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           A COMPLETE


    PRACTICAL TREATISE

              ON


VENEREAL  DISEASES,

            AND THEIR

  IMMEDIATE AND REMOTE CONSEQUENCES.

         INCLUDING OBSERVATIONS ON

 CERTAIN AFFECTIONS OF THE UTERUS,

       ATTENDED WITH DISCHARGES.
       BY WILLIAM ACTON,
  LATE EXTERNE AT THE FEMALE VENEREAL HOSPITAL, PARIS.


         SECOND AMERICAN EDITION,
WITH ADDITIONAL ILLUSTRATIONS AND COLORED PLATES.
        NEW YORK:
J. S. REDFIELD, CLINTON HALL,
    CORNER OF NASSAU AND BEEKMAN STREETS.
           1848.
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TO
          PHILIP   RICORD,  D.M.P.

SURGEON TO THE VENEREAL HOSPITAL, PARIS J  LAUREATE OF THE  INSTITUTE OF
                       FRANCE, &C, &C, &C.
  My  dear Sir :
  Europe may admire the genius of the author of the " Traite Pra-
tique sur  I'lnoculation," the British critic may call you  the French
Hunter, and the Institute may crown you with its  laurels ; but the
pupil  who, for a series of years, has watched  you at the bedside,
performing the varied experiments which are overturning long-received
opinions, and  collecting those facts which form the basis of a new
school, can alone adequately feel, and sufficiently appreciate, that
honest and  manly  candor which  is always ready to acknowledge
errors, and  that  generosity  which  allows  others to participate in
opinions still unpublished.
  To have acquired and still to retain the friendship of such a man,
will always be a source of pride  and satisfaction—feelings which
have been not  a little increased by your kindly permitting me  to in-
scribe  this volume  to  you, and thus  affording me an opportunity of
stating to my countrymen the friendly relations which  subsist be-
tween us.
                 Believe me, my dear Sir,
                         To be your grateful friend,
                                         WILLIAM ACTON.
5, George Street, Hanover Square,
         March, 1841. 
 
PREFACE.
  Among the valuable works and  monographs which the  English
language possesses on the subject of this treatise, a surgical lecturer
would  be embarrassed in selecting or recommending any one book
as affording a complete view  of Venereal Diseases.   Volumes on
Stricture, Syphilis, Gonorrhoea, &c, fill his shelves, and each work
has its peculiar recommendations ;  but, with the exception of Astruc
and Hunter, he will in vain inquire  for the authors who have treated
on Venereal Diseases  at length.
  The pupil who wishes to investigate this subject,  is obliged to
consult a variety of works, and he soon finds himself embarrassed by
the most glaring contradictions between contemporary or preceding
writers, and  the limited number of  cases that come under his obser-
vation  does not allow him to separate  what is truly  valuable from
among the  chaotic mass of authorities.
  The author has attempted to fill up this blank in medical literature ;
he has consulted the principal authors that have written on the sub-
ject ; he has retained  what is practical, and from  the  extensive op-
portunities  of observing  the natural history of the disease, and the
various plans of treatment  in  British and  Continental  hospitals, he
hopes to have succeeded in reconciling some of the apparent  incon-
sistencies of previous writers ;  and  in presenting a body of doctrines
compatible with the present advanced state of Pathology.
   Once  for  all, he pleads guilty to the charge of  introducing some
few terms  new to English readers,  and leaves them, in the words of
Johnson, " Candidates or probationers, which must depend for their
adoption on the  suffrage of  futurity."   Let the critic suspend his 
6
PREFACE.
 judgment upon them until he  be  in possession of the reasons which
 induced the author to attempt to  alter the nomenclature of his sub-
 ject.   Although fully aware of the truth of the observation of Hooker,
 that " change  is not made without inconvenience, even from worse to
 better," still he has not  dared to preserve terms sanctioned by their
 antiquity, " such as hernia humoralis and condylomata," at the expense
 of rendering himself unintelligible.
   The reader will find a very copious Analytical Table of Contents,
 which,  it is  hoped, will at once explain the system followed, and
 enable him to  refer to any subject he  may wish to investigate.
   The author  can  not but refer  with pleasure  to the  illustrations ;
 and hopes that being the first of the kind that have ever been published
in England, they will  meet, with the  approbation of the profession.
The original drawings,  he feels  confident, bear the stamp of their
own value as true copies of  nature, and  he has only  to add that they
were chosen  from among the thousands of cases  witnessed  at  M.
Ricord's Clinique,  and submitted to his approbation.   He has spared
no expense in securing the assistance of first-rate artists, as the exe-
cution of the plates proves.
   He would ill requite the favor  that  has been shown him, did he
not publicly acknowledge how much he is indebted  to the scientific
liberality of the administration of the French hospitals, as well as to
the surgeons of the female venereal institutions, in placing the patients
at his  disposal; thus  affording  him  unexampled opportunities of
studying female complaints.   How far he has profited  by such op-
portunities the Plates themselves will testify ;—how  deeply he  is
indebted to the officers of those institutions, no words can express. 
ANALYTICAL   TABLE   OF   CONTENTS.
INTRODUCTION.
                    HISTORY OF VENEREAL  DISEASES.


  Reasons for supposing that venereal diseases were known to the  ancients; historical
documents cited to prove this position from Leviticus, the Proverbs, Ecclesiastes; quota-
tions from Peter Paul Vergerius, Gulielmus de Saliceto, Bartholomew Glanville, Lan-
franc of Milan, Bernard Gordon, Petrus de Argeleta; notices by Beckett in the Philoso-
phical Transactions; quotations from John of Gaddesden ;  different  terms by which the
disease was known at the commencement of the sixteenth century;  first called venereal
disease by  Bethencourt; description of the disease by Fracastorius, as seen in 1530;
extract from the writings of Fernel in 1548; first methodical account  of the effects of the
disease given by Astruc ; summary of that author's opinions ; analysis of John Hunter's
views; those of Benjamin Bell; opinions of Broussais; investigations of M. Ricord :
divisions of the subject which he adopts.                                 [Page 17.
  History of  the Theories entertained on the Nature and Origin of  Vene-
real Diseases.—Slight allusions in the sacred writings;  opinions  of the Greek  and
Latin authors ;  theories  of the thirteenth century; origin attributed to sidereal influence
toward the fifteenth and sixteenth centuries ; opinion of Van Helmont; general belief
at that time that the venereal disease was unknown previously to the taking of Naples;
opinion of Astruc, Sanchez, Hunter, and Broussais ; belief in the spontaneous origin of
venereal  diseases; opinions of M.  Ricord and the  author that syphiloid diseases, or
non-virulent  affections, may arise spontaneously, and that syphilis or the virulent affec-
tions never arise spontaneously at the present day ; origin of syphilis not known; similar
ignorance as to the origin of other morbid poisons; probable causes of the aggravated
forms in which  it is generally met with.                                     [p. 23.
PART  I.
SYPHILOID  DISEASES.


    CHAPTER  I.
                              BLENNORRHAGIA.

