the consequent cessation of the secretion of bile. In all the subjects examined after death by Gubler, he always found the bile in the gall-bladder of a pale yellow color and very sticky; that is to say, very rich in mucus and very poor in coloring matter. "The blood had almost always undergone a marked change, its solid portion having the consistence of soft currant jelly and the fluid portion being unusually abundant. In one subject this change coincided with an extreme discoloration of all the tissues and with innumerable ecchymoses. In one case the lungs presented the characters of acute pneumonia, and in two that of chronic or pan- creatiform pneumonia. Lastly, the concomitant syphilitic lesions consisted in patches of psoriasis, pustules of lenticular ecthyma, mucous patches, fissures at the circumference of the natural outlets, and in the folds about the joints, and inflammation of the nasal fossae, with purulent and sanguineous secretion."1 1 Syphilis in New-born Children; Sydenham Society's translation, p. 92. 676 CONGENITAL SYPHILIS. Gubler regards this lesion as of the same nature as gummy tumors, and consequently classifies it among tertiary symptoms. Diday, on the other hand, looks upon induration of the liver as identical with that of the base of the chancre and neighboring gan- glia, and therefore assigns its place among secondary lesions. The fact that it yields most readily to mercurials appears to favor the latter classification. The symptoms of this affection, so far as they have been deter- mined, are excessive restlessness of the infant, who is apparently in great pain, vomiting and diarrhoea, or constipation, swelling and tenderness of the abdomen, and a small and quick pulse. By pal- pation and percussion, an increase in the volume and density of the liver may, perhaps, be ascertained. Jaundice has never been noted in any of the reported cases; although, according to Emile Vidal,1 Gubler has met with one instance not yet published. The prog- nosis in this affection is very unfavorable, and death generally ensues in a very few days. Peritonitis.—Prof. Simpson,2 of Edinburgh, in a large proportion of the cases in which the children of syphilitic parents die during the latter months of pregnancy, ascribes the mortality to peritoni- tis; farther observation, however, is requisite to determine whether congenital syphilis is capable of producing simple peritonitis inde- pendently of induration of the liver, with which it was associated in some of Gubler's cases. Affections of the Periosteum and Bones.—These affections, although occasionally met with as an effect of congenital syphilis, are con- fessedly rare. In addition to the cases referred to upon page 465 of the present work, the following have been reported. Underwood3 saw an exostosis upon the cranium of a child, born of a syphilitic mother who had been infected by her husband. Bertin4 met with a periostosis upon the superior and posterior surface of the cubitus, in an infant thirty-five days old, whose body was covered with pustules. Laborie* mentions a case of caries of the tibia in a subject of congenital pemphigus. 1 De la Syphilis Congeuitale, Paris, I860, p. 32. 2 Obstetric Memoirs, Edinb., 1856, vol. ii. p. 172. 3 Traite des Mai. des Enfants, Paris, 1786, p. 361. 4 Traite de la Mai. Vener. chez les Enfants Nouveau-nes, p. 69. s Session of the Acad, de Med., July 1, 1857. PROGNOSIS. 677 Cruveilhier1 speaks of a child born at full term, poorly devel- oped, with pustules on different parts of the body, in whom the dura mater, corresponding to the angle of union of the frontal bones with the superior walls of the orbits, was infiltrated with pus, and the bones themselves denuded and eroded in a part of their thickness. Bouchut2 has described an affection of the long bones, differing from caries and degeneration of the periosteum, which he states he has often observed in the subjects of inherited syphilis. Instead of the soft, spongy, vascular, imperfectly formed and easily cut structure of the bones at this age, he has found the middle portions of the tibiae and femora, solid, compact, eburnated, and not to be broken or divided by a cutting instrument. Bouchut supposes that these changes indicate an abnormal activity in the development of bony tissue, similar to the plastic exudation which takes place in other organs. Hydrocephalus.—Hydrocephalus has been attributed to an in- herited syphilitic taint by Gros and Lancereaux,3 Rayer, Haase,4 and De Me'ric;4 and several cases have been reported in which the connection as cause and effect between these two diseases has appeared to be highly probable. Affections of the Supra-renal Capsules and Pancreas.—Virchow6 states that he has met with an increase of volume and complete fatty degeneration of the supra-renal capsules, and also fatty degen- eration of the pancreas, in infants affected with congenital syphilis. Prognosis.—The mortality from congenital is undoubtedly much greater than from acquired syphilis, although statistics to determine the exact proportion of deaths are wanting. Bassereau7 says that an examination of his notes and of cases reported by others leads him to believe that in at least one-third, death ensues within a few months after birth. Trousseau8 has never seen an infant recover when the disease appeared within a few days after delivery. 1 Anatomie Pathologique, 10th obs. 2 Traite Pratique des Mai. des Nouveaux-nes, 1852, p. 863. s Memoire crowned by the Academy, 1859 (as quoted by Emile Vidal, op. cit./ p. 33). 4 Allgemein. Medic. Annal., Feb. 1829, p. 194. 5 Lettsomian Lectures, 1858, p. 65. 6 La Syphilis Constitutionnelle, p. 161. 7 Op. cit., p. 544. 8 Lemons sur la Syphilis Congenitale, Union Medicale, 1857. 678 CONGENITAL SYPHILIS. Treatment.—The propriety of treating a pregnant woman for syphilis has been the subject of much discussion, and has, at times, been denied on the ground that mercury was a powerful cause of abortion, and that the death and expulsion of the foetus was more frequently due to the administration of this mineral than to syphilis itself. It would serve no useful purpose to enter into the arguments which have been advanced for and against this supposition; suffice it to say that modern surgeons, with but few exceptions, regard the fear referred to as chimerical, and believe that specific treatment of the mother is the surest means of prolonging gestation to its full term and of affording security to the infant after birth. Ricord's views upon this subject are very explicit and decided. He says: " The period of gestation in women, far from contraindicating ener- getic treatment, demands increased attention and promptitude within the bounds of prudence. I have seen very many more abortions among syphilitic women who had not been treated, than among those who, taken in time, had been subjected to methodical medication." There is strong ground for believing that in those cases in which mercurials have appeared to favor abortion, they have done so only in consequence of their irritant effect upon the intestinal canal, and not from any abortive power inherent in the remedy itself. Thus, six cases reported by Colson1 of abortion in pregnant women who were subjected to mercurial treatment, were analyzed by Bertin,3 who showed that in four there was violent vomiting, and in a fifth convulsions at the sixth month of pregnancy; while in the remain- ing case treatment had been commenced only a fortnight before, and sufficient time had not elapsed to obtain its full effect; hence, that in none was there reason to ascribe the death of the foetus to the judicious employment of mercury. The sympathy existing between the intestinal canal and the uterus is well known, and in the treatment of pregnant women affected with syphilis, we should carefully guard against any irri- tant action upon the stomach or bowels. Fortunately, this end may be accomplished, and at the same time the full action of the remedy be obtained by mercurial inunction, which is by far the best method of treatment in such cases. The same opinion was expressed a long time ago by Bell, who said: " During pregnancy, 1 Arch. Gen. de Med., 4th series, t. xviii. p. 24. 2 Compte Rendu des Travaux de la Soc. de Med. de Bruxelles, 1858, p. 82 (as quoted by Euiile Vidal, op. cit., p. 84). TREATMENT. 679 mercury ought in every instance to be used in the form of unction, as we thereby with most certainty prevent it from acting upon the stomach and bowels, and thus avoid the hazard of abortion taking place as the effect of irritation upon these parts. Nothing, indeed, more readily excites abortion than purgatives when severe in their operation upon the bowels, or when they even only produce any considerable degree of tenesmus; and as the internal exhibition of mercury is frequently the cause of this, it cannot but with much hazard be given in any considerable quantity during pregnancy." When the father is known to have been the subject of syphilitic manifestations at the time of impregnation, or when previous abor- tions afford reason for supposing that the disease, although appa- rently latent in him, has still been active enough to infect the ovum, it is the part of prudence to subject the mother to treatment during pregnancy, in the same manner as if she herself had pre- sented syphilitic symptoms. The same method of treatment above recommended for the mother, viz., mercurial inunction, is no less appropriate for an infant affected with congenital syphilis. The internal administra- tion of mercury, as in one of the accompanying formulae, will some- times succeed, but too frequently irritates the bowels, and, in my own experience, affords far less satisfactory results than the method by inunction. ty. Hydrargyri cum creta gr. ij-vj. ty. Hydrarg. chloridi corrosivi gr. ss-j. Sacchari albi gr. xij. Ammonia} muriatis gr. iij. M. et div. in ch. No. xii. Syrupi papaveris ^ij. One three times a day. Aquse giv. M. A teaspoonful three times a day. Van Swieten's solution and Plenck's gummy mercury2 are often used by the French, who also employ baths containing from half a drachm to a drachm of the bichloride of mercury. My own prefer- ences are in favor of the gray powder for internal administration. The advantages of mercurial inunction and the method of em- ploying it are thus set forth by Sir Benjamin Brodie:3 "The mode 1 A Treatise on Gonorrhoea Virulenta, &c, Edinb., 1793, vol. ii. p. 435. 2 " Plenck's gummy mercury" contains mercury gr. xv, powdered gum Arabic gr. xlv, and syrup of diacode (an electuary containing a small quantity of extract of poppies) 3j. Triturate in a porcelain mortar until the mercury disappears. Uosf.—^a in an appropriate vehicle. (Diday.) 5 Clinical Lectures on Surgery, Phil, ed., 1846, p. 230. 680 CONGENITAL SYPHILIS. in which I have treated these cases for some years past has been this: I have spread mercurial ointment, made in the proportion of a drachm to an ounce, over a flannel roller, and bound it round the child once a day. The child kicks about, and, the cuticle being thin, the mercury is absorbed. It does not either gripe or purge, nor does it make the gums sore, but it cures the disease. I have adopted this practice in a great many cases with the most signal success. Very few children recover in whom mercury is given in- ternally, but I have not seen a case where this method has failed." Treatment should by no means be laid aside as soon as all syphi- litic manifestations have disappeared, but should be continued as a prophylactic for several months afterwards. Indirect treatment by means of remedies administered to the child's nurse is not to be depended upon in a disease which makes such rapid progress and is so destructive in its tendency as con- genital syphilis. MM. Lutz and Personne have carefully analyzed the milk of nurses who were subjected to mercurial treatment, pushed in some instances to salivation, without being able to dis- cover the slightest trace of this mineral. Experiments upon animals, however, have shown that a very minute quantity of mercury may be detected in the milk of a goat that has been salivated by mer- curial inunction, and cases have been reported in which infants have been cured of syphilis by being fed upon milk derived from such a source; but this method, for obvious reasons, could not be generally adopted, even if its efficacy were fully established. The administration of iodide of potassium to the infant's nurse may be resorted to with much greater probability of the remedy finding its way into the mammary secretion, and may often be em- ployed with advantage as an adjuvant to the direct treatment of the child. The local treatment of syphilitic symptoms is the same in the child as in the adult; but the utmost cleanliness should be main- tained and the affected parts be carefully preserved from contact with the urine and feces. INDEX. Abortion, 664 Abortive treatment of chancres, 404 of gonorrhoea, 56 Acetate of zinc injections, 69 Acne, 564 Adams, prostatitis, 139 Alopecia, 575 Alum injections, 70 • Amaurosis, 631 American origin of syphilis, 24 Anti-blennorrhagics, 72 Aphonia, 605 Aphthae, 591 Arabian treatment of syphilis, 499 Aromatic wine, 167 Astruc, diminished intensity of syphilis, 348 epochs of syphilis, 31 Auzias-Turenne, syphilization, 533 B Babington, induration, 378 Balanitis, 99 causes, 99 symptoms, 100 treatment, 100 Bassereau. engorgement of cervical gan- glia, 548 syphilitic virus, 332 incubation of general symptoms, 455 history of venereal diseases, 17, 25 prognostic value of suppuration in buboes, 435 Beadle, dry gonorrhoea, 46 Benzoic acid, 281 Bichloride of mercury, 518 Bigelow (Dr. H. J.), model bougies, 278 Bismuth injections, 71 Black wash, 418 Bladder, inflammation of, 146 puncture of, 318 in stricture, 258 Blancard's pills, 528 Blennorrhagia, 39 Blisters in gleet, 96 treatment of syphilis, 543 Blood, contagion of, 482 state of, 547 Boeck, syphilization, 535 Bones, affections of, 652 in infants, 676 effects of mercury, 515 Bonnet, extirpation of eye, 191 Bougies, 274 twisted, 274 bulbous and knotted, 276 model, 278 in gleet, 90 Bouisson, muscular tumors, 644 Boutonniere operation, 299 Brassavolus, history of syphilis, 28 Bridle stricture, 250 Brockedon's wafers, 63 Buboes, 426 gonorrhceal, 44 in women, 161 simple, 427 virulent, 427 indurated, 430 prognostic value of suppuration, 433 d'emblee, 437 treatment, 440 constitutional, 447 method of opening, 443 Buchanan's instrument, 289 Buck (Dr. Gurdon), perineal fascia, 232 Bullae, 561 Camphor, in chordee, 81 Canada turpentine, 80 Canquoin's paste, 414 Cantharides in gleet, 90 Capsules of copaiba, 76 Carbo-sulphuric paste, 414 Caries, 657 Carmichael, plurality of poisons, 330 682 INDEX. Castelnau, epididymitis, 115 Catheters, 272 curvature, 273 introduction, 276 Caustics in stricture, 291 Cazenave, incubation, 457 Cephalic chancre, 358 Chabalier, history of venereal, 17 Chancres, definition, 355 seat, 355 contagion, 358 form, 361 classification, 366 simple, 367 infecting, 369 Hunterian, 369 " parchemines," 376 complications, 386 inflammatory, 386 phagedenic, 387 diagnosis, 390 capable of spontaneous cicatrization, 395 " larves," 422 of urethra, 54, 422 of the fraenum, 421 of vagina, 424 of anus and rectum, 424 of mouth, 425 treatment, 3!