  Definition of syphiloid diseases ;  meaning of the word blennorrhagia ; synonymous
terms; reasons for preferring the term blennorrhagia;  observations on blennorrhagia as
it occurs on  all or any of the mucous  membranes; predisposing causes; age;  sex;
opinion of M. Lisfranc ; influence of temperament;  locality; season; hygiene.   [p. 27.
  Exciting Causes.—Various articles of food; influence of onanism ; local irritation;
various eruptions; syphilis (secondary)  how far an exciting cause ;  case illustrative
of labor; inattention to cleanliness; menstruation; worms.  Reflections on the  fore-
going causes.                                                          [p- 30. 
8
ANALYTICAL TABLE OF  CONTENTS.
   Contagion : definition of; influence of; habit as a protection against the disease;
 case illustrative of this view; the medical man must not be  too credulous; form of
 certificate that a surgeon may be called upon to give.                          [P- 35-
   Epidemics of Blennorrhagia.—Description of one;  how far deserving the name ;
 on the time that elapses between the action of the cause and the occurrence of the affec-
 tion ; case cited by Bell; explanation of.                                     [P; 36-
   Symptoms.—Local symptoms ; characters of the discharge ; course of the affection;
 may terminate in ;  metastasis; resolution; continuation under the chronic form.  [p. 37.
   Pathology  of  Blennorrhagia.—Simple increased  redness; excoriation; granu-
 lation ; ulceration;  references to the plates ; recurrence of the disease.         [p- 39-
   Complications.—Local swelling ;  buboes;  hemorrhage ;  chancre ;  constitutional
 syphilis; rheumatism.                                                      [p. 41.
   Diagnosis.—Of the position of the affection derived from the  secretions; their chymi-
 cal characters; physical characters; value  of blood in  the  secretion, as a sign of the
 complication  of chancre; of semen; diagnosis  of mind  and virulent blennorrhagia;
 consideration of the previous opinions on this subject;  buboes ; morality of the female ;
 color of the discharge; the  duration and acute  nature of the complaint; induration;
 pain, &c, along the canal; M. Ricord's researches on this subject; inoculation the only
 sure sign; means of forming a rational  diagnosis.                              [p. 42.
   Prognosis; dependence upon the mucous membrane affected; influenced by  the
 duration  of the  complaint;  previous attacks; complications, &c.  The probability of
 secondary symptoms ; of swelled testicle occurring after peculiar treatments considered
 the pircumstances which indicate that the complaint is contagious ; rules to be followed
 line of conduct the surgeon ought to adopt in delicate affairs.                    [p. 47
   Treatment.—History of the various plans that have been recommended ;  the opinion
 of the humoral pathologists; when and why mercury was used;  treatment recom
 mended by Sydenham; Bell the  first to propose a direct treatment;  division of the sub
ject of treatment:—1. prophylactic ; 2. abortive ;  3. curative.                   [p. 49
   Prophylactic Treatment.—Precautions to  be taken, 1st, by diseased persons, so
 that  they do  not communicate the disease to healthy individuals; 2d, by a  sound in
 dividual who exposes himself to  the contagion.                               [p. 51
   Abortive Treatment.—Reasons for employing it; the objects we wish  to attain
 general means; direct or local means.                                       [p. 52
   Curative Treatment.—In the acute stage ; remarks on the application of leeches;
 baths; injections;  diluent drinks; in the chronic stage, or blennorrhoea;  revulsive
 general treatment.                                                         [p. 54.
   Copaiba.—Therapeutic effects of; action on the stomach ; intestinal canal; urinary
 organs; skin ; nervous system ;  the dose of copaiba necessary ;  administration by the
 rectum; various forms under which  it may be given.   The copaiba capsules:  their
 advantages;  preference shown to those of M. Mothes ; dose ; rules to be followed in the
 administration.                                                            [p. 55.
   Cubebs.—Action on the stomach ;  ill effects which sometimes follow its administration;
 the dose of;  manner of administering it; capsules of cubebs; action of cubebs on the
 urinary organs ; notice of turpentine ; tonics ; blisters.                        [p 59.
  Direct Treatment.—Enumeration of the preparations in use.              [p. 60.
CHAPTER II.
              OBSERVATIONS  ON BLENNORRHAGIA IN THE MALE.

  Section I.—Balanitis.—Synonymous  terms ;  definition ; causes; influence of the
prepuce.                                    ,,-,..                [P- 61.
  Symptoms.—Circumstances which  may»render the diagnosis  difficult;  course and
termination of the complaint; complications ;  secondary symptoms never follow simple
balanitis; causes which have induced authors to form a different opinion.        [p. 62.
  Diagnosis.—Difficulties that may present themselves; importance of inoculation, [p. 64!
  Prognosis.                                      .                        [p. 64.
  Treatment.—In simple cases; in inflammatory affections;  treatment of the complica-
tions ; observations on phymosis ; indications for the employment of cauterization and
incision.                                                                  [p. 64.
                         SECTION II.—Gonorrhoea.

  Synonymous terms;  reasons for retaining the term gonorrhoea.                [p. 66.
  Causes.—Individual circumstances  which predispose  to gonorrhoea;  influence of  a
large meatus urinarius;  mechanism of the introduction of the contagious matter;  the
situation of gonorrhoea.                                                    [p. 66. 
ANALYTICAL  TABLE  OF CONTENTS.
9
   Symptoms.—Cause of the dysuria, chordee, &c.;  observations on the  divisions of
 gonorrhoea, as described by Bell;  reasons for not adopting them.               [p. 67.
   Diagnosis.—Of a simple  case ; difficulties that a surgeon may meet with ; means of
 ascertaining  the exact situation of the affection; importance of" becoming acquainted
 with the exact seat of the disease, as foretelling the probable complications.     [p. 68.
   Complications.—Abscess; inflammation of the prostate; buboes; balanitis; chancre ;
 immense practical importance of a knowledge of this  complication.             [p. 68.
   Chronic Gonorrhoea or Gleet.—Symptoms.—Nocturnal pollutions;  influence on
 gleet; inflammatory stricture.  Impotence—causes of; treatment of nocturnal pollu-
 tions,                                                                     [p. 69.
   Treatment of Gonorrhoea.—The abortrve treatment; general and local  means;
 plan of employing injections;  position of the patient; sort  of instrument; quantity of
 fluid ;  consequences which follow injections ; strength of the injection; other plans of
 employing injections; method recommended by Mr. Carmichael of Dublin; the reason
 why they have fallen into disrepute ; injections do not occasion strictures;  when arose
 this belief; proof that injections cure stricture.                                [p. 71.
   Curative  Treatment of the Acute Stage of Gonorrhoea.—General and local
 treatment; treatment of complications;  chordee; retention of urine; abscess; hemor-
 rhage ; inflammation of the neck of the bladder; chancre; buboes.              [p. 75.

                         SECTION III.—Epididymitis.

   Synonymous  Terms—from  Sir A.  Cooper,  Sir B. Brodie, Wallace, Rochoux, Ri-
 cord, &c.                                                                  [p. 78.
   Symptoms first met with in the epididymis;  condition of the  gonorrhoeal discharge;
 manner in which the other parts contained in the scrotum become successively attacked;
 constitutional symptoms.                                                    [p. 79.
   Pathological  Anatomy.—Cases cited  by authors to  prove  that the affection is
 principally confined to the epididymis.                                       [p. 80.
   Causes.—Predisposing;  exciting;  period at which the exciting cause acts; the great
 importance of statistics in a therapeutical point of view.                        [p. 81.
   Complications.—Enumeration, and their relative frequency ;  rarity of affection of the
 testis itself.                                                                [p. 82.
   Terminations.—Their importance and relative frequency.                    [p. 82.
   Diagnosis.—Cases which  present  peculiar  difficulties;  instance  of  epididymitis
 occurring when the testis was in the canal;  all authors agreed that the  epididymis is
 the first part  affected; opinion of Sir A. Cooper,  Sir B. Brodie, &c.;  M. Velpeau's
 means of detecting fluid in the tunica vaginalis; diagnosis of affection of the testis
 itself;  eczema and its complications may occasionally simulate epididymitis; characters
 of abscess of the scrotum.                                                   [p. 83.
   Prognosis.—Generally favorable; chances of the occurrence of complications con-
 sidered ; will the  testis  completely  recover its functions ?   means of  forming an
 opinion.                                                                   [p. 86.
   Treatment.—Indications for the prevention of the complaint; observations on leeches;
 puncturing the scrotal veins; treatment necessary for the gonorrhoea;  of the com-
 plications,                                                                [p. 87.
  Method of  employing Compression.—Explanation of woodcut; consequences of
 compression;  indications for its employment;  counter-indications; modus operandi of
 compression; necessity for its reapplication.                                  [p. 88.
  Treatment of Chronic Stage of Gonorrhoea.—Recommendation of similar plan
 to that spoken of under the head of Abortive Treatment; treatment of gleet, by cauteri-
 zation with the instrument of Lallemand; consequences of this treatment;  employment
 of the proto-ioduret of iron—its doses, &c.; advantage to be expected from the  Tent;
 plan of introducing it; counter-indication to its use; other plans that have been proposed;
 their relative merits alluded to.                                             [p. 90.

                         SECTION IV.—Strictures.

  Definition.—Division into spasmodic, inflammatory, and organic or permanent, [p. 95.
  Spasmodic Stricture.—Causes; frequency of attacks, attributed to muscular con-
 traction.  Symptoms; quotation from Sir  B. Brodie.  Diagnosis; prognosis; treatment,
 as recommended by Sir B.  Brodie.                                          [p. 95.
  Inflammatory Stricture.—Causes  of the affection ; frequent complication of the
 other forms;  treatment should be of an active antiphlogistic nature; the employment
of instruments prejudicial.                                                  [P- 97.
  Permanent Stricture.—Definition; may depend upon—1st, alterations of the sur-
face of the mucous membrane; 2dly, alterations of the substance or parietes; 3dly,
alterations of surrounding  parts.  Description  of the lesions  of the  surface—Ulcers;
vegetations; false membranes; cicatrices; hemorrhoidal  state  of.—Description of the 
10                ANALYTICAL TABLE OF  CONTENTS.
Lesions of the substance or parietes—Simple hypertrophy with softening, or induration ,
fungous degeneration ; specific induration ; various general affections may give rise to
stricture.—Description of the alterations of surrounding Parts—Abscesses, indurations,
affections  of the prostate, &c.                                               y  '
  Causes.—Blennorrhagia a frequent one;  case  showing  that other causes proauce
stricture ;  injections are not a cause ; general situation of;  opinion of Hunter, ^maj®'
Ricord, Crosse, on the number of strictures ; form may be various.            |p.  luu.
  Symptoms.—Description of those derived from passing water;  other  causes  man
stricture may give rise to them ;  symptoms derived  from  ejaculation ol the semen;
other symptoms ;  gleet often a symptom of  stricture ; difference of opinion on the part
from which it  proceeds ; these symptoms insufficient  to distinguish  stricture ; value ol
the diagnosis derived from an exploration of the canal by instruments; necessary to try
to pass various sizes and shapes before coming to an opinion on  the existence of stric-
ture; two plans of exploring the  canal—1st, from before backward—2d,  from  behind
forward;  appreciation of;  means of ascertaining the depth of a stricture; exact position
and direction of, by means of the porte empreinte ;  description of woodcut.     [p.  102.
  Diagnosis.—Of stricture generally, and of the various lesions  on which it depends
of vegetations; of the  oedematous and hcemorrhoidal state; cicatrices;  simple  callous
strictures; specific indurated stricture.                                      IP" .  '•
  Prognosis.—Of stricture depending on vegetations ; hypertrophy, with ramolhsse-
ment; cicatrices;  callous stricture; specific  induration; spasmodic stricture.   [p.  109.
  Treatment— Circumstances which counter-indicate any treatment; general reflections
on; division into general and local treatment; notice of constitutional treatment; means
of local treatment; injections.                                      .        fP-  }?Q-
  Dilatation.—Various means of employing it; 1st, sudden dilatation, or duatatwn
brusque of M. Ricord ;  appreciation of; in what cases useful; in what instances it may
be prejudicial; Mr. Mayor's observations on the  employment of bougies; 2d, rapid
dilatation, or Lallemand's plan; cases which do not admit of this treatment; reasons
for rejecting it; 3d, gradual dilatation ; rales for employing it; period that the bougie
should remain in the stricture ; their repetition; cases unfitted for dilatation in general;
cases which will be benefited by it;  comparison  between permanent and temporary
dilatation ; observations on permanent dilatation; ill consequences which sometimes
follow ;  advantages to be expected from.  Temporary Dilatation.—Time during which
a bougie should be kept in the stricture ; objections to it; M. Ricord's plan; action of
dilatation  threefold; 1st, acts by compression; 2d, acts by  suppuration; 3d, by ulcera-
tion :  it should be our object to produce only the effect of compression; dilatation may
act on the face, or on the parietes  of the stricture; Dupuytren's  treatment; Ducamp's
treatment; plan of M. Benique ; instruments with which dilatation should be performed;
conical bougies; their  advantage: recommended  by Dupuytren; advantages  of  em-
ploying the bougie a ventre; remarks on flexible soft bougies; Sir B. Brodie's observa-
tions on wax bougies;  gum  elastic bougies the best; inflexible or hard instruments;
flexible  ivory  bougies: whalebone bougies; appreciation  of them; observations on
maintaining the cure of stricture.                                            [p.  111.
  Cauterization.—History of; this treatment not applicable to all cases; beneficial
effect in spasmodic structure ; in vegetations, &c, useful in some cases of permanent
stricture;  in what cases useless;  Hunter's employment of caustic  to the face of the
stricture ;  Ducamp to the parietes; rules for the employment of cauterization ; strictures
may be cauterized with a variety of substances; preference shown to the nitrate of
silver; M. Ricord's plan of cauterization, when he is unable to penetrate the stricture ;
method of cauterizing  the parietes of, or Lallemand's plan of treatment; explanation
of wood cuts ;  length of time that the caustic remains in contact with the tissues ;  ob-
servations on its reapplication ; consequences of cauterization; opinion of Sir B. Brodie
on the armed bougies.                                                     [p.  119.
  Scarification or Incision.—History; means of employment; puncture; scarifica-
tion of the parietes;  description of M. Ricord's instrument; manner of employing it;
notice of other plans; filing a stricture; employment of the  actual cautery.     [p.  124!


             SECTION  V.—Affections of the  Prostate Gland.

   Causes.—Enumeration of.                                               [p.  12c
   Symptoms.—Rarely met with alone ; the more usual train; symptoms as characterized
by the catheter;  stream of urine ; notice of the age and temperament in which the dis-
ease occurs; course of the affection ;  opinion of Sir A. Cooper.               [p.  126.
   Pathology.—Sir E. Home's opinions.                                      p.  12s]
   Prognosis.                                                              p. 129.
   Diagnosis.—Means of forming one.                                        p.  129.
   Treatment in the first stage of the disease ; objections to the use of bougies; observa-
tions of Sir E. Home on the  use of instruments.                              [p. 129, 
ANALYTICAL TABLE OF  CONTENTS.
11
                       SECTION VI.—False Passages.

  Portions of the urethra most subject to; dimensions and directions of; predisposing
causes; influence of instruments in occasioning false passages; false passages produced
by small instruments, of slight importance;  precautions to be taken to avoid making
f*8.l8G D9.S88.Gf6S                                                          Lr* ■Ll*A*
  Symptoms.—Notice of the causes of errors.                         .     LP- \3Z-
  Prognosis.—Circumstances which modify it; necessary to study the direction ot. [p. lii.
  Treatment in recent cases; observations on overcoming the obstacle.       LP-136.


               SECTION VII.—Disease of  Cowper's  Glands.

   Symptoms may be mistaken for circumscribed abscess of the urethra.       [p. 136.
   Treatment—Termination in infiltration of urine ; consequences of treatment. lp. 1J7.


                  SECTION VIII.—Infiltrations  of Urine.


   Causes.   Symptoms.—Direction  which the urine follows.                   Ip-137.
   Treatment.—Importance of free incisions.                                LP- lM-


                      SECTION  IX.—Fistulous Openings.