>4 general, 395 abortive, 404 topical applications, 417 Chancroid, 367 definition of, 355 distinct from syphilis, 332 history of, 1!) Chlorate of potash, 513 Chloride of zinc injections, 69 Chordee, 43 treatment, 80 Choroiditis, 629 Circumcision, 107 Civiale's urethrotome, 297 Clerc, syphilitic virus, 338 Collyria, gonorrhceal ophthalmia, 188 Columbus, origin of syphilis, 24 Compressor urethrse muscle, 236 Condylomata, 581 Congenital syphilis, 660 etiology, 660 transmissibility, 663 period of development, 665 symptoms, 670 prognosis, 677 treatment, 678 Conjunctiva, syphilitic affections, 615 Consecutive symptoms defined, 354 Constitutional syphilis defined, 353 Contagion, mediate, 360 Copaiba, 72 formulae containing, 74 Copaiba, solidified, 75 capsules of, 76 dragees of, 76 by the rectum, 77 cutaneous eruptions, 77 action on kidneys, 77 Copper color, 551 Cornea, affections of, 615 Corpora cavernosa, 228 Corpus spongiosum, 227 Coryza, in infants, 670 Cubebs, 75 formulae containing, 76 Cullerier, mediate contagion, 360 tertiary enteritis, 600 Cystitis, 146 D Danielssen, syphilization, 541 De Baerensprung, classification of general symptoms, 466 Demarquay, vaginitis, 169 De Meric (Victor), incubation of general symptoms, 455 Depaul, changes in the lungs, 673 Destructive treatment of chancres, 410 Diday, abortive treatment, 408 bubo d'emblee, 438 incubation of general symptoms, 454 inoculation of blood, 483 self-limitation of syphilis, 495 deep urethral injections, 96 syphilization, 533, 540 unicity of syphilis, 350 syphilitic aphonia, 605 syphilitic orchitis, 640 gonorrhoea of the nose, 40 leucorrhceal origin of gonorrhoea, 50 Dilatation of strictures, 282 continuous, 287 rapid, 288 Donne, trichomonas, 152 Dry gonorrhoea, 46 Dubois, thymus gland, 672 Dupuytren's pomade, 577 Duverney's glands, 155 E Ear, affections of, 633 Ecthyma, 566 Elliot (Dr. Geo. T.), pelvic cellulitis, 163 Epididymitis, 114 causes, 115 seat, 117 symptoms, 120 pathological anatomy, 128 terminations, 121 INDEX. 683 Epididymitis, duration, 121 treatment, 130 Epilepsy, 648 Eruptions, syphilitic, 551 Erythema, 555 of mucous surfaces, 591 Exostosis, 655 Expansion of stricture, 290 Extravasation of urine, 323 Eyeball, protrusion of, 611 Eyelids, affections of, 614 Eyes, affections of, 611 F Fasciae, perineal, 228 Faye, syphilization, 538 Fever, syphilitic, 546 Fischer (Dr. H. E.), eruptions from iodine, 530 Fournier, etiology of gonorrhoea, 50 syphilitic virus, 341 Fraenum, chancres of, 421 French disease, 20 Fricke, strapping testicle, 132 Fumigations, mercurial, 505 G Ganglia, engorgement of, 548 Gangrenous chancre, 386 Gargles, 597 Gaussail, epididymitis, 123, 128 General syphilis, 450 always follows a chancre, 450 period of incubation, 452 classification, 460 contagiousness, 467 treatment, 494 Gibert, inoculation of secondary symp- toms, 468 Gleet, 83 symptoms, 84 pathology, 85 contagion, 85 treatment, 87 injections, 92, 95 blisters, 96 Godard, epididymitis, 126 Gonorrhoea, distinct from syphilis, 34 history of, 18 causes of, 46 nature of, 46 leucorrhceal origin of, 46 poison of, 55 in the male, 39 symptoms, 41 duration, 82 treatment, 55 in the female, 149 Gonorrhoea in the female, causes, 149 symptoms, 152 complications, 161 diagnosis, 163 treatment, 164 of the rectum, 39 • of the anus, 39 of the nose, 39 • from asparagus, 53 " virulenta," 422 Gonorrhceal ophthalmia, 175 causes, 177 symptoms, 180 diagnosis, 183 treatment, 183 rheumatic, 202 Gosselin, epididymitis, 124 hypertrophy of labia, 424 stricture of rectum, 601 Grassi, analysis of blood, 548 Graves, injection for gonorrhoea, 69 Gross, prostatitis, 140 Grunbeck, origin of syphilis, 21 Gubler, affection of liver, 674 Gummata, 586 H Hairion, gonorrhceal ophthalmia, 183 Halsted (Dr. T. M.), treatment of chan- cres, 401 Hancock, muscles of urethra, 226 stricture of urethra, 244 Hematuria, 263 Hemorrhage from urethra, 43, 81 Hereditary syphilis, 660 Hermann, effect of mercury upon the bones, 515 Huguier, glands of vulva, 154 Hunt, treatment of syphilis, 521 Hutchinson, infantile iritis, 625 circumcision, 103 notching of teeth, 616 Hydrocephalus, 677 Hygiene in syphilis, 497 I Impermeable stricture, 252 Impetigo, 565 Impotence from epididymitis, 124 Incision of stricture, 295 internal, 296 external, 299 Incubation of chancres, 370 of general syphilis, 452 Induration, 374 time of development, 377 duration of, 378 parchment, 376 684 INDEX. Infecting chancre, 369 incubation of, 370 forms of, 372 induration of, 374 usually single, 379 not auto-inoculable, 380 treatment, 395 Inflammatory chancre, 386 Injections, mode of using, 57, 67 objections to answered, 66 composition of, 68 in gleet, 92 for women, 165 intra-uterine, 173 Inoculation, artificial, 363 Intestines, affections of, 599 Inunction, mercurial, 508 " Inversions du testicule," 118 Iodide of iron, 528 Iodide of potassium, stricture, 281 Iodine, 524 unpleasant effects of, 529 eruptions from, 530 Iodism, 531 Iritis, 617 infantile, 625 J Jameson, perineal section, 301 John de Vigo, induration, 23, 374 K Keratitis, 615 L Lachrymal passages, affections of, 612 Lacuna magna, 224 Lafayette mixture, 74 Laryngitis, 606 Larynx, affections of, 605 Ledwich, chronic prostatitis, 141 Lee (Mr. Henry), infecting chancre, 3 Lente, perineal section, 302 Leroy d'Etiolles, twisted bougies, 275 Lichen, 557 Liver, affection of, 674 Lungs, affections of, 673 Lymphangitis, virulent, 429 Lymphatics, induration of, 436 inflamed in gonorrhoea, 44 M Maisonneuve, " cathetensme a la 290 Malapert and Reynaud, buboes, 442, 446 Maximilian I, decree "contra blasphe- mos," 21 Meot's pills, 76 Mercury, 500 in primary sores, 395 by fumigation, 505 by inunction, 508 salivation from, 510 effect upon the bones, 515 duration of treatment, 517 Milk, contagiousness of, 663 Milton, treatment of chordee, 81 treatment of gonorrhoea, 62, 70 Mixed chancre, 382 Mucous membranes, affections of, 590 Mucous patches, 579 developed from a chancre, 381 contagious, 482 treatment of, 585 in infants, 671 N Naples, origin of syphilis, 20 Necrosis, 657 Nerves, affections of, 647 Nitrate of silver injections, 57 Nitric acid, 413, 533 Nodes, 654 Nose, affections of, 603 Notta, muscular contraction, 642 0 Oesophagus, stricture of, 598 Onychia, 577 Opaline patches, 583 Orchitis, 635 Osteocopic pains, 653 Ovaritis, gonorrhceal, 162 P Panaris, 578 Pancreas, affection of, 677 Papules, 557 Paralysis of nerves of the eye, 631 Paraphymosis, 111 Parker (Mr. Langston), effect of iodine upon the tongue, 531 mercurial fumigation, 506 treatment of buboes, 445 Pelvic cellulitis, from gonorrhoea, 163 Pemphigus, 561, 672 Perineal section, 299 Perineal testicle, 126 Periosteum, affections of, 652 | in infants, 676 INDEX. 685 Periostitis, 654 Peritonitis, 676 Peters (Dr. Geo. A.), bulbous sounds, 275 Phagedena, not due to a distinct virus, 343 Phagedenic chancre, 387 prognostic value of, 389 treatment of, 396, 403, 415 Phillips, catheterism, 286 impermeable stricture, 253 gleet, 87, 90 Phymosis, 103 Piringer, gonorrhceal ophthalmia, 179 Pityriasis, 559 Plaques muqueuses, 579 Plenck's gummy mercury, 679 Poisons of gonorrhoea, the chancroid and syphilis, compared, 346 Pomades for the hair, 576 Porter (Dr. W. H.), contagiousness of the sperm, 487 Potassio-tartrate of iron, 418, 404 Pregnancy, vegetations, 221 Primary symptoms defined, 353 Probe-pointed catheter, 315 Prostatitis, acute, 137 chronic, 140 Prostatorrhcea, 140 Psoriasis, 559 Puche, induration, 378 auto-inoculation of chancre, 380 Pustules, 564 Pustulo-crustaceous eruption, 565 R Rectum, stricture of, 601 Resolvent ointment, 441 Retention of urine, 264 treatment, 312 Retinitis, 629 Rheumatoid neuralgia, 547 Ricord, abortive treatment of chancres, 405 artificial inoculation, 363 chlorate of potash, 513 classification of general symptoms, 460 duration of mercurial treatment, 520 engorgement of cervical ganglia, 548 incubation of general symptoms, 457 injections in gonorrhoea, 71 pad for buboes, 442 Rilliet, iodism, 531 Rinecker, inoculation of secondary symp- toms, 473 Rochoux, epididymitis, 119 Rollet, treatment of phagedena, 415 contagiousness of secondary symp- toms, 476 Rollet, distinction between gonorrhoea and syphilis, 33 gonorrhceal rheumatism, 195 mixed chancre, 384 Roseola, 556 Royet, "inversion du testicule," 118 Rupia, 562 Rupture of stricture, 291 S Saint Yves, gonorrhceal ophthalmia, 175 Salivation, mercurial, 510 Salmon, gonorrhoea of the vulvo-vaginal gland, 156 Sarsaparilla, 533 Scanzoni, vaginitis, 169 Scarlet fever, vaginitis, 151 Secondary syphilis, 460 Semen, contagiousness of, 486 Sigmund, abortive treatment of chancres, 405 epididymitis, 117, 119 incubation of general symptoms, 457 protiodide of mercury, 503 induration, 378 Simple chancre, 367. See Chancroid. Simpson, medicated pessaries, 170 Skey, origin of gonorrhoea, 51 Skin, affections of, 551 Smoking, in gonorrhoea, 65 Sounds, 274 bulbous, 275 Speculum vaginae, 157 Sperino, syphilization, 535 Spermatorrhoea, 143 Squamae, 559 Stearate of iron pomade, 418 Stewart's (Dr. F. C.) instrument, 60 Stricture of oesophagus, 598 Stricture of rectum, 601 Stricture of urethra, 222 transitory, 240 organic, 243 seat of, 246 number, 250 form, 250 pathology, 254 symptoms, 261 constitutional effects, 260 causes, 266 diagnosis, 271 treatment, 280 Sub-pubic curve, 239 Sulphate of zinc injections, 68 Suppuration of buboes, prognostic value, 433 Suspensory bandage, 61 Swelled testicle, 114 Syme, impermeable stricture, 252 perineal section, 299, 307 686 INDEX. Syphilis, history of, 20 Italian epidemic, 20 unicity of, 348 nomenclature of, 353 Syphilitic fever, 546 Syphilization, 533 Syphilodermata, 551 characteristics of, 551 classification of, 554 treatment of, 572 Syringes for urethral injections, 57 T Tendons, affections of, 642 Tertiary syphilis, 460 Testicle, syphilitic, 635 Thayer's fluid extracts, 533 Thiry, " granular virus," 55 Thompson, etiology of gonorrhoea, 51 length of urethra, 237 seat of stricture, 247 causes of stricture, 266 probe-pointed catheter, 315 urethrotome, 298 Thymus, affection of, 672 Tobacco in gonorrhoea, 65 Tongue, tubercles of, 594 Trachea, affection of, 608 Trichomonas, 153 Tubercles, 568 of the tongue, 594 of the lips, 595 Tyrrell, gonorrhoeal ophthalmia, 185 U Ulcers, 572, 591 Ulcus elevatum, 386 Urethra, anatomy of, 222 dimensions of, 236 curves of, 239 glands of, 224 Urethral fever, 310 Urinary abscess, 256 treatment of, 324 Urinary fistula, 256 Urine, retention of, 264 treatment, 312 V Vaccination, communication of syphilis, 483 Vaginitis, 157 Van Buren (Dr. W. H.), tertiary symp- toms in congenital syphilis, 465 Van Roosbroeck, gonorrhceal ophthalmia, 179 poison of gonorrhoea, 346 Van Swieten's liquid, 504 Vegetable decoctions and infusions, 532 Vegetations, 218 Vella, history of venereal, 26 Velpeau, epididymitis, 134 Venereal diseases, history of, 17 Vesicles, 560 Vetch, gonorrhoeal ophthalmia, 177 Vidal, epididymitis, 135 incubation of general symptoms, 458 Viennois, vaccination and syphilis, 483 Virchow, absorption, 347, 429 classification of general symptoms, 466 effect of mercury upon bones, 515 Virus, syphilitic, 327 duality of, 328 compared with other poisons, 346 Vulva, gonorrhoea of, 153 Vulvo-vaginal glands, 155 W Wade, caustics in stricture, 293 Wakley's instrument, 289 Waller, inoculation of secondary symp- toms, 483 West, stricture of oesophagus, 598 Whitlow, 578 Wilde, diseases of ear, 633 Wilks, pathology of affections of air-pas- sages, 593, 607 Williams (Dr. H. 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OWKN REESE AND ALFRED MARKWICK One S VOp1pUT6'0.rll12512,nO' CXtra C,°th> WUh B mv 'Si ^INICAL LECTURES ON SUR- GERY. 1 vol. 8vo. cloth. 350pp. 8125. AND SCIENTIFIC PUBLICATIONS BUMSTEAD (FREEMAN J.) M. D., Lecturer on Venereal Diseases at the College of Physicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. With illustrations on wood. In one very handsome octavo volume, of nearly 700 pages, extra cloth; $3 75. (Now Ready.) By far the most valuable contribution to this par- ticular branch of practice that has seen the light within the last score of years. His clear and accu- rate descriptions of the various forms of venereal disease, and especially the methods of treatment he proposes, are worthy of the highest encomium. In these respects it is better adapted for the assistance of the every-day practitioner than any other with which we are acquainted. In variety of methods proposed, in minuteness of direction, guided by care- lul discrimination of varying forms and complica tions, we write down the book as unsurpassed. It is a work which should be in the possession of every practitioner.— Chicago Med. Journal. Nov. 1861. Tne foregoing admirable volume comes to us, em- bracing the whole subject of syphilology, resolving many a doubt, correcting and confirming many an entertained opinion, and in our estimation the best, completest, fullest monogiaph on this subject in our language. As far as the author's labors themselves are concerned, we feel it a duty to say that he has not only exhausted his subject, but he has presented to us, without the slightest hyperbole, the best di- gested treatise on these diseases in our language. He has carried its literature down to the present moment, and has achieved his task in a manner which cannot but redound to his credit.—British American Journal, Oct. 1861. We believe this treatise will come to be regarded as high authority in this branch of medical practice, and we cordially commend it to the favorable notice of our brethren in the profession. For our own part, we candidly confess that we have received nany new ideas from its perusal, as well as modified many views which we have long, and, as we now think, erroneously entertained on the subject ot syphilis. To sum up all in a few words, this book is one which no practising physician or medical student can very well afTord to do without.—American Med. Times, Nov. 2, 1861. The whole work presents a complete history of venereal diseases, comprising much interesting and valuable material that has been spread through med- ical journals within the last twenty years—the pe- riod of many experiments and investigations on the subject—the whole carefully digested by the aid of the author's extensive personal experience, and offered to the profession in an admirable form. Its completeness is secured by good plates, which are especially full in the anatomy of the genital organs. We have examined it with great satisfaction, and congratulate the medical profession in America on the nationality of a work that may fairly be sailed original.—Berkshire Med. Journal, Dec. 1861. One thing, however, we are impelled to say, that we have met with no other book on syphilis, in the English language, which gave so full, clear, and impartial views of the important subjects on wnich it treats. We cannot, however, refrain from ex- pressing our satisfaction with the full and perspicu- ous manner in which the subject has been presented, and the careful attention to minute details, so use- fu I—not to say indispensable—in a practical i reatise. In conclusion, if we may be pardoned the use of a phrase now become stereotyped, butwhich we hero employ in all seriousness and sincerity, we do not hesitate to express the opinion that Dr. Bumstead's Treatise on Venereal Diseases is a " work without which no medical library will hereafter be consi- dered complete."—Boston Med. and Surg. Journal, Sept. 5, 1661. BARCLAY (A. W.),' M. D., Assistant Physician to St. George's Hospital, &c. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Second American from the second and revised London edition. In one neat octavo volume, extra cloth, of 451 pages. $2 25. (Now ready.) The demand for a second edition of this work shows that the vacancy which it attempts to sup- Cly has been recognized by the profession, and that the efforts of the author to meet the want have een successful. The revision which it has enjoyed will render it better adapted than before to afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For this latter purpose its complete and extensive Index renders it especially valuable, offering facilities for immediately turning to any class of symptoms, or any variety of disease. The task of composing such a work is neither an easy nor a light one; but Dr. Barclay has performed it in a manner which meets our most unqualified approbation. He is no mere theorist; he knows his work thoroughly, and in attempting to perform it, has not exceeded his powers.—British Med. Journal. We venture to predict that the work will be de- servedly popular, and soon become, like Watson|s Practice, an indispensable necessity to the practi- tioner.— N. A. Med. Journal. An inestimable work of reference for the young practitioner and student.—Nashville Med. Journal. We hope the volume will have an extensive cir- culation, not among students of medicine only, but practitioners also. They will never regret a faith- ful study of its pages.—CincinnatiLancet. An important acquisition to medical literature. It is a work of high merit, both from the vast im- portance of the subject upon which it treats, and also from the real ability displayed in ;ta elabora- tion. In conclusion, let us bespeak for this volume that attention of every student of our art which it so richly deserves — that place in every medical library which it can so well adorn.—Peninsular Medical Journal. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. A new and revised edition. By Alonzo Clari , M. D., Prof. of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, dec. In one octavo volume, of six hundred pages, extra cloth. Price $3 00- It is a work of great practical value and interest. containing much that is new relative to the several diseases of which it treats, and, with the additions of the editor, is fully up to the times. The distinct- ive features of the different forms of fever are plainly and forcibly portrayed, and the lines of demarcation carefully and accurately drawn, and to the Ameri- can practitioner is a more valuable and safe guide than any work on fever extant.—Ohio Med. and Surg Journal. This excellent monograph on febrile disease, has stood deservedly high since its first publication. It will be seen that it nas now reached its fourth edi- tion under the supervision of Prof. A. Clark, a gen- tleman who, from the nature of his studies and pur- suits, is well calculated to appreciate and discuss the many intricate and difficult questions in patho- logy. His annotations add much to the interest of the work, and have brought it well up to the condi- tion of the science as it exists at the present day in regard to this class of diseases.—Southern Med. and Surg. Journal. 0 BLANCHARD & LEA'S MEDICAL BARWELL (RICHARD,) F- R. C. S., Assistant Surgeon Charing Cross Hospital, kc. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- ings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $3 00. (Now Ready.) "A treatise on Diseases of the Joints equal to, or rather beyond the current knowledge of the dav ha«> long been required—my professional brethren must judge whether the ensuing pages may supply the deficiency No author is fit to estimate his own work at the moment of its completion, but it may be permitted me to say that the study of joint diseases has very much occupied my atten- tion, even from my studentship, and that for the in»t six or eight years my devotion to that subject has been almost unremitting.....Therenlweightofmyworkhasbeenatthebeds.de, and the greatest labor devoted to interpreting symptoms and remedying their cause. —Author s Prefack. At the outset we may state that the work is to be of much use to the practising surgeon who worthy of much praise, and bears evidence of much may be in want of a treatiBe on diseases of the jo i nts, thoughtful and careful inquiry, and here and there and at the same time one which contains the latest of no slight originality. We have already carntd information on articular affections and the opera- tes notice further than we intended to do, but not tions for their cure.—Dublin Med. Press, Feb. 27, to the extent the work deserves. We can only add,1 1861. that the perusal of it has afforded us great pleasure. | This volume will be welcomed, both by the pa- The author has evidently worked very hard at his | thologist and the surgeon, as being the record of subject, and his investigations into the Physiology and Pathology of Joints have been carried on in a manner which entitles him to be listened to with attention and respect. We must not omit to men- tion the very admirable plates with which the vo- lume isenriched. We seldom meetwith such strik- ing and faithful delineations of disease.—London Med. Times and Gazette, Feb. 9, 1861. much honest research and careful investigation into the nature and treatment of a most important class of disorders. We cannot conclude this notice of a valuable and useful book without calling attention to the amount of bon&firie work it contains. In the present day of universal book-making, it is no Blight matter for a volume to show laborious investiga- tion, and at the same time original thought, on the We cannot take leave, however, of Mr. Barwell, part of its author, whom we may congratulate on without congratulating him on the interesting \ the successful completion of his arduous task.— amount of information which he has compressed I London Lancet, March 9, 1861. into his book. The work appears to us calculated [ CARPENTER (WILLIAM BJ, M. D., F. R. S., &c, Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands, f 4 25. In the preparation of this new edition, the author has spared no labor to render it, as heretofore, a complete and lucid exposition of the most advanced condition of its important subject. The amount of the additions required to effect this object thoroughly, joined to the former large size of the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate them in his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- siology of Man, the work in its present condition therefore presents even greater claims upon the student and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter'sl To eulogize this great work would be superfluous. work has been considered by the profession gene- j We should observe, however, that in this edition rally, both in this country and England, as the most the author has remodelled a large portion of the valuable compendium on the subject of physiology former, and the editor has added much matter of in- in our language. This distinction it owes to the high ! terest, especially in the form of illustrations. We attainments and unwearied industry of its accom- | may confidently recommend it as the most complete plished author. The present edition (which, like the j work on Human Physiology in our language.— last American one, was prepared by the author him- Southern Med. and Surg. Journal self), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in conclud ing this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Phy- siology. Nothing need be said in its praise, for its merits are universally known ; we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Ckirurg. Review. >urg. The most complete work on the science in our language—Am. Med. Journal. The most complete work now extant in our lan- guage.—JV. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —N. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed bv any work in any department of medical science It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- The greatest, the most reliable, and the best book plTsurT to* evervTuZTof Pftv-fn^ th<5 l^f heBt AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taming the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $4 00; leather, $4 50. Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher, eminently qualify him to produce what has long been wanted—a good text-book on the practical use of the microscope. In the present volume his object has been, as stated in his Preface, " to combine, within a moderate compass, that information with regard to the use of his ' tools,' which is most essential to the working microscopist, with such an account of the objects best fitted for his study, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microsco- pists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to clinical medicine, together with an account of American Microscopes, their modifications and acceoories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it ia hoped, will adapt the volume more particularly to the use of the American student. Those who are acquainted with Dr. Carpenter's , medical work, the additions by Prof. Smith give it frevious writings on Animal and Vegetable Physio ogy, willfully understand how vast a store of know ledge he is able to bring to bear upon so comprehen- sive a subject as the revelations of the microscope j and even those who have no previous acquaintance with the construction or uses of this instrument, will find abundance of information conveyed in clear and simple language.—Med. Times and Gazette. Although originally not intended as a strictly a positive claim upon the profession, for which we doubt not he will receive their sincere thanks. In- deed, we know not where the student of medicine will find such a complete and satisfactory collection of microscopic facts bearing upon physiology and practical medicine as is contained in Prof. Smith's appendix; and this of itself, it seems to us, is fully worth the cost of the volume.—Louisville Medical Review. BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word "Elements" for that of " Manual," and with the author's sanction the title of " Elements" is still retained as being more expressive of the scope of the treatise. Those who have occasion for an elementary trea- tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. The best and most complete expose of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. To say that it is the best manual of Physiology now before the publ ic, would not do sufficient justice to the author.—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subjectof Physiology. In the present, he gives the essence, as it were, of the whole.—N. Y. Journal of Medicine. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp.752. Extra cloth, $4 80; leather, raised bands, $5 25. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and com- prehension of those truths which are daily being de- veloped in physiology .—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respectB— a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it is one no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general. critical, and unprejudiced view of those labors, ana of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable maimer in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.—Medical Times. BY the same author. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 9 BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D.t tec. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large volume, 8vo., leather, of over 750 pages. 93 25. (Just Issued, lSVJ.) In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect "a complete and faithful exposition o the pathology and therapeutics of the maladies incident tq the earlier stages of existence—a lull and exact account of trie diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough'revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of pnniitioners and observers have been tho- roughly incorporated, and that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reterence in infantile affections. A few notices of previous editions are subjoined. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has bren published, we still regard it in that light.—MedUal Examiner. The value of works by native authors on the dis- eases which the physician is called upon to combat, will be appreciated by all; an i the work of Dr. Con- die has gained for itself the character of a safe guide for students, and a useful work for consultation by those engaged in practice.—N. Y. Med. Times. This is the fourth edition of this deservedly popu- lar treatise. During the interval since the last edi- tion, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said bt fore, we do not know of a better book on diseases of chil- dren, and to a large part of its recommendations we yield an unhesitating concurrence.—Buffalo Med. Dr. Condie's scholarship, acumen, inductry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment. Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction__Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—iV. V. Journal of Medicine. A veritable pediatric encyclopaedia, and an honoi to American medical literature.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, bat aa the vert best "Practical Treatise on the I Journal. Diseases of Children."—American Medical Journal Perhaps the mostfull and complete work now be- In the department of infantile therapeutics, the fore the profession of the United States; indeed, we work of Dr. Condie is considered one of the best may say in the English language. It is vastly supe- which hue been published in the English language, rior tomostof its predecessors.—Transylvania Med. —The Stethoscope. \Journal CHRISTISON (ROBERT), M. D., V. P. R. S. E., &.C. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS.—Edited by Beansby B. Coofk*, F. R. S., &c. With additional Ob- servations by Prof. J. C. Waeren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. S3 25. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial Svo., extra cloth, with 252 figures, on 36 plates. «2 50. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., ex- tra cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 80 cents. CLYMER ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT In one octavo volume, leather, of 600 pages. 91 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Mkigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. dd. 720 83 50. vy CARSON (JOSEPH), M. D.. Professor of Materia Medica and Pharmacy in the University of Pennsylvania SYNOPSIS OF THE COURSE OP LECTURES ON MATERIA' MEDICA AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- turn. In one very neat octavo volume, extra cloth, of 208 pages. $150. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunterian Society ice A PRACTICAL TREATISE ON DISEASES OP THE TESTIS SPERMA TIC CORD, AND SCROTUM. Second American, from the second and ^nlrged Sfet tion. In one handsome octavo volume, extra cloth, with numerous illustrations pp 420 *2 00 AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 194 illustrations In one very handsome octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) This work has lieen so long an established favorite, both as a text-book for the learner and as a reliable aid in consultation lor the practitioner, that in presenting a new edition it is only necessary to call attention to the very extended improvements which it has received. Having had the bene fit of two revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been t ho- roughly brought up with the latest results of European investigation in all departments of the sci- ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelf y for the American editor to introduce, but he has endeavored to insert whatever has since appeared, together with such matters as his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. Tne result of all these additions is that the work now con- tains fully one-half more matter than the last American edition, with nearly one-half more illus- trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction; the opinion of all writers of authority is given on questions of diffi- culty, as well ns the directions and advice of the learned autiior himself, to which he adds the result of statistical inquiry, putting statistics in their pio per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It ap- pears to be written with the true design of a book on medicine, viz: to give all that is known on the sub- ject of which he treats, both theoretically and prac- tically, and to advance such opinions of his own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Chur- cnill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the student, and we hope it may be extensively pur- chased amongst our readers. To them we most Btrongly recommend it. — Dublin Medical Press, June 20,1860. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everythingrelating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. by the same author. (Lately Published.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject acce«sible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size o/ the work. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. The most popular work on midwifery ever issued rrom the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but »n« work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the greatamountof statistical researeh which it contains, have served to place it in the first rank of works in this departmentof medical science. —N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for ths frequent consultation of the young practitioner. — American Medical Journal. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD) M. D., M. R. I. A., tec. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condik, M.D., author ot "A Practical Treatise on the Diseases of Children." With nume- rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions us ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most ex- | extent that Dr. Churchill does. His, indeed, is the act and comprehensive expositions of the present only thorough treatise we know of on the subject; stateof medical knowledge in respect to the diseases and it may be commended to practitioners and stu- of women that has yet been published.—Am. Journ. ' dents as a masterpiece in its particular department. Med. Sciences. j —Thi Western Journal of Medicine and Surgery. This work is the mOBt reliable which we possess As a comprehensive manual for students, or a on this subject; and is deservedly popular with the | work of reference for practitioners, it surpasses any profession.—Charleston Med. Journal, July, 1857. , other that has ever issued on the same subject float We know of no author who deserves that appro- the British press.—Dublin Quart. Journal. bation, on "the diseases of females," to the same I DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thcra- peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume of 750 pages, leather. $3 75. (Just Issteed.) The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) A work which like Druitt's Surgery has for so many years maintained the position of a lead- ing favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artistical execution of the work which, printed in the best style, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. vucupcoi This popular volume, now a most comprehensive ! nothing of real practical importance has been omit- work on surgery, has undergone many corrections, , tea ; ^presents a faithful epitome of everythinTre improvements, and additions, and the principles and , luting t> surgery up to the n esent hour YIt ?s de he EtreVoraand'bser^thfn11 cTthSn' *°T " Ktfa a P°Pular manual botl with 'the t'uden m^ery ^ I MMi P™™">»er.-London Lancet, Nov. 19, 1859. descriptions are so clear and concise, and theillus- ' In closing this brief notice, we recommend as cor- trations so accurate and numerous, that the student dially as ever this most useful and comprehensive can have no difficulty, with instrument in hand, and hand-book. It must prove a vast assistance not book by his side, over the dead body, in obtaining on,y t0 tne student of surgery, but also to the busy a proper knowledge and sufficient tact in this much practitioner who may not have the leisure to devote neglecteddepartmentofmedicaledueation.—British 1 himself to the study of more lengthy volumes — and Foreign Medico-Chirurg. Review, JantlSflO | London Med. Times and Gazette, Oct. 22 1859. In the present edition the author has entirely re- I In a word this ei«rhth eriiti™. ««■ t>, r» ■;., written many of the chapter, and ha. incorporated ManualTlurgery i.ll that he suLfcal Sad!.. the various .mprovemenls ana additions ,n modern or practitioner could desire. -DrilVn OwrUril surgery. On carefully going over it, we find that. Jou,nal of Med. Sciences, Nov. Ib59. VuarUrl* AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $4 00; leather, raised bands, $4 50. (Just Issued, 1861.) The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Im- bibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and the work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is in- tended It will be seen, therefore, that Dr. Dalton's best efforts have been directed towards perfecting his work. The additions are marked by tne same fea- tures which characterize the remainder of the vol- ume, and render it by far tlic most desirable text- book on physiology to place in the hands of the student which, so far as we are aware, exists in the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's book for the classes for which it is intend- ed, satisfied as we are that it is better arapted to their uee than any other work of the kind to which they have access.—American Journal of the Med. Sciences, April, 1861. It is, therefore, no disparagement to the many books upon physiology, most excellent in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the cur- rent year. It states in comprehensive but concise diction, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from the discussion of unsettled or theoretical points. Herein it is unique; and these characteristics ren der it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physi- ology thus presented that lies at the foundation of correct pathological knowledge; and this in turn is the basis of rational therapeutics ; so that patholo- gy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. —Cincinnati Lancet, May, 1861. Dr. Dalton needs no word of praise from us. He is universally recognizea as among the first, if not the very first, of American physiologists now living. The first edition of his admirable work appeared but two years since, and the advance of science, his own original views and experiments, together with a desire to supply what he considered some deficien- cies in the first edition, have already made the pre- sent one a necessity, and it will no doubt be even more eagerly sought for than the first. That it is not merely a reprint, will be seen from the author's statement of the following principal additions and alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admira- ble tor their clearness in expressing exactly what their author intended.—Boston Medical and Surgi- cal Journal, March 28, 1861. It is unnecessary to give a detail of the additions; suffice it to say, that they are numerous and import- ant, and such as will render the work still more valuable and acceptable to the profession as a learn- ed and original treatise on this all-important branch of medicine. All that was said in commendation of the getting up of the first edition, and the superior style of the illustrations, apply with equal force to this. No better work on physiology can be placed in the hand of the student.—St. Louis Medical and Surgical Journal, May, 1861. These additions, while testifying to the learning and industry of the author, render the book exceed- 1 ingly useful, as the most complete expose of a sci- . ence, of whieh Dr. Dalton is doubtless the ablest l representative on this side of the Atlantic.—New Orleans Med. Times, May, 1861. A second edition of this deservedly popular work having been called for in the short space of two years, the author has supplied deficiencies, which existed in the former volume, and has thus more completely fulfilled his design of presenting to the profession a reliable and precise text-book, and one which we consider the best outline on the subject of which it treats, in any language.—N. American Medico-Chirurg. Review, May, 1861. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *** This work contains no less than four hundred and eighteen distinct treatises, contributed by ■ixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day__as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a The editors are practitioners of established repu- tation, and the list of contributors embraces many of the most eminent professors and teachers of Lon- don. Edinburgh, Dublin, and Glasgow. It is, in- deed, the great merit ot this work that theprincipal articles have been furnished by practitioners who have not only devoted especial attention to the dis- eases about which they have written, but have also enjoyed opportunitiec for an extensive practi- cal acquaintance with them and whose reputation carries the assurance of their competency justly to work for ready and frequent reference, one in which | appreciate the opinions ol others, while it stamps modem English medicine is exhibited in the most their own doctrines with high and just authority.— advantageous light.—Medical Examiner. I American Medical Journal. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections. In one octavo volume, extra cloth, of600 pages. S3 20. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. The last edition. In one volume, octavo, extra cloth, 548 pages. $2 80 DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. $3 00 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, Arc. Notices'of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, Arc. With French and other Synonymes. Revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, ia small type ; Btrongly bound in leather, with raised bands. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the page. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care hns been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. tells us in his preface that he has added about Bi4 thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language.—Silliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universnlly acknowledged, we believe, that this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louts Med. and Surg. Journ.. Jan. 1858. ' It is the foundation stone of a good medical libra- ry, and should always be included in the first list of books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly the most perfect in the English language__Med. and Surg. Reporter, Jan. 1858. It is now emphatically the Medical Dictionary of the English language, and for it there is no substi- tute.— N. H. Med. Journ., Jan. 1858. It is scarcely necessary to remark that any medi- cal library wanting a copy of Dumrlison's Lexicon must be imperfect.—Cin. Lancet, Jan. 1858. We have ever considered it the bestauthority pub- lished , and the present ed ition we may safely say has no equal in the world.—Peninsular Med. Journal. Jan.1858. ' The most complete authority on the subject to be found in any language.— Va. Med. Journal, Feb. '88. This work, the appearance of the fifteenth edition of which, it has become our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use nf the pre- ceding editions, where we have never failed to find a sufficiently full explanation of ever) medical term, that in this edition " about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is withoutdoubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison and competition__Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, may be Baid to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation ' and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical j Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, ' are the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example i is something appalling to contemplate. The author ', BY THE SAME AUTHOR. THE PRACTICE OP MEDICINE. A Treatise on Special Pathology and Tb©. rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25. AND SCIENTIFIC PUBLICATIONS. IJ DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- plete repertory of facts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.—Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a poi ice t mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.—Nashville Journ. of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the great encyclopaedia on the subject, and worthy of a place in every phy- sician's library.—Western Lancet. BY the same AUTHOR. (A new edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. In announcing a new edition of Dr. Dunglison's General Therapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he has made to the work, and the careful re- vision to which he has subjected the whole.—N. A. Medico-Chir. Review, Jan. 1858. The work will, we have little doubt, be bought and read by the majority of medical students j its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful as a work of refer- ence. The young practitioner, more especially, will find the copious indexes appended to this edizion of great assistance in the selection and preparation of suitable formulas.—Charleston Med. Journ. and Re- view, Jan. 1858. by the same author. (A new 'Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the " New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection ; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.—Preface. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to •nhanceits value.—New York Med. Gazette. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire te examine the original papers.—The American Journal of Pharmacy. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. (Preparing.) 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, Ac. TnE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical iNjTThiKs, Diseasfs. and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, leather, raised bands. $4 50 (Just Issued.) The verv di-t,neui«hed favor with which this work has been received on both sides of the Atlan- tic hn- stimulated the author to render it even more worthv of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pases, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little ha> been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. step of the operation, and not deserting him until the final issue of" the case is decided —Sethoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapterfull and explicit, each It is, in cur humble judgment decidedly the best book of the kind m the English language. Strange that just such hooks are noioftener produced by pub- lic teachers of surgery in this country and Greal Britain Indeed, it is a matter of great astonishment. hut no less true than astonishing, that of the many work? on surgery republished in this country within the la«t fifteen or twenty years a« text-books for medical students, this is the only one that even ap subject faithfully exhibited, we can only express out estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and proximates to the-fulfilment of the peculiar wants of j with great pleasure we add it to our text-books.— youngmen just entering upon the study of this branch of the profe--;on.— Western.Tour, of Med. ami Surgery. lis value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable cotitributions to modern surgery. To one entering his novitiate of practice, we regard it the most serviceable guide which he can consult. He j for information, both to physician and surgeon, in ths will find a fulness of detail leading him throLgh every I hour of peril.—iV. 0. Med. and Surg. Journal. Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING/THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We regard it, in point both of arrangement and of the marked ability of its treatment of the subjects, as destined to take the first rank in works of this class. Sn far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the diagnosis of doubtful ciiurs, and in shedding light upon difficult phenomena.—Buffalo Med. Journal. A work of original observation of the highest merit. We recommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon cases numerically examined, it carries the evidence of careful study and discrimina- tion upon every page. It does credit to the author, and, through him, to the profession in this country. It is, what we cannot call every book upon auscul- tation, a readable book.—Am. Jour. Med. Sciences. by the same author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $2 75. great force and beauty, and, with his previous work. places him at the head of American writers upon diseases of the chest. We have adopted his work upon the heart as a text-book, believing it to be more valuable for that purpose than any work of the kind that has yet appeared .—Nashville Med. Journ. We do no' know that Dr. Flint has written any- thing which is not first rate ; but this, his latest con- tribution to medical literature, in our opinion, sur- passes all the others. The work is most comprehen- sive in ir.- scope, and most sound in the views it enun- ciates. The descriptions are clear and methodical; the statements are substantiated by facts, and are made with such simplicity and sincerity, that with- out them they would carry conviction. The style 16 admirably clear, direct, and free from dryness With Dr. \V alshe'8 excellent treatise before us, we have no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language —Boston Med. and Surg. Journal. We have thus endeavored to present our readers with a fair analysis oi this remarkable work. Pre- With more than pleasure do we hail the advent of this work, for it fills a wide gap on the list of text- books for our schools, and is, for the practitioner, the most valuable practical work of its kind.__N. O. Med. News. In regard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and ju- dicious. Considering the present state of science such a work was much needed. It should be in the ferring to employ the very words of thedistinguished I hands of every practitioner —Chicago Med. Journal. author, wherever it was possible, we have essayed But these are very trivial spots, and in no wise to condense into the briefest spucea general view of prevent us from declaring our most hearty anoroval his observations and suggestions, and to direct the of the author's ability, industry, and conscientious attention of our brethren to the abounding stores of ness.—Dublin Quarterly Journal of Med. Sciences He haslabored on with the same industry and care and his place among theirs* authors of our country isbecoming fully established. To this end, the work whose title is given above, contributes in no small degree. Our spa^e will not admit of sn extended analysis, and we will clost this orief notice by valuable matter here collected and arranged for their use and instruction. No medica1 library will here sfter be considered complete without this volume ; and we trust it will promptly find its way into the hands of every American student and physician__ A' Am. Med. Chir. Review. This last work of Prof. Flint will add much to mis last worn ot frot. I lint will add much to commending it without reserve to every class of his previous well-earned celebrity, as a writer of | readers in the profession.-Peninswfar Med. Journ. AND SCIENTIFIC PUBLICATIONS. 15 FOWNES (GEORGE), PH. D., See. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. From the seventh revised and corrected London edition. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo volume, of 600 pages. In leather, $1 65; extra cloth, $1 50. (Just Issued.) The death of the author having placed the editorial care of this work in the practised hands of Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The addition* requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been u>ed to muintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- ment of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedingly clear type the matter of a large octais been received. Every portion has been subjected to close examination and revision ; any defi- ciencies apparent have been supplied, and the results of recent progress in the science and'art of mrgeiy have been everywhere introduced; while the series of illustrations has been enlarged by the addition of nearly tlnee hundred wood-cuts, rendering it one of the most thoroughly illustrated work- ever laid belore the profession. To accommodate these very extensive additions, the work has been printed upon a smaller type, so that notwithstanding the very large increase in the matter and value of the book, its size is more convenient and less cumbrous than before. Every care has been taken in the printing to render the typographical execution unexceptionable, and it is confi- dently presented as a work in every way worthy of a place in even the most limited library of the p acutioner or student. ' A few testimonials of the value of the former edition are appended. Has Dr. Gross satisfactorily fulfilled this object? ,.,..br..i ..«*..««! ,.f i—____i______________i_i-____._ A mi etui perusal of his volumes enables us to give an answer in the affirmative. Not only has he given to the render an elaborate and well-written account of his oyn vait experience, but he has not failed to embody in his pages the opinions and practice of surireons in this and other countries of Kurope. The result has been a work of such completeness, that it his no superior in the systematic treatises on Bur- gen which have emanated from English or Conti- nental authors. It has been justly objected that these have been far from complete in many essential particulars, many of them having been deficient in some of the most important points which should characterize such works Some of them have been elaborate—too elaborate—with respect to certain dmeases, while they have merely glanced at, or given an unsatisfactory account of, others equally important to the surgeon. Dr. Gross hus avoided thiserror, and has produced the most complete work that has yet issued from the press on the science and practice of surgery. It is not, strictly Bpeaking, a Dictionary of Scarry, buc it gives to the reader all the information rh if Ii- may requin for his treatment of surgieal diseases. Having said so much, it might apnear superfluous to add another w »rd ; but it is only due to Dr. Grois to state that he has embraced the opportunity of transferring to his pHges a vast number of engravings from English and other au- tnors, illustrative ot the pathology anil treatment of surgical diseases. To these are added several hun dred original wood-cuts The work altogether com- mends itself to the attention of British surgeons, from whom it cannot fail to meet with extensive patronage.—London Lancet, Sept. 1, 1800. Of Dr. Gross's treatise on Surgery we can say I no more than that it is the most elaborate and eom- j plete work on this branch of the healing art which has ever been published in any country. A sys- tematic work, it admits of no analytical review; but, did our space permit, we should gladly give some extracts from it, to enable our readers to judge of the classical style of the author, and the exhaust- ing way in which each subject is treated.—Dublin Quarterly Journal of Med. Science. The work is so superior to its predecessors in matter and extent, as well as in illustrations and style of publication, that we can honestly recom- mend it as the best work of the kind to be taken home by the young practitioner__Am. Med. Journ. With pleasure we record the completion of this long-anticipated work. The reputation which the author has for many years sustained, both as a Pur- geon and as a writer, had prepared us to expect a treatise of great excellence and originality: but we confess we were by no means prepared for the work which is before us—the most complete treatise upon surgery ever published, either in this or any otn. r country, and we might, perhaps, safely say, the most original. There is no subject belonging pro- perly to surgery which has not received from the author a due share of attention. Dr. Grots has sun- plied a want in surgical literature which has long been fe t by practitioners; he has furnished us with a complete practical treatise upon surgery in all its departments As A meric ins, we are proud of the achievement; as surgeons, we are most sincerely thankful to him for his extraordnary labors in our behalf.—N. Y. Monthly Review and Buffalo Med ELEMENTS OP PATHOLOGICAlTnATOMY. Third edition thorough, Price in extra cloth, jffi; ttE^btdt J** '&Z SUSS,^1 dt^^ J*r£Z£^Z££ motion °off^ist^r1 "T^ «""?* the last few J™ *™ nent of the present stateoF?h™ subject The ££?« 'af*.* * VWW °f Tkin% il a correct e*P°- executed.and the amount of3tera1& whic^t h!7nn^imarer '" Zhlf\thi« task has »*« » with the many changes and KrowmenN now^n^ ^T,'i.haVe e."abled the author to S&V th*« a new treatise/ while the efforToffhTautho.hi S' ^ T^ may * re*arded almost " execution of the volume, renderinglttVof^ infest» .^I^J'^rejy congratulate the author on the We have been favorably impret'd w th t'h g 1- ral manner in which Dr. drossI has executed hifSS l?5ofdtr.a/°mprehen8ive dif?e8t ot the preset have much n frature.of Pathological Anatomy, and nave much pleasure m recommending his work to our readers, as we believe one we/de.ervhig of ctr,Seepri8l7nd CarefUl *My~*»«r*a?Me1. ^H^W ?eatiseBonf6re7ghnorbodies in the air pas. SAGES. In one handsome octavo volume, extra cloth, with illuatrations. ,££* W J^ successful manner in which he has accomplished his proposed object. His book is most admirably cal- culated to fill up a blank which has long beenfelt to exist in this department of medical literature, and as such must become very widely circulated amongst all classes of the profession.-Dublin Quarterly Journ.of Med. Science, Nov. 1857. * AND SCIENTIFIC PUBLICATIONS. 17 GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, tec. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. In leather, raised bands, $5 25; extra cloth, $4 75. Philosophical in its design, methodical in its ar- ' agree with us, that there is no work in the English rangement, ample and sound in its practical details, I language which can make any just pretensions to it may in truth be said to leave scarcely anything to be its equal.—N. Y. Journal of Medicine. be desired on so important a subject.—Boston Med. and Surg Journal. Whoever will peruse the vast amount of valuable practical information it contains, will, we think, A volume replete with truths and principles of the utmost value in the investigation of these diseases.— American Medical Journal. GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, Ice. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather, raised bands, $7 00. (Now Ready, 1802.) The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- cution have been found to present superior practical advantages in facilitating the study of Anato- my. In presenting it to the profession a second time, the author has availed himself of the oppor- tunity to supply any deficiencies which experience in its use had shown to exist, and to correct any errors of detail, to which the first edition of a scientific work on so extensive and complicated a science is liable. These improvements have resulted in some increase in the size of the volume, while twenty-six new wood-cut* have been added to the beautiful series of illustrations which form so distinctive a feature of the work. The American edition has been passed through the press under the supervision of a competent professional man, who has taken every care to render it in all respects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired to exist in this country. Mr. Gray writes through- out with both branches of his subject in view. His description of each particular part is followed by a notice of its relations to the parts with which it is connected, and this, too, sufficiently ample for all the purposes of the operative surgeon. After de- scribing the bones and muscles, he gives a concise statement of the fractures to which the bones of the extremities are most liable, together with the amount and direction of the displacement to which the fragments are subjected by muscular action. The section on arteries is remarkably full and ac- curate. Not only is the surgical anatomy given to every important vessel, with directions for its liga- tion, but at the end of the description of each arte- rial trunk we have a useful summary of the irregu- larities which may occur in its origin, course, and termination.—N. A. Med. Chir. Review, Mar. 1659. Mr. Gray's book, in excellency of arrangement and completeness of execution exceeds any work on anatomy hitherto published in the English lan- With little trouble, the busy practitioner whose knowledge of anatomy may have become obscured by want of practice, may now resuscitate his former anatomical lore, and be ready for any emergency. It is to this class of individuals, and not to the stu- dent alone, that this work will ultimately tend to be of most incalculable advantage, and we feel sat- isfied that the library of the medical man will soon be considered incomplete in which a copy of this work does not exist.— Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and eularged, and contains several new illustrations by Dr. Westma- cott. The volume is a complete companion to the dissecting-room, and saves the necessity of the stu dent possessing a variety of " Manuals."