   Their situation ; course; direction; consequences of.                     [P- *?9
   Treatment in simple cases; Mr. Dieffenbach's plan of treating them.        LP- i«-
CHAPTER III.
BLENNORRHAGIA IN THE FEMALE.
  Notice of causes which are peculiar to the female  genito-urinary mucous mem-
brine                                                                  L*
  Morbid Appearances.—Description of the state of the mucous membrane as to color,
&c; papular vaginitis;  the various characters it may assume;  vagina subject to various

erTPhe°appearances of the discharges from the female genito-urinary organs in the acute
and chronic affections; importance to study them as diagnostic signs.          [p. 144
  Symptoms.—Similar, though depending upon various causes; usually local;  general
symptoms often absent; enumeration of local symptoms which are common to all these
affections; symptoms of blennorrhagia. Of the  Vulva of the  Utethra.-Me&ns of
detecting disease in the urethra; relative frequency of the affection.  Of the Vagina.
—Indolent character of symptoms; where to find traces of a discharge.  Of the Uterus.
—The discharge is  sometimes the only  symptom; advantages of  employing the
speculum- the bivalve speculum recommended; description of the instrument; method
of introducing it; indications for finding the neck of the uterus; counter indications  to
the employment of the speculum; description of the speculum chair           [p. 14o.
  Complications in blennorrhagia of the vulva.  Description of, and their diagnosis;
phymosis of the vulva—of the urethra—of the uretus.  Oyante, symptoms,  one ot the
causes of ovarian dropsy ; specific ulcers ; simple ulcers; diagnosis of.         [p. iav.
  Observations on Contagion.—The mucous membrane usually diseased  when the
complaint is contagious; impossibility of distinguishing whites  from  contagious dis-
charges; diagnosis of virulent from simple blennorrhagia; form  of certificate recom-

m Prognosis.—Of blennorrhagia of the vulva—of the urethra—of the vagina—of the

   Tre'atment.-Of blennorrhagia of the vulva; of prevention; abortive treatment not
usually  applicable  in  the  acute stage;  of the  urethra-of  the vagina—oi ttie

   Complications.—Retention of urine;  cystitis; stricture; abscess; fistula;  P^0^
bubo j nervous complications; ovaritis.                                    LP" 
»   12
ANALYTICAL TABLE  OF CONTENTS.
                               CHAPTER IV.


            FORMS OF BLENNORRHAGIA COMMON  TO BOTH SEXES.


                 SECTION I.—Blennorrhagic Oththalmia.

  Synonymous terms;  frequency; situation.                                [p. 156.
  Causes.—Difference  of opinion upon;  two theories; description of the first, or sym-
pathy ;  appreciation of it;  reasons for disbelieving it; reasons for believing in the
opposite opinion, or in direct contact of the secretion ; considerations on predisposing
causes, such as age sex, &c.; deductions.                                   [P; 157.
  Symptoms.—At an early period ; examination of the eye ; state of the secretions;
granular condition ; no  deduction can be drawn from it; course of the disease ; rapidity
in disorganizing the structures of the eye.                                   [P- 158.
  Diagnosis—No one symptom sufficient; considerations on the intensity of the in-
flammation ; coincidence of the blennorrhagia.                              (p- 159.
  Prognosis.—Very severe; recommendation to call in a second opinion ; Dupuytren's
practice.                                                                [p. 160.
  Treatment.—Lisfranc's opinion; M. Ricord's  treatment; leeches, observations on ;
the employment of nitrate of silver in substance ;  how applied;  rules for the reapplica-
tion of; on the use of mercury.                                            [p- 160.

                SECTION II.—Blennorrhagia of the Anus.

  Does there exist such  a disease ?  Yes.  Reasons for supposing it  common; no
foundation for the opinion.                                                [p- 162.
  Symptoms.—Description of.                                            [p. 163.
  Causes.—Direct contact; influence of general causes.                      [p. 163.
  Diagnosis.—Always difficult; the value of the funnel-shape of the anus; causes which
give rise to it;  not always present; color of the discharge; its value as a diagnostic
sign ; inoculation, its value; buboes; the antecedents of the patients; no one unequivocal
Bign ; importance to be placed on a rent of the rectum.                       [p. 163.
  Prognosis.—Unfavorable ; why.                                         [p. 164.
  Treatment.—The first indications; general means ; direct means.           [p. 164.

      SECTION III.—Blennorrhagia of the Mouth, Nose, and Ears.

  Fabulous.                                                            [p. 165.
  Blennorrhagia of the Umbilicus and Groin.—Causes.  Treatment, &.  [p. 165.

                        SECTION IV—Vegetations.

  Synonymous Terms.                                                   [p. 165.
  Pathology.—Color, stricture, &c.                                         [p. 165.
  Causes.—Opinion of Sir A. Cooper on their contagion ; case illustrative of  the im-
portance  of a correct opinion of cause.                                      [p. 166.
  Complications.  Diagnosis.  Prognosis.                                [p. 167.
  Treatment.—Appreciation of the several  plans of treatment.                [p. 168.

                     SECTION V.—Herpes Pr.eputialis.

  Case from note-book, detailing cause, symptoms, diagnosis, and treatment.    [p. 169.

                          SECTION VI.—Eczema.

  Causes.  Symptoms.  Treatment.                                       [p. 172.

                       SECTION VII.—Excoriations.
Definition.  Situations.
Treatment.—Preventive and curative.
[i 
ANALYTICAL  TABLE OF  CONTENTS.               13
PART  II
CHAPTER I.
                              PRIMARY  SYMPTOMS.

  Definition of syphilis; division into stages;  meaning of first, second, third stages.
                                                                          [p. 175.

                             SECTION I.—Chancre.

  M. Ricord's Definition.  Anatomical Characters.—As proved by inoculation ; natural
manner in which chancre may commence; microscopic examination of the secretion
of.                                                                        [p. 176.
  Varieties of Chancres in the Ulcerative Stage.—1st, Phagedenic  chancre; 2d, Diph-
theritic  phagedenic;  3d, Indurated;  4th, Indurated  phagedenic;  5th, Gangrenous
chancre.                                                                  [p. 178.
  Period of Reparation; Varieties of; Cause of Chancre.—Meaning of the term cause;
traced in the present instance to the secretion of another chancre ; circumstances which
compose, form part  of, dispose to, prevent the action of; impossibility of isolating the
cause ; influence of chymical agents upon  it; reasons for calling it a virus.      fp. 180.
  Origin of the Syphilitic  Virus.—Not spontaneous at the present day;  hypothesis
founded on analogy.  Circumstances and conditions necessary for the production of the
effects of the Virus.                                                        [p. 182.
  Of the chancre from which the virus is taken.                              [p. 183.
  Means and conditions of the agents of transmission ; refutation of received opinions
on this subject, practical illustrations of which are important to the surgeon.     [p. 184.
  The necessary conditions of the parts about to be contaminated;  destruction of the
epidermis necessary; apparent exceptions; explanation of;  influence of age; state
of the skin; influence of sex; the question, Are there any persons insusceptible of
syphilis ?  answered in the  negative; incubation does not exist; apparent  exceptions
explained.  Is there more than one cause of chancre ?   Only one.             [p. 187.
  Causes of the Varieties of Chancre.—Varieties  not to be attributable  to  any one
cause; examples, enumeration of the most  frequent in cases of the diphtheritic varieties;
gangrenous phagedenic; serpiginous; indurated.                            [p._ 191.
  Diagnosis of Chancre during its ulcerative stage.—The means of  forming a rational
diagnosis; observations on the appearance as  aiding the diagnosis;  the situation ; the
history; the value of various complications; how far a diagnosis can be formed from
the course.                                                               [p- 194.
  Observations  on the  absolute diagnosis; value of  inoculation;  cases  illustrative
of.                                                                        [p. 196.
  Diagnosis of the reparative stage of chancre.                               [p. 197.
  Prognosis  of Chancre—Consideration  of it as a local disease; usual period of cure;
probability of the  occurrence of the  varieties supervening on simple chancre, such as
diphtheritic; serpiginous; gangrenous;  indurated.   Relative to the probable duration
of a  simple chancre; enumeration of the causes which influence it, such as situation,
size, number, constitution ; probable duration of a diphtheritic, serpiginous, gangrenous,
indurated chancre.                                                         [p- 198.
   Probability of the occurrence of complications.                             [p. 20"-
   Prognosis in reference to the probability of successive accidents; meaning of this term ;
of chancre (successive); of bubo; circumstances which will tend to modify the prognosis,
such as situation, &c.; influence of treatment on prognosis.                   [P-. 202.
   Prognosis considered in reference  to the probability of  general  and constitutional
infection; the  circumstances to be borne in mind ; stage of the  sore ; duration of the
chancre; number and size; probability derived from the  varieties, viz.,  phagedenic
 gangrenous; influence of the indurated; influence of the complications on the prognosis..
 such as  phymosis;  bubo:  prognosis  to be derived from the treatment, local  and
 general.                    V  B                                          [P- 202. 
14
ANALYTICAL TABLE OF  CONTENTS.
   Treatment—Prevention of chancre ; reflections upon ; methods employed in France ;
 duties of the medical practitioner ;  Is it possible to prevent the occurrence of chancre 1
 Proposed means of preventing the spreading of the affection ; precautions to be taken
 by the recipient; those  recommended to be used by the already infected, to prevent
 transmission.                                                              [P- 204-
   Curative Treatment.—Of the chancre on its first appearance; observations on the
 employment of lunar caustic;  treatment of the variety called  phagedenic diphtheritic;
 indications necessary to be attended to ; gangrenous phagedenic ; serpiginous chancre;
 observations on the obstinacy of this sore; general and  local means ; indurated chancre;
 objects the surgeon ought to have in view in treating this form ; local treatment; general
 treatment; observations  on the use  of mercury; its  dose;  preparation;  preparatory
 measures; prejudicial effects of; treatment of;  mention made of excision.       [p. 208.
   Treatment of indurated phagedenic chancre.                                [P- 209.
   Treatment of the complications of chancre.—From position;  chancres in the urethra;
 diagnosis  of this  affection; prognosis; treatment;  chancre  situated at  the  fraanum ;
 balanitis; phymosis; the indications and method of employing caustic in these last two
 forms.                                                                    [p. 216.
   Operation for phymosis; M. Ricord's plan of circumcision.                   [p. 219.
   Paraphymosis; reduction of; operation for relieving.                        [p. 221.