—The Lon- don Lancet, Feb. 9, 1861. The work before us is one entitled to the highest praise, and we accordingly welcome it as a valu- able addition to medical literature. Intermediate in fulness of detail between the treatises of S.iar pey and of Wilson, its characteristic merit lies in I guage, affording a complete view of the structure of tne number and excellence of the engravings it ! the human body, with especial reference to practical contains. Most of these are original, of much I surgery. Thus the volume constitutes a perfect book larger than ordinary size, and admirably executed, of reference for the practitioner, demanding a place The various parts are also lettered after the plan in even the most limited library of the physician or adopted in Holden's Osteology. It would be diffi- ! surgeon, and a work of necessity for the student to cult to over-estimate the advantages offered by this fix in his mind what he has learned by the dissecting mode of pictorial illustration. Bones, ligaments, knife from the book ofnature.—The Dublin Quar- muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names; thus enabling the student to comprehend, at a glance, what would otherwise often be ignored, or at any rate, acquired only by prolonged and irksome ap- plication. In conclusion, we heartily commend the work of Mr. Gray to the attention of the medical profession, feeling certain that it should be regarded as one of the most valuable contributions ever made to educational literature— N. Y. Monthly Review. Dee. 1859. In this view, we regard the work of Mr. Gray as far belter adapted to the wants of the profession, and especially of the student, than any treatise on anatomy yet published in this country. It is destined. we believe, to supersede ill others, both as a manual of dissections, and a standard of reference to the student of general or relative anatomy. — N. Y. Journal of Medicine, Nov. 1859. For this truly admirable work the profession is indebted to the distinguished author of "Gray on the Spleen." The vacancy it fills has been long felt terly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present, volume cannot but present many ad- vantages to the student of anatomy. To the zealous disciple of Vesalius, earnestly desirous of real im- provement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simply desirous of "cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of their development. The study of these parts is thus made one of comparative ease, if not of positive pleasure: and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work of reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.—Am. Journ. Med. Sci., July, 1859. IS BLANCHARD & LEA'S MEDICAL GMISO.VS INSTITUTES AND PRACTICE OF Sl'RGERY. Eighth edition, Improved and al tertd. With thirty-four plates. In two handsome octavo volumes, containing about 1,000 pages, j leather, raised band'. 96 50. I BARDNER'S MEDICAL CHEMISTRY, fer the use of Students and the Profession. In one royal 12mo. vol.. cloth, pp. 396, with wood cuts SI. GLl'GES ATLAS OF PATHOLOGICAL HIS- TOLOGY. Translated, with Notes and Addi- I tions. by Joseph Lkidy, M O. In one vo ume, »e"large imperial quarto, extra cloth, wiM MO copper plate figures, plum and colored, 85 00. unrHKS' INTRODUCTION TO THE PRAC- TICK OK AUSCUl.TA.ION ANh OTHER MODE90F PHYSICAL DIAGNOSIS IN DIS- EASES OF THE LUNGS AND HEART fee- cond edition 1 vol. royal lamo., ex. cloth, pp. 304. 81 00. HAMILTON (FRANK H.), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. In one large and handsome octavo volume, of over 750 pages, with 289 illustrations. $4 25. (Now Ready, January, l$t30.) Among the many good workers at surgery of whom America may now boast rot the least is Frank Hast- ings Hamilton; and the volume before us is (we say it with a pang of wqunded patriotism) the best and handiest book on the subject in the English lan- guage. It is in vain to attempt a review of it; nearly as vain to seek for any sins, either of com- mission or omission. We have seen no work on practical surgery which we would sooner recom- mend to our brother surgeons, especially those of opinion may be gathered as to its value.—Bosom Medical and Surgical Journal, March 1, 1860. The woTk is concise, judicious, and accurate, and adapted to the wants of the student, practitionei, and investigator, honorable to the author and to the profession.—Chicago Med. Journal, March, 1860. We regard this work as an honor not only to its author, but to the profession of our country. Were we to review it thoroughly, we could not convey to .. in i,.nun;nnnn.,„ k..i___h <■ ordinary conknlhition.-Cha'rleston Med. Journ. Hobl>n'f Dictionary has long been a favorite with ,„ ... »»»"». Ui It is the best book of definitions we have, and We know of no dictionary better arranged and ought always to be upon the student's table — adapted. It is not encumbered with theobsoleteterms I Southern Med. and Surg. Journal. of a bygone age, but it contains all that are now in { H?H'.rSmv«MILDICAir ?l0TiS a-SK^\ T°LOGY- Eighth edition. Extensively revised FLKCTIO.NS. From the third London edition. and modified. In two large octavo volumes ex In one handsome octavo volume, extra cloth. 83. tra cloth, of more than 1000 pages, with over 300 HORXER'S SPECIAL ANATOMY AND HIS- illustrations. $6 00. AND SCIENTIFIC PUBLICATIONS. 19 HODGE (HUGH L.), M. D., Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &c. ON DISEASES PECULIAR TO WOMEN, including Displacements of the TJlerus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 pages, extra cloth. $3 25. (Now Ready.) priate management—his ample experience, his ma- tured judgment, and his perfect conscientiousness— invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim.— Am. Journ. Med. Sciences, Jan. 1861. Indeed, although no part of the volume is not emi- nently deserving of perusal and study, we think that the nine chapters devoted to this subject, are espe- cially so, and we know of no more valuable mono- graph upon the symptoms, prognosis, and manage- ment of these annoying maladies than is constituted by this part of the work. We cannot but regard it as one of the most original and m >st practical works of the day: one which every accoucheur and physi- cian should most carefully reid; for we are per- Buaded that he will arise from its perusal with new ideas, which will induct him into a more ratiomtl practice in regard to many a suffering female, who may have placed her health in his hands.—British American Journal, Feb. 1661. Of the many excellences of the work we will not speak at length. W* advise ail who would acquire a knowledge of the proper management of the mala- dies of which it treats, to study it with care. The Becond part is of itself a most valuable contribution to the practice of our arc.—Am. Med. Monthly and New York Review. Feb. 1861. We will say at once that the work fulfils its object capitally well j and we will moreover venture the Bssertiou that it will inaugurate an imnroved prac- tice throughout this whole country. The secretsof the author's success are so clearly revealed that the attentive student cannot fail to insure a goodly por- tion of similar success in his own practice. It is a credit to all medical literature; and we add, that the physician who does not place it in his library, and who does not faithfully con'its pages, will lose a vast deal of knowledge that would be most useful to himself and beneficial to his patients. It is a practical work of the highest order of merit; and it will take rank as such immediately.—Maryland and Virginia Medical Journal, Feb. 1861. This contribution towards the elucidation of the pathology and treatment of some of the diseases peculiar to women, cannot fail to meet with a favor- able reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obt-euiity; the amount, of malaise and even of actual suffering by which they are invariably attended; their obstinacy, the difficulty with which they are overcome, and tleir disposition again and again to lecur—these, taken in connection with the entire competency of the author to render a correct ac- count of their nature, their causes, and their appro- The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, CESOPHAGUS, STOMACH, O/ECTJM, AND INTES- TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra cloth $1 75. (Now Ready.) JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. JONES (C. HANDFIELD), F.R.S., &. EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. $3 75. obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work As a concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy,it is perhaps the best work in the English language; Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.—Western Lancet. KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A new American, from the third and Improved London edition. With two hundred illustrations. In one large and handsome royal 12mo. volume, leather, pp. 586. $2 00. (Lately Published.) This is a new and very much improved edition of Dr. Kirkes' well-known Handbook of Physiology. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.—Dublin Quarterly Journal. One of the very best handbooks of Physiology we possess—presenting just such an outline of the sci- ence as the student requires during his attendance upon a course of lectures, or for reference whilst preparing for examination.— Am. Medical Journal Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs. Kirkes and Paget, have the gift of telling us what we want to know, without thinking it necessary to tell us all they know— Boston Med and Surg. Journal. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know.—Charleston Mid. Journal. 20 BLANCHARD & LEA'S MEDICAL KNAPP'S TECHNOLOGY; or,Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richardson, and Prof. W. R. Johnsom. In two handsome 8vo. vols., with about 600 wood-engravings. 86 00. LAYCOrK'S LECTURES ON THE PRINCI- PLES AND METHODS OF MEDICAL OB- SERVATION AND RESEARCH. For the Use of Advanced Students and Junior Practitioners. In one royal 12mo. volume, extra cloth. Price81. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by Henry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESICULAE SEMINALES; and their associated organs. With special refer- ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) LA ROCHE (R.), M. D., &.c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. From Professor S. H. Dickson, Charleston, S. C, September 18, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is qestined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will be very gene- rally read in the south.—Memphis Med. Recorder. by day and by night, in the work of combating this very disease, now prevailing in our city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. LAWRENCE (W.), F. R. S., «tc. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. LUDLOW (J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, leather, of 816 large pages $2 50. We know of no better companion for the student I crammed into his head by the various professors to r«ni.nB ♦ i UfB spLent m the lecture room>or t0 re- whom he is compelled to listen.—Western Lancet, iresd, at a glance, his memory of the various topics May, 1857 LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by ?uG mEj Dil;Y,\M- D-' F- R- S' &c> edited by R- E- Rogers, M. D., Professor of Chemistrv aZ j 0f PhyM0 °?,cal Chemi8try. and an Appendix of plates. Complete in two large tTations fm6e0°0CtaV° ^^^ "*" d°th' ^^"OOPVi. with nearlyPtwo hunaTed illus* The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which it treats.—Edinburgh Journal of Medical Science The most important contribution as yet made to Physiological Chemistry—Am. Journal Med. Sci- ences, Jan. 1856. by the same author. (Lately Published.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German with Notes and Additions, by J. Cheston Morris M D with . i„," ^ . » merman. Force, by Profe^or Samuel Jackson, M D° of the UniveTskv of PennZTY EsS$?k ^Ual trations on wood. In one very handsome o^.o^S^LI^^^. W££]°* i . . „ ,Pro*2.'PZ0f- JaeJcson's Introductory Essay. for their more mature >tudies, the high value of his re'earr hZ «nH .hf ?LOGICAL Chemistry nty in that important department of mediS science are Lily recimzed^" ^ °f ^ aUlh°- AND SCIENTIFIC PUBLICATIONS 21 LYONS (ROBERT D.), K. C. C, Late Pathologist in-chief to the British Army in the Crimea, &c. A TREATISE ON FEVER; or. selections from a course of Lectures on Fevpr. Being part of a courscof Theory and Pructice of Medicine. In one neat octavo volume, of 362 pages, extra cloth; $2 00. (Now Ready.) From the Author's Preface. "I am induced to publish this work on Fever with a view to bring within the reach of the student and junior practitioner, in a convenient form, the more recent results of inquiries into the Pathology and Therapeutics of this formidable class of diseases. " The works of the great writers on Fever are so numerous, and in the present day are scattered in so many languages, that they are difficult of access, not only to students but also to practitioners. I shall deem myself fortunate if I can in any measure supply the want which is felt in this respect. We have great pleasure in recommending Dr. Lyons' work on Fever to the attention of the pro- fession. It is a work which cannot fail to enhance the author's previous well-earned reputation, as a diligent, careful, and accurate observer.—British M'«. Journal, March 2, 1861. Taken as a whole we can recommend it in the highest terms as well worthy the careful perusal and study of every student and practitioner of medi- cine. We consider the work a most valuable addi- tion to medical literature, and one destined to wield no little influence over the mind of the profession.— Med. and Surg. Report'r, May 4, 1861. This is an admirable work upon the most remark- able and most important class of diseases to which mankind are liable.—Med. Journ. of N. Carolina, May, 1861. MEIGS (CHARLES D.), M. D., Professor of Obstetrics, Ice. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. Though the work has received only five pages of enlargement, its chapters throughout wear the im- press of careful revision. Expunging and rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions.—Western Lancet, Jan. 1857. The best American work on Midwifery that is accessible to the student and practitioner—N. W. Med. and Surg. Journal, Jan. 1857. This is a standard work by a great American Ob- stetrician. It is the third and last edition, and, in the language of the preface, the author has "brought the subject up to the latest dates of real improve- ment in our art and Science."—Nashville Journ. of Med. and Surg., May, 1857. BY THE SAME AUTHOR. (Just Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lec- tures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume, leather, of over 700 pages. $3 60. In other respects, in our estimation, too much can- not be said in praise of this work. It abounds with beautiful passages, and for conciseness, for origin- ality, and for all that is commendable in a work on the diseases of females, it is not excelled, and pro- bably not equalled in the English language. On the whole, we know of no work on the diseases of wo- men which we can so cordially commend to the student and practitioner as the one before us.—Ohio Med. and Surg. Journal. The body of the book is worthy of attentive con- sideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external or- gans, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality.—The British and Foreign Medico-Chi- rurgical Review. Every chapter is replete with practical instruc- tion, and bears theimpress of being the composition of an acute and experienced mind. There is a terse- ness, and at the same time an accuracy in his de- scription of symptoms, and in the rules for diagnosis, which cannot fail to recommend the volume to the attention of the reader.—Ranking's Abstract. It contains a vast amount of practical knowledge. oy one who has accurately observed and retained the experience of many years.—Dublin Quarterly Journal. Full of important matter, conveyed in a ready and agreeable manner.—St.Louis Med. and Surg. Jour. There is an off-hand fervor, a glow, and a warm- heartedness infecting the eff>rt of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. BY THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. The instructive and interesting author of this work, whose previous labors have placed his coun- trymen under deep and abiding obligations, again challenges their admiration in the fresh and vigor- ous, attractive and racy pages before us. It is a de- lectable book. * * * This treatise upon child- bed fevers will have an extensive sale, being des- tined, as it deserves, to find a place in the library of every practitioner who scorns tolag in the rear.__ Nashville Journal of Medicine and Surgery. BY THE SAME AUTHOR ," WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style ot art. In one handsome octavo volume, extra cloth. $4 50. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial auarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-prej--. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $11 00. %* The size of this work prevents its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. One of the greatest artistic triumphs of the age I A work which has no parallel in point of accu- in Surgical Anatomy.—British American Medical racy and cheapness in the English language.—N. r. Journal. I Journal of Medicine. No practitioner whose means will admit should We gre extremely ?ratified to announce to the ! profession the completion of this truly magnificent work, which, as a whole, certainly standB unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of tha subject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. In those sudden emergencies that so often arise, and which require the instantaneous command Its plates can boast a superiority which places 0f minute anatomical knowledge, a work of thiB kind them almost beyond the reach of competition.—Medi- . KeepS the details of the dissecting-room perpetually tal Examiner. I fregh m the memory.—The Western Journal of Medi- Country practitioners will find these plates of im- I cine and Surgery. mense value.—N. Y. Medical Gazette. I MILLER (HENRY), M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c; including the Treat- ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- tavo volume, of over 600 pages. (Lately Published.) $3 75. We congratulate the author that the task is done. | tion to which its merits justly entitle it. The style We congratulate him that he hasgiven to the medi- is such that the descriptions are clear, and. each sub- cal public a work which will secure for him a high ject is discussed and elucidated with due regard to and permanent position among the standard autho- its practical bearings, which cannot fail to make it fail to possess it.—Ranking's Abstract. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- tal and Surgical Journal. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is ofTered at so moderate a price.—Charleston Medical Journal. rities on the principles and practice of obstetrics. Congratulations are not less due to the medical pro- fession of this country, on the acquisition of a trea- tise embodying the results of the studies, reflections, and experience of Prof. Miller. Few men, if any, in this country, are more competent than he to write on this department of medicine. Engaged for thirty- five years in an extended practice of obstetrics, for many years a teacher of this branch of instruction in one of the largest of our institutions, a diligent student as well us a careful observer, an original and independent thinker, wedded to no hobbies, ever ready to consider without prejudice new views, and to adopt innovations if they nre really improvements. and withal a clear, agreeable writer, a practical treatise from his pen could not fail to possess great value.—Buffalo Med Journal. In fact, thisvolumemust take its place among the standard systematic treatises on obstetrics; a posi- acceptable and valuable to both students and prac- titioners. We cannot, howeveT, close this brief notice without congratulating the author and the profession on the production of such an excellent treatise. The author is a western man of whom we feel proud, and we cannot but think that his book will find many readers and warm admirers wherever obstetrics is taught and studied as a science and an art—The Cincinnati Lancetand Observer. A most respectable and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country prac- titioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the science; and we hope to see this American produc- tion generally consulted by the profession.—Va. Med. Journal. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, ice. ice. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section oi the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavovolume, leather, raised bands, with plates and numerous wood-cuts. $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases of the Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the subject, practically as well as theoretically,and the MAYNE S dispensatory and thera^ PELTICAL REMEMBRANCER. With every Practical Formula contained in the three British Pharmacopoeias Edited, with the addition of the Formulas of the U.S. Pharmacopoeia, by R. E. Griffith.M.D 112mo.vol.ex.cl.,300pp. 75c. able manner in which the author's stores of learning and experience were rendered availablefor general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firmly established. We consider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make him- self familiar with this the most complete work in the English language upon the diseases of the eye. —Med. Times and Gazette. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- » n »T0m«the French &y Frederick Brittan, A.B..M.D. Withnumerousillustrationsonwood. In one handsome octavo volume, extra eloth, ol nearly six hundred pages. 82 25. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, ice. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two hundred and forty illustrations on wood. $3 75. The work of Mr. Miller is too well and too favor- The work takes rank with Watson's Practice of ably kriown among us, as one of our best text-books, Physic; it certainly does not fall behind that great to render any further notice of it necessary than the work in soundness of principle or depth of reason- announcement of a new edition, the fourth in our ing and research No phvsireian who values his re- country, a proof of its extensive circulation among putation, or seeks the interests of his clients, can acquit himself before his-God and the world without making himself familiar with the sound and philo- sophical views developed in the foregoing book.— New Orleans Med. and Surg. Journal. BY THE SAME AUTHOR. (Just Issued.) THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. Journal. No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art.—Southern Med. and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the "Principles" atid the "Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. By the almost unanimous voice of the profession, his works, both on the principles and practice of Burgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author has in this and his" Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding theattention. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recom- mended.—Southern Journal of Med. ana Physical Sciences. MORLAND (W. W.), M. D., Fellow of the Massachusetts Medical Society, &c. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, of about 600 pages, extra cloth. (Just Issued.) $3 50. refer. This desideratum has been supplied by Dr. Morland, and it has been ably done. He has placed before us a full, judicious, and reliable digest. Each subject is treated with sufficient minuteness, yet in a succinct, narrational style, such as to render the work one of great interest, and one which will prove in the highest degree useful to the general practitioner.—N. Y. Journ. of Medicine. Taken as a whole, we can recommend Dr. Mor- land's compendium as a very desirable addition to the library of every medical or surgical practi- tioner.—Brit, and For. Med.-Chir. Rev., April, 1859. Every medical practitioner whose attention has been to any extent attracted towards the class of diseases to which this treatise relates, must have often and sorely experienced the want of some full. yet concise recent compendium to which he could I BY THE SAME author.—(Now Ready.) THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11, 1861. In one small octavo volume, 83 pages, extra cloth. 75 cents. MONTGOMERY (W. F.), M. D., M. R. I. A., tVc, Professor of Midwifery in the King and Queen's College of Physicians in Ireland, ice. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pages. (Lately Published.) $3 75. A book unusually rich in practical suggestions.— | fresh, and vigorous, and classical is our author's Am. Journal Med. Sciences, Jan. 1857. i style; and one forgets, in the renewed charm of These several subjects so interesting in them- '-very page, that it, and every line, and every word selves, and so important, every one of them, to the haB been. weighed and reweighed through years of most delicate and precious of social relations, con- P^?-10?' that tn,« ,B,°? a11 othe,r8 th.e book °( trolling often the honor and domestic peace of a I Obstetric Law, on each of its several topics; on all family, " parent, fulness oi i. soning, unparalleled in obstetrics, and unsurpassed in ,n5 precedent, and governing alike the juryman, ad- medicine. The reader's interest can never flag, so , vocate, and judge.-iV. A. Med.-Chir. Review. MOHR (FRANCIS), PH. DM AND REDWOOD (TH EOPHILUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75. 24 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital,ice.; and FRANCIS GURNEY SMITH, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. S3 00. The very flattering reception which has been accorded to this work, and the high estimate placed upon it by the profession; as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with the advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by a slight enlargement of the page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, again presented as eminently worthy of the favor with which it has hit herto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge of the changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are acquainted.—Med. Examiner. Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class.—Transylvania Med. Journal. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in moBt of the divisions, the most, unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. There is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the gradu- ates in medicine of more than ten years' standing. who have not studied medicine since. They will perhaps find ou t from it that the science is not exactly now what it was when they left it off.—The Stetho- scope. NEL1GAN (J. MOORE), M. D., M. R. I.A., Sec. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the profession some years since. The publishers feel justified in saying that few more beautifully exe- cuted plates have ever been presented to the profession of this country. Nelipan's Atlas of Cutaneous Diseases supplies a long existent desideratum much felt by the largest class of our profession. It presents, in quarto size. 16 plates, each containing from 3 to 6 figures, and forming in all a total of 90 distinct representations give, at a coup d'ceil, the remarkable peculiarities of each individual variety. And while thus the dis- ease is rendered more definable, there is yet no loss of proportion incurred by the necessary concentra- tion. Each figure is highly colored, and so truthful ^eathedriTr«ne'rPr ttU tnf newly observed and accurately re- be conceded that Taylor is superior to anything that ! ?£»• " nav«,Deen inserted, including much has preceded it.—N. W. Medical and Surg. Journal ' ;? , 18 re<|ent °f Chemical, Microscopical, and Pa- It is at once comprehensive and eminently prac- I £b&K.ve?E^ tical, and by universal consent stands at the head of I Journal and Review. vuul,B"eu' ^«a««*«o» Med. BY THE SAME AUTHOR. —^i^r? T0 MEDICAL JURISPRUDENCE AND Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi nary advantages in acquiring experience on these subjects, nearly all caseT of mLentbein* referred to him for examination, as an expert whose testimony is generally acceX as firm? The results of his labors, therefore., as gathered together in thi/volume, ca efXSethed and s.fted, and presented in the clear and intelligible style for which he is noted mayte received as an acknowledged authority, and as a guide to be followed with implicit conSS CCeiVed AND SCIENTIFIC PUBLICATIONS. 29 TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price $4 50. f3F Gentlemen who have received portions of this work, as published in the " Medical News and Library," can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts I., II., III. (pp. 25 to 552), $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00. Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. A magnificent contribution to British medicine, and the American physician who shall fail to peruse it, will have failed to read one of the most instruc- tive books of the nineteenth century.—N. O. Med and Surg. Journal. 11 is more concise than Carpenter's Principles, and more modern than the accessible edition of Mailer's Elements; its details are brief, but sufficient; its descriptions vivid; its illustrations exact and copi- ous; and its language terse and perspicuous.— Charleston Med. Journal. We know of no work on the subject of physiology so well adapted to the wants of the medical student. Its completion has been thus long delayed, that the authors might secu re accuracy by personal observa- tion.—St. Louis Med. and Surg. Journal. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, already tran- scends our limits ; and, with the indulgence of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands. — The Northwestern Med. and Surg. Journal. TODD (R. B.) M. D., F. R. S., &c. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume, 284 pages. $1 50. BY THE SAME author. (Nov) Ready.) CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra cloth. $1 75. TOYNBEE (JOSEPH), F. R. S., Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one very handsome octavo volume, extra cloth, $3 00. (Just Issued.) The work, as was stated at the outset of our no- tice, is a model of its kind, and every page and para- graph ot it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated, and happily il- lustrated with cases and drawings—it is by far the ablest monograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable contributions to the art and science of sur ment, and with a sincere and unbiassed judgment, when we affirm that as a treatise on Aural Surgery, it is without a rivtl in our language or any other.— Charleston Med. Journ. and Review, Sept. 1660. The work of Mr. Toynbet is undoubtedly, upon the whole, the most valuable production of the kind in any language. The author has long been knowa by his numerous monographs upon subjects con- nected with diseases of the ear, and is now regarded gery in the nineteenth century.—N. Amer. Medico- as tne highest authority on most points in his de Chirurg Review, Sept. 1860. partment of science. Mr. Toynbee's work, as we To recommend such a work, even after the mere I have already said, is undoubtedly the most reliable hint we have given of its original excellence and I guide for the study of the diseases of the tar in any value, would be a work of supererogation. We are | language, and should be in the library of every phy- speaking within the limits of modest acknowledg- ' sician.— Chicago Med. Journal, July, I860. WILLIAMS (C. J. B.), M.D., F. R. S., Professor of Clinical Medicine in University College, London, ice. PRINCIPLES OF MEDICINE. An Elementaiy View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- servation of health. A new American, from the third and revised London edition. In one octavo volume, leather, of about 500 pages. $2 50. (Just Issued.) We find that the deeply-interesting matter and style of this book have bo far fascinated us, that we have unconsciously hung upon its pages, not too long, indeed, for our own profit, but longer than re- viewers can be permitted to indulge. We leave the further analysis to the student and practitioner. Our judgment of the work has already been sufficiently expressed. It is a judgment of almost unqualified praise.—London Lancet. A text-book to which no other in our language is comparable.—Charleston Medical Journal. No work has ever achieved or maintained a more deserved reputation.—Va. Med. and Surg. Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. $1 00. To the observer who prefers acenracy to blunders I One of the finest aids to a young practitioner we and precision to carelessness, this little book is in- \ have ever seen.—Peninsular Journal of Medicine. valuable.—N. H. Journal of Medicine. 30 BLANCHARD & LEA'S MEDIOAL New and much enlarged edition—(Just Issued.) WATSON (THOMAS), M.D., Ac, Late Physician to the Middlesex Hospital, ice. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; the whole strongly bound in leather, with raised bands. Price $4 25. That the high reputation of this work might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases incident to our climate which are little known in England, as well as those points in which experience here has led to different modes of practice; and he has also added largely to the series of illustrations, believing that in this manner valuable assistance may be conveyed to the student in elucidating the text. The work will, therefore, be found thoroughly on a level with the most advanced state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, und be in the hands of every student, the publishers have put it at aprice within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English Ian guage is read, to be beyond all comparison the best s) stematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with ihe advancing know- ledge of the day, and to bring the results of the labors, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. One scarcely knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical in- foimation condensed into the Lectures—or the man- ly, kind-hearted, unassuming character of the lec- turer shining through his work__I^ond. Med. Times. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— London Lancet. The lecturer's skill, his wisdom, his learning, are equalled by the ease of his graceful diction, ins elo- quence, and the far higher qualities of candor, of courtesy, of modesty, and of generous appreciation of merit in others.—N. A. Med -Chir Review. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth edition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of a new—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been severely felt for the last three years. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work we find additions or altera- tions which prove that the author has in eveTy way sought to bring up his teaching to the level of ihe most recent acquisitions in science.—Brit, and For. Medico-Chir. Review. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London &c A PRACTICAL TREATISE ON DIxKASES OF THE LUNGS; including the Principles of Physical Diagnosis. A new American, from the third revised and much en- larged London edition. In one vol. octavo, of 468 pages (Just Issued, June, 1860.) $2 25. The present edition has been carefully revised and much enlarged, and may be said in the main to be rewritten. Descriptions of several diseases, previously omitted, are now introduced Mhe causes and mode of production of the more important affections, so far as they possess direct pra£ tical significance, are succinctly inquired into; an effort has been made to bring the description at anatomical characters to the level of the wants of the practical physician ; and the diagnosis a °d prognoMs of each complaint are more completely considered. The* sec.ions on Treatment and BY THE SAME AUTHOR. Ar?^VCvf^i s™^™^2'- TaK DI^ASES OF THE HEART AND GREAT VL^EL», including the Principles of Physical Diagnosis. Third American from th* From the Author's Preface. The present edition ha< been carefully revised ; much new matter has been added, and the entire work in a measure remodelled. Numerous facts and discussions, more or leLcomXtelv novel! will be found in the description of the pnncip es of physical diasno«i« • h„t thT^Ki r a i •^ y , el> J-mademthep^^ had been given in the previous editions, are now treated of in detail Funcional disorderofTh« heart, the frequency ot which is a most riva led bv the miserv thi»v infl;„7 h k a,s°raer,s 01 lne ..dered; more especially an attempt has been -Se^S'^^ consequently their treatment more successful, by an analysis of their dynamic e ements. ' AND SCIENTIFIC PUBLICATIONS 31 New and much enlarged edition—(Just Issued.) WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged English Edition. Edited by W. H. Gobrecht, M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, of over 600 large pages; leather. $3 25. The publishers tru>t that the well earned reputation so long enjoyed by this work will be more than maintained by the present edition. Besides a very thorough revision by the author,, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increa>ed experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustra- tions, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. It may be recommended to the student as no less distinguished by its accuracy and clearness of de- scription than by its typographical elegance. The wood-cuts are exquisite.—Brit, and For. Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take ut) this volume without being struck with the great beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally evident. Let students, by all means examine tne claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. We regard it as the best system now extant for students.— Western Lancet. It therefore receives our highest commendation.— Southern Med. and Surg. Journal. BY THE SAME AUTHOR. (Just Issued.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. The writings of Wilson, upondiseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition isa great improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us, seriatim, would indeed be an agreeable service; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount of space in this Journal. We will, however, look at some of the more salient points with which it abounds, and which make it incomparaoiy superior in excellence to all other treatises on the subject of der- matology. No mere speculative views are allowed a place in this volume, which, without a doubt, will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion.—Am. Jour. Med. Science, Oct. 1657. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delineation and perfect accuracy of illustration are concerned.—Medico-C'hirurgieal Review. Of these plates it is impossible to speak too highly, The representations of the various forms of cutane- ous uisease are singularly accurate, and the color- ing exceeds almost anything we have met with in point of delicacy and finish.—British and Foreign Medical Review. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the Skin. The plates are comprised in a separate volume, which we counsel all those who possess the text to purchase. It is a beautiful specimen of color print- ing, and the representations of the various forms of skin disease are as faithful as is possible in plates of the size.—Boston Med. and Surg. Journal, April 8, 1858. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25. BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00; paper cover, 75 cents. BY THE SAME AUTHOR. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demorfstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. 32 BLANCHARD & LEAS MEDICAL PUBLICATIONS. WINSLOW (FORBES), M.D., D. C. L., &.C. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE Ml Nil; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one handsome octavo volume, of nearly 600 pages. (Just Issued.) $3 00. We close this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work, by expressing our conviction that it is long since so important and beautifully written a volume has is- sued from the British medical press.—Dublin Med. I'ress, July 25,1660. We honestly believe this to be the best book of the Bcuson.— Hanging's Abstract, July, 1860. It car i «i us back to our old days of novel reading, it kept us from our dinner, from our business, and fn ii. our slumbers; in short, we laid it down only wnen we had got to the end of the last paragraph. and even then turned back to the repeiusat of several passages which we had marked as requiring further study We have failed entirely in the above notice to give an adequate acknowledgment of the profit and pleasure witti which we have perused the above worx. We can only say to our readers, study it yourselves; and we extend the ihvitation to unpro- fessional as well as professional men, believing that it contains matter deeply interesting not to physi- cians alone, but toall who appreciate the truth that: " The proper study of mankind is man."—Nashville Medical Record, July, 1800. The 'atter portion of Dr. Winslow's work is ex- clusively devoted to the consideration of Cerebral Pathology. It completely exhausts the subject, in the same manner as the previous seventeen chapters relating to morbid psychical phenomena left nothing unnoticed in reference to the mental symptoms pre- monitory of cerebral disease. It is impossible to overrate the benefits likely to result from a general perusal of Dr. Winslow's valuable and deeply in- teresting work.—London Lancet, June 23, I860. It contains an immense mass of information.— Brit, and For. Med.-Chir. Review, Oct. 1860. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, ice. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one handsome octavo volume, extra cloth, of about 500 pages; price $2 50. (Now Ready, July, 1861.) *£* Gentlemen who received the first portion, as issued in the " Medical News and Library," can now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter, &c, Svo., cloth, price SI. Wc must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician isapparent on every page.—N.Y. Journal of Medicine, March, 185S. We know of no treatise of the kind so complete and yet so compact.—Chicago Med. Jour. Jan. 1858. A fairer, more honest, more earnest, and more re- liable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal, January 1858. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language; and that it stumps Dr. West as the facile princeps of British obstetric authors.—Edinb. Med. Journ. As a writer, Dr. West stands, in our opinion, sec- ona only to Watson, the " Macaulay of Medicine;" he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either sate, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a can- did,safe,and valuable guide.—N. A. Med.-Chirurg. Review, July, 1858. Happy in his simplicity of manner, and moderate in his expression of opinion, the author is a sound reasoner and a good practitioner, and his book is worthy of the handsome garb in which it has ap- peared.— Virginia Med. Journal. We must take leave of Dr. West's very useful work, with our commendation ot the clearness of its style, and the incustry and sobriety of judgment of which it gives evidence.—London Med Times. Sound judgment and good sense pervade every chapter ol the uook. From its perusal we have de- rived unmixed satisfaction.—Dublin Quart. Journ. BY THE SAME AUTHOR. (Just Issued.) LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Third American, from the fourth enlarged and improved London edition. In one handsome octavo volume, extra cloth, of about six hundred and fifty pages. $ i 75. The three former editions of the work now before diseases it omits to notice altogether. But those us have placed the author in the foremost rank of those physicians who have devoted special attention to tne diseases of early life. We attempt no ana- I) sis of this edition, but may refer the reader to some of the chapters to which the largest additions have been made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a proor that the work is really a new edition; not a mere reprint. In its preient shape it will be lound of the greatest possible service in the every-day practice of nine- tenths of the profession.—Med. Times and Gazette, London, Dec. 10, 1859. All things considered this book of Dr. West is by far the best treatise in our language upon such modifications of morbid action and disease as are witntssed when we have to deal with infancy and childhood. It is true that it confines itself to such eiehtv-eieht nost-mnrt^m «.vnm7.7.Tfi'.'.'„I —--"•- ■""■ disorders as come wnhin the province, of the phy- nelrly !£rtyP thousa„TcSen who XrinTth! sician, and even with resect tc.these it is unequal past twenty years, have been un^er'his cafe - as regards minutentss of consideration, and some | British Med. Journal, Oct. 1, 1859. care~ BY THE SAME AUTHOR. ^tio^^Je^d™ ?ATH0L<>GICAL IMPORTANCE OF ULCER. ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. WHITEHEAD ON THE CAUSES AND TREAT-I Second Ameri«.»7i Frfiti™ t„ ,. vtj^\.'Lr»c^iu/ju'rjr»Tu__»wrk a-^c-r.,..™,- I ■3CCUnu American Edition. In one volume. ni>t». who know anything of the present condition of paediatrics will readily admit that it would be next to impossible to effect more, or effect it better, tnan the accoucheur of St. Bartholomew's has done in a single volume. The lecture (XVI.) upon Disorctrs of the Mind in chiloren is an admirable specimen of the value ot the later information conveyed in tne [^tun* ^of Dr. Charles West.-iondon Lancet, Since the appearance of the first edition, about eleven years ago, the experience of the author has doubled; so that, whereas the lectures at first were founded on six hundred observations, and one hun- dred and eignty dissections made among nearly four- teen thousand children, they now embody the results of nine hundred observations, and two hundred and X.