                             SECTION II.—Bubo.

   Definition of;  meaning  of the term venereal  bubo;  syphilitic bubo; anatomical
 characters of syphilitic bubo; termination of, in delitescence;  resolution;  suppuration;
 in induration.                                                             [p. 222.
   Causes of Syphilitic Bubo.—Remarks on lymphatic  vessels  ; action of  the virus may
 be twofold, by absorption,  by  irritation.  The predisposing causes—Influence of age,
 sex, temperament; general condition of the patient; influence from the situation of the
 chancre;  size of; how far the treatment of primary sores may  influence buboes, [p. 224.
   Symptoms of bubo.                                                     [p. 228.
  Diagnosis of Syphilitic  Bubo.—1.  Previous to the suppurating stage; importance to
 be placed on the antecedents ; distinction between syphilitic bubo and bubon d'emblee;
 description of this last-mentioned form.  2. W hen suppuration exists ; inoculation the
only sure guide.                                                          [p. 228.
   Prognosis of Syphilitic Bubo.—Inquiries necessary previous to forming our prognosis;
 prognosis of bubo depending upon absorption, or upon irritation; the probability of a
 syphilitic bubo suppurating; the probable  duration of a bubo; circumstances which
 influence the prognosis ;  probability of the occurrence of secondary symptoms, [p. 230.
   Treatment of Syphilitic Bubo.—The Prophylactic  Treatment—Indications  to  be
 borne in mind, particularly of chancres; treatment of the early stages of bubo ; influence
of compression upon ; treatment of the inflammatory stage of bubo ; influence of blisters;
observations on the use  of caustics;  indications for puncturing buboes; method of
 puncturing ; treatment of suppurating open buboes.                          [p. 232.
                               CHAPTER II.

                     SECTION I.—Secondary Symptoms.

  Definition; synonymous terms; history of secondary symptoms; classification of;
M. Ricord's and the author's division explained ;  general  observations on secondary
symptoms; are secondary symptoms dependent upon absorption of the virus ?  reasons
for the belief; can tbey occur without previous chancres ? the chances of error, [p. 239.
  Predisposing  Causes; influence of temperature, food, age, sex, temperament; does
absorption of the virus take place by means of the veins or absorbents ?  Hypothesis on
this subject.                                                              [p. 241.
  Period  at which secondary symptoms appear after  the  occurrence  of primary
symptoms.                      ...                          [p- 244.
  Observations on the average period; exceptional cases.                    [p. 245,

             SECTION II.—Secondary Affections on the Skin.

  Division of, into the following forms; Exanthematous; Papular; Vesicular; Pustu-
lar ;  Tubercular.                   . ,  , .  .                              [P« 246«
  Description of Exanthemata; period of their appearance; natural course of. [p. 247. 
ANALYTICAL TABLE OF  CONTENTS.
15
   The  Papular.—Parts most liable to; divisions of.  Lichen.  Psoriasis.  Lepra.
 on the palms of the hands.                                                [p. 247.
   The Vesicular.—Rarity of the affection.                                [pi 249!
   Pustular.—Course;  termination.  In Rupia.—Ulcerations;  general state of the
 system; variety of the pustular form.  Impetigo.                             [p. 249.
   The Tubercular form.—Description of; description of the variety called  Condy-
 loma, and of the  French term  Mucous  Tubercle;  situation of; predisposing  causes;
 liability of  mistakes; course of the affection; termination of;  varieties  of  Condy-
 lomata,                                                                  [p. 250.
   Complications of Secondary Symptoms above described.—Influence of itch in, as a
 complication ;  existence of eczema; lepra and various afiections of the skin; primary
 symptoms, a complication; importance of the knowledge of this fact; the influence of
 scrofula, scurvy, as complications.                                          [p. 253.
   The Diagnosis.—Importance to be placed on the previous history; whether positive
 or negative ; value of concomitant disease  as influencing the diagnosis; what dependence
 is to be placed on the color of the eruption; how far can the diagnosis be substantiated
 by the treatment which has preceded, or that under which the patient recovers, [p. 254.
   The Prognosis.—Circumstances under  which it may be considered  favorable ; cir-
 cumstances  which lead to an opposite conclusion.                            fp. 256.
   Treatment of Secondary Symptoms.—The Curative Treatment.—Indications to
 be borne in  mind ; general treatment; baths ;  importance in the opinion of the author ;
 method of employing baths; on the employment of  sarsaparilla;  on the use of gold,
 and its preparations; those of silver.  On the employment of mercury; on the history
 of; observations on the doctrines of the mercurialists and non-mercurialists;  author's
 opinions on  the efficacy of mercury; in what cases it should be employed ; manner of
 employing it;  on the action of mercury on secondary symptoms.               [p. 259.
   Salivation.—Predisposing causes of;  quantity of mercury necessary to produce it;
 period of  time most to be dreaded, at which it will appear;  description, course, and
 treatment  of salivation ;  termination of; diagnosis of salivation ; on the employment of
 mercurial ointment;  mercurial plasters ; calomel; fumigations; internal use of mercury;
 calomel and  opium; corrosive sublimate ;  proto-ioduret of mercury; local applications
 to the various syphilitic affections  of the skin—as lichen,  lepra, psoriasis, mucous
 tubercle, &c.                                                           [p. 263.

      SECTION III.—Syphilitic Affections  of the Mucous Membrane.

   Mucous membranes that may be the seat of the affection.                  [p. 270.
   Syphilitic Affections of the Mouth and  Throat.—Division into.              [p. 270.
   Primary  Affections.—Causes; other instances cited; anatomical  characters of:
 cause ; reasons for believing it a rare affection ; opinion  of Mr. Colles;  M. Guersent's
 opinion; symptoms; diagnosis; cases which present difficulties; means of arriving at
 a correct opinion ; prognosis ;  treatment.                                   [p. 271.
   Secondary Syphilitic Affections of the Mouth  and  Throat.—Cases;  ana-
 tomical  characters; cases;  the predisposing  and  exciting considered;  symptoms;
 concomitant  disease; diagnosis;  prognosis ; treatment.                       [p. 280.
   Tertiary Syphilitic Affections  of the Mouth and Throat.—Anatomical
 characters;  sketch of its commencement and progress; history.               [p. 288.
  Diagnosis.—Value of each symptom; inquiry if  a strumous sore  throat exists;  does
 a chronic inflammatory affection ever appear? cases; can scorbutic disease of the throat
 be mistaken  for a syphilitic affection ? the  diagnosis of syphilitic affections and  cancer
 considered.                                                             [p. 290.
  Prognosis.  Treatment                                                [p. 296.

             SECTION IV.—Syphilitic Affections  of the  Eye.

  Division of.                                                           [p. 298.
   Secondary  Affections.—Quotation from Mr. Lawrence.                 [p. 299.
   Syphilitic  Iritis.—History; known  and  described in 1773;   symptoms of;  Mr.
 Tyrrell's opinion on; statistics  by Mr. Lawrence; showing at what period of life it
 occurs, &c.                                                             [p. 301.
   Causes.—Predisposing and exciting; probable reason why the disease is rarely met
with in  Paris; prognosis; diagnosis; value of each symptom individually consider-
ed,                                                                    [p. 302.
   Treatment.—Employment of mercury.                                   [p. 305.

           SECTION V.—Syphilitic  Affections  of the testicle.

  Synonymous terms; symptoms; pathology;  extract from Sir A. Cooper's  work;
predisposing and exciting causes; diagnosis; prognosis and treatment.        [p. 308. 
16               ANALYTICAL TABLE OF CONTENTS.
CHAPTER III.
                             TERTIARY SYMPTOMS.

  Definitions; history; Hunter's opinion upon ; cause; predisposing causes; influence
of previous disease; influence of treatment of the primary and secondary affections;
course of tertiary symptoms ;  complications of; prognosis; diagnosis.          [p. 309.
  Description of Tertiary Symptoms affecting the Cellular Tissue.—Tuber-
cles of; tertiary affections in the osseous system.                              [P- 313.
  Periostitis.—First, second, and third variety.                              [p  314.
  Ostitis.—Divisions of; terminations various.                         _    [p. 315.
  Treatment of Tertiary Symptoms.—Indications of treatment; preventive means ;
curative means; employment of opium; mercury—observations upon; on the employ-
ment of the hydriodate of potass ; dose; manner of increasing it; effects of the salt on
the  system;  treatment of the individual forms of tertiary symptoms ; local treatment of
tumors situated in the subcutaneous cellular tissue; treatment of ulcers;  observations
on the submucous tumors.                                                 [P- 316.
  Treatment of Affections of the Osseous System.—Pains in the bones; treatment of
periostitis and its varieties; treatment by means of blisters; local  treatment of ostitis;
observations on necrosis and caries.                                        [p- 320.
CHAPTER  IV.
                           SYPHILIS  IN CHILDREN.

  Primary Symptoms considered;  ulcerations which may be mistaken for.   [p. 321.
  Secondary Symptoms.—How does the foetus become affected; does  the mother
infect the child by means of the  milk 1 can the father directly contaminate the foetus;
reasons for our disbelief;  allusion  to Messrs. Colles'  and Carmicheal's opinions; does
syphilis cause abortion at the seventh month ? reasons for doubting it.         [p. 322.
  Symptoms.  Prognosis.  Treatment.—Can the child communicate the disease to its
nurse ? the conditions under which this may take place;  consideration of some  errors
the surgeon may fall into.                                                 [p. 324. 
INTRODUCTION.
        HISTORY  OF  VENEREAL  DISEASES,

  A very  superficial consideration of the laws which  regulate the  animal
economy in a state of health and disease, together with the various operations
of these laws on the diflerent structures of the human frame, is sufficient, I
think, to entitle the pathologist of the present day to infer that various affec-
tions, both  organic and functional, now recognised  as  following  sexual inter-
course, must have existed in all ages and in all  climates •  these I have included
under the collective term of " Venereal Diseases."*
  Believing, however, that it is not sufficient for the purposes of this work to
render such an inference merely probable, I  shall in  the following pages at-
tempt to prove, from authentic historical records, that various diseases answering
to this definition were known, and  have been  described, by persons living in
the early ages.  These I shall trace down to the present time; but in doing so
I shall be as concise as possible, and only dwell upon such points as may be of
practical use.
  An attentive perusal of the twelfth and fifteenth chapters of Leviticus must
convince any  impartial person that the Jewish lawgiver, in strictly enjoining
ablution and separation to women after  delivery and menstruation, or, as is
said at the  eighteenth verse, particularly to " the woman with whom man shall
lie with seed of copulation," must have had in view the prevention or  cure of
affections liable to follow sexual intercourse at that time.   This regulation was
promulgated about the year 2400 A. M.
  On referring to the fifth chapter of Proverbs, the reader will find Wisdom ad-
monishing her pupil, and desiring him to  avoid  strange women, lest his flesh
and body be  consumed.  And in Ecclesiastes it is stated, that " whosoever
joineth himself to  adulterers  shall become impudent,  and that rottenness  and
worms shall have him to heritage."  Thus we find allusion made to it again
about the year 2950 A. M.
  On the authority of Peter Paul Vergerius the elder, it is stated that "TJber-
tinus of Carrara, the seventh of that name, and the third  governor of that city,
died at Padua, the 29th of March, in the year 1245, of a  lingering disease of
his private parts, occasioned by too much venery."f

  * By the term venereal diseases,  I mean all those  affections which are, more or less, di-
rectly or indirectly, the consequence of sexual intercourse, in whatever way effected.
  t Astruc, p. 58.
                                    2 
18
INTRODUCTION.
  Gulielmus de Saliceto, a  physician of Placenza, in 1270, states in his work
"De Apostemate in Inguinibus,"* "This disease, called a bubo,dragoncelli, or
impostume of the groin, for the most part arises from a  cold humor which is
expelled  from the liver to those places which  are weak and empty;  it some-
times also proceeds from a hot humor, and sometimes it comes from a foulness
in the yard (in virga corruplio), contracted by lying with an  unclean woman,
or from some other cause.
  In Astruc's treatise,f it is stated that an eyewitness, Theodoric, a celebrated
physician in the year 1290, in his Chirurg., lib. vi., cap. 55, says, that " whoever
converses with a woman who has lain with a leper will catch the distemper."
  Bartholemew Glanville, in  his book De Proprietatibus Rerum, translated in
1398  by  John Trevesa, speaks of  "TJnclene spostyd glemy and guyttery, the
nosethrilles  ben stopyl, the  wasen  of the  voys is rough, and the  voyce  is
hoorse, and the heere falls."   This disease of leprosy " comyth of fleshly lying
by a woman  after that a leprous man hathe laye  by her; also it comyth of fader
or moder; and  so thys contagyon passyth into the chyle, &c.  And also when
a chylde  is fedde wyth corrupte mylke of a leprouse nourryce."  In Henry the
Eighth's  time there were six  leprous or lazar houses.
  Lanfranc of Milan, a pupil of Gulielmus de Saliceto, who consequently lived
about the year 1290,t states, that chancres and ulcers of  the penis follow from
coition with a foul woman.   Bernard Gordon, professor of physic in the Uni-
versity of Montpelier in 1300,|| says that "diseases of the yard  are numerous,
following lying with a woman whose womb is  unclean, full of putrid sanies,
virulence,"  &c.
  In  a manuscript, in Lincoln College, Oxford, cited by  Beckett, and corrobo-
rated by  Dr. Wagstaff, in the thirtieth volume of Phil. Transact., it is  stated on
the authority of Thomas Gascoigne, chancellor of that university, that " Joan, dc
Gaunt mortuus  est ex tali putrefactione membrorum genitalium, et corporis sui
causata per frequentionem mulierum."  This took place in the year  1399.
  About the year 1423, Petrus de Argelata, of Bologna,§ says, that the reten-
tion of the poisonous matter lodged between the glans and prepuce, after a man
has had  to do with a foul woman, causes the part to become black, and the sub-
stance of the yard mortifies,  &c.   He likewise speaks of the occurrence of bubo
in the groin as a consequence of this affection.
   In the thirtieth volume of the Philosophical Transactions, page 843, Beckett
cites the following passage from a book in  the  custody of the bishop of Win-
chester,  supposed to be written in the year 1430, and entitled " De his qui cus-
lodiunt mulieres habentes nephandam infirmitatem :" " That  no stew-holder keep
noo woman wythin his house that hath any sycknesse of brenning ;ir but that
 she be putte out, upon the peyne of makeit a fyne unto the Lord of a hundred
 shylyngs."

   ' Lib. i., cap. 42.                                              t L. c, p. 53.
   t Tract. 3, Doct. ii., cap. 11.  Practicae seu artis completae, <fec.  And also in Tract. 3
 Doct. iii., cap. 11.  De ficu et cancro et ulcere in Virga virili.
   || Lilii  Medicinae Particul, vii., cap. 5. De passionibus virgae.
   I) Chirurgiae, lib. ii., tract. 30, cap. 3.  " De pustulis qua adveniunt virga propter conversationem
 cumfceda muliere, qua alba sunt vel rubra."
   1 On the authority of a manuscript of John Arden, surgeon to Richard II., the word bren-
 ning is thus denned:  " A certain heat and excoriation of the urethra." 
INTRODUCTION.
19
  Beckett quotes the following questions as being put to persons who were said
to he lepers;  he cites them from  an ancient book of surgery : " If there were
any of his lygnage that he knew to be lazares, and especially their faders and
moders, for by any other  of their kynred they aught not  to be  lazares, then
aught ye to enquire if he hath had the company of  any leprous woman, and if
any lazar hath meddled with  her afore him;  and lately, because of the infect
matter and contagious filth that she had received of hym.  Also his nosthrills
be wide outward, narrow within,  and gnawn.   Also if his lips and gumma are
foul, stynking, and coroded.  Also  if his voice  be  hoarse, and as he speaketh
in the nose."
  John of Gadesden* not only alludes to the  possibility of contracting the  com-
plaint  from a leprous woman, but mentions the precautions which should be
adopted to avoid contagion.  " Hie qui concubuit cum muliere  cum qua coivit
leprosus puncturas intra carnem et corium sentit, et aliquando calefactiones in
toto corpore.
  " Primo notandum est ille qui timet et excoriationem et arsura virgae post co-
itum statim lavet virgam cum aqua mixta aceto, vel cum  urina propria, et  nihil
mali habebit."f
  " Si quis vult membrum ab omni corruptione servare,  cum recedit a muliere
quam suspectam de immunditie, lavet illud cum aqua frigida cum  aceto  mixta,
vel cum urina propria interius vel exterius intra preputium."}
  The affections to which we have alluded, and which were described as exist-
ing previously to the 15th century, had received no particular name;  but after
the severe epidemic observed at Naples, and which was so well described by
Fracastorius, they became known under the title Morbus  Neapolitanus, or  Gal-
licus, Mai des Francois, and soon after the terms Gore,  Grande Gore, Verolle,
Grande Verolle, were successively given to them in consequence of the general
pustular eruption by which they were attended.
  Lastly, the affections were described under  the title Scorra Pestilentialis, by
Sebastian Brant, in 1496, and by Grunpeck, a German physician.   Gaspar To-
rella writes on the subject a treatise, Contra Pudendagra, in 1498.
  It was generally known by one or other of these denominations until Jaques
de Bethencourt of Rouen called it the Venereal Disease, in a book entitled Nova
Pcenitentialis  Quadragesima, nee  non Purgatorium  in Morbum Gallicum, sive
Venereum.  Paris, 1527.
  In the year 1530 Fracastorius || writes thus:  "When it  first broke out  among
us, it discovered itself by the following symptoms : the patient was low-spirited,
complained of weariness, and had a  pale look; at last, for the most part, little
ulcers appeared about the  pudenda, which were  extremely obstinate, and, after
they were cured in one part, broke  out  afresh in another.  Afterward  a kind
of crusty pustules appeared upon the skin, beginning in  some upon the scalp
(which was most frequently the case), and upon other parts in others.  At first
they were only small, but increased, by degrees, in a short time, to the size of
the husk of an acorn, and  had a  good deal  the same appearance,  not  unlike
those scabs which appear on  the heads of boys.  Of these scabs there werr

  *Doct. 61.
  t Rosa Anglica.  Pavia, 1492. Car. 61.  In the library of the College of Surgeons.
  1 Car., 107.             II De Morbis Contagiosis.  Lib. ii., cap. 2. De Morbo Gallico. 
20
INTRODUCTION.
several different kinds, some of them small and  dry, others large and moist;
some of a livid color, some of a palish white, and some hard and reddish.  All
of them opened in a few days, and discharged a  thick foetid matter;  nor is it
possible to express what the quantity of that matter perpetually discharged was,
nor how nasty it was in quality.   Afterward the ulcerated parts became eroded
in' the same manner as  those ulcers which are called phagaedenic, and sometimes
they infected not only the flesh, but likewise the very bones. When it attacked
the  head chiefly, it produced acrid rheums,  which eroded sometimes the palate,
sometimes the uvula, sometimes the jaws and tonsils.  In some it destroyed the
lips, in others the nose, in others the eyes, and in others the whole pudenda.
Besides this the limbs in a great many were disfigured with gummy tumors, which
frequently grew to the  size of an  egg, or a  small loaf, and,  being laid open, dis-
charged a white mucilaginous matter. That tough hardness appeared chiefly in
the  legs and arms, and, sometimes  became ulcerated; sometimes it continued
entire till death.  But, besides all the above-mentioned  symptoms, as  if they
were only trifling, there occurred violent pains of the arms, frequently, together
with pustules, sometimes  before,  sometimes after, very obstinate and lasting,
and excessively tormenting.  They were most violent in the night, and  the pain
was not properly in the joints, but in the muscles and nerves.  However, there
were pustules sometimes without  pains; and in some, pains without pustules ;
but the greater part was afflicted with both.  In the meantime, all the limbs
became feeble, the body emaciated, the appetite quite lost; the patient had no
sleep, but was either melancholy  or very irritable, with a strong inclination to
lying in bed.  His face and legs swelled; sometimes, though rarely, the disease
was attended with a slight fever; some had a pain in the head, which was last-
ing, and  not to be subdued by any medicines."*
  During the  following years, John de Vigo, Peter Maynard, Nicholas Massa,
Fallopius, and others, make mention of the remaining symptoms, which are now
universally recognised.
  Fernel, in 1548, thus writes : " On whatever part of  the body the Lues first
settles, there  fixing itself, it excites  a pustule,  and soon  after a  small ulcer.
Thence extending further, it fixes its roots, and sensibly  penetrates the interior
by a forced unceasing action;  and in fine,  unless you  shall have  opposed to it
some remedial measures, it devastates and  commits ravages on the whole by its
virulence.  From this it is manifest that a certain poison  constitutes the essence
of the disease, creeping over or insinuating itself into the whole body, in no
manner differing from  the poison  of the rabid dog or scorpion.   The signs of it
are various, depending on the nature of the parts over which it spreads. When
the virus, for  the sake  of illustration, has its origin in copulation, from  the pri-
vate parts bedewed with  moisture, it determines, first, pustules in those parts
which are very obstinate, and then small ulcers which are difficult to treat, and
are of rather a bad character.  Then the vapor or effusion, creeping inward by

  ► This description of Fracastorius may apply even at the present day.  Let any one who is
 cognizant with large venereal hospitals be asked if he does not often meet with cases of this
 kind. Females of abandoned lives apply for admission, giving the description here spoken
 of,  viz., laboring under severe secondary symptoms, and do not mention, or altogether deny
 the previous existence of primary symptoms.  Fracastorius was unaware of the relation be-
 tween secondary and primary symptoms.  There are Fracastorii at the present day, in spite
 of  the progress of surgery. 
INTRODUCTION.
21
the hollow canal of the pudendum (for it is not credible that any humor or fluid
enters it), it impoverishes (labefactat) the blood of the vena cava and the spirit
contained in the  larger artery, and  then the bubo breaks  out  in the groin.
Hence a gonorrhoea manifests  itself from the diseased spermatic ducts and kid-
neys, by which this most foul virus  is ejected as by belching.  When this exe-
crable disorder has invaded  the  liver and stomach, a certain slight abdominal
flux breaks out, and soon after the blood is infected with the  liver, by which all
the veins of the body become implicated;  and in this manner disseminated in
the limbs, muscles, and skin, it having  been repulsed, breaks out silently,  and
worse than before.  Livid  and  reddish pustules  occur, ulcers  covered with
crusts and teters,  in  some persons  excavated and malignant ulcers, and in bil-
ious persons phagedenic and corroding sores ; in the melancholic temperament,
cancrous or cancerous ulcers;  and in the phlegmatic they are more superficial
(leviori), but more foul, and discharging  a fcetid, mucous humor; and in san-
guineous persons  they are more thickly  set, and resemble carbuncles.   All, in-
deed, with very hard, indurated,  tumid,  and inverted edges, which (ulcers) hav-
ing eaten the flesh, feed upon the bones themselves ;  at first  the thin bones  (as,
for instance, those of the palate and nose), then those of a more solid consist-
ence, which, becoming putrid and carious, are thrown off.  It follows, as a nat-
ural consequence, that when the head is attacked, or the brain is the seat of the
disease, many pituitous humors,  disproportionate to the condition  of  the part,
collect, which, if  shut up in the  head, produce a severe and  considerable pain;
but if they  point under the scalp, and should be determined toward the joints
and limbs,  they excite most  dreadful and  daily tortures, increased greatly at
night; or they excite very hard tophi and  scirrhous tumors,  by no means free
from pain.  Although the matter appears pituitous, nevertheless, being  im-
pregnated with this deadly matter of poison, it partakes of its acrid properties.
Thus hiding itself under the periosteum of the bones, it produces pain both by
its acrimony and by distension.  Penetrating the substance  of the bones as  it
were by minute tubes, it expands them and dilates  them into tumors—which
(bones) at length  being attacked with caries, become  putrid.   If the matter be-
ing less biting and acrid does not destroy the skin, its malignity or noxious va-
por, being poured out around the hair, occasions (in the language of Fernel)
an effluvium;  on  which account the greater part appear without hair on  the
head, eyebrows, or body; but the hair may be reproduced.
   " But its  effects are not confined to the external parts alone; they extend to
the internal parts, affecting even the viscera, which are found, as in exanthema-
tous diseases, on dissection, covered with pustules and ulcers."*
  * Joan. Fernelius  de Abditis Rerum Causis.   Lugduni. Liber ii., cap. xiv.  De Morbis
Contagiosis, p. 210.
  Who can deny this accurate description of the ravages of syphilis ? No author of the pres-
ent day can add to the category of the affections successively attacking the various parts of
the body, but their relation to primary  symptoms was unknown ; this, however, was not  sur-
prising ; at the present day I not unfrequently meet with such cases  at St. Bartholomew's
Hospital, among the  female patients, the genital organs covered with primary sores, the body
concealed, as it were, by scabs, the throat and bones suffering  simultaneously.  Such cases,
of course, are contagious, and were arranged under the head of contagious diseases, but no
distinctions  were made in those days.   Fernel, like many modern surgeons, viewed the
ulcers as one and the same, and considered  them contagious—an  error as will  afterward
appear. 
22
INTRODUCTION.
  In the year 1736, Astruc, physician to Louis the Fifteenth, wrote his celebra-
ted treatise on the Venereal Disease; to him is due the merit of having writ-
ten the most learned book of the ^lay, and of having treated the subject in a
methodical manner.
  The work of Astruc is divided into two parts; in the first  he describes  the
first stage, or local venereal diseases;  in the second he  treats of the  second
stage, or confirmed pox; in other words, of the venereal  disease when it  has
become universal.
  Under the first  stage he included, 1. Virulent gonorrhoea and all its conse
quences.  2. Venereal buboes.  3. Chancres.  4.  Verrucac  and condylomata-
  Under the second stage, or confirmed pox, he describes successively, 1. Dis
eases of the genitals.  2. Diseases of the skin.  3.  Diseases of the mouth  and
nose.  4.  Venereal pains.  5. Diseases of the bones.  6.  Glandular and lym-
phatic tumors.  7. Diseases of the eyes.  8. Diseases of  the ears.  9. Disor-
ders  of the functions.
  Hunter, in 1784, like  Astruc, admitted the  existence of a venereal virus,  and
traced an  admirable picture of the disease;  he, moreover, taught that this virus
on which  the venereal disease  depended, might affect the system in two modes.
Primarily or locally,  secondarily or constitutionally.  By his  experiments on
inoculation, he proved that these divisions existed, and might easily be distin-
guished.
  The same learned  author believed  that  the  primary effect  of  the venereal
virus was twofold.  When it came in contact with a mucous surface, a gonor-
rhoea resulted; when, on the contrary, it was  placed in  apposition with the
skin, chancres would follow.  Hence his classification of gonorrhoea and syphilis
as the primary effects of one and the same virus.
  He called public attention  to  the induration which he believed always at-
tended true primary sores,* and did not consider as  syphilitic such primary ul-
cerations as presented no such appearance.
  John Hunter further professed lhat the venereal virus  in either  of  its  two
primary forms could give rise to constitutional effects, which he has so  ably
described in his valuable work, under the term Lues Venerea.
  In 1782, Benjamin Bell brought forward his experiments and  reasons for  sep-
arating gonorrhoea from syphilis  or chancre, and his views  were afterward
adopted and corroborated, in 1812, by Hernandez of Toulon.
  In 1815, the celebrated Broussais taught that syphilis is an  irritation which
affects the exterior of the body as does scrofula; that the physiological school
of medicine ought only to note the forms and  degree  of irritation in the differ-
ent  organs, and that it should alone  occupy itself with  means to oppose it.
Messrs. Jourdan and Richond, the pupils of Broussais, followed up the doctrine
of their teacher, and denied the existence of a virus; " Call  it  what you will "
say they, " but name it not virus."  They consequently reject  the idea  of the
constitutional phenomena of poisoning, which they regarded merely sympathetic
of local irritation.
   In 1830, M. Ricord commenced his investigations on the causes and natural
 history of venereal diseases.   The first result he obtained was to convince  him-

   * De Vigo had long before done this, but Hunter laid  stress upon a point which seems to
 have been generally overlooked. 
INTRODUCTION.
23
 self and the public that a special cause (perfectly independent of the sexual or-
 gans) gave rise to and occasioned  the  propagation of syphilis; he moreover
 attached a strict meaning to each term  he employs, instead of that  chaos of
 synonymous terms which existed in the writings of preceding authors.
   Considering the term "venereal  diseases" in its most  extended sense, he
 defines it to be, " all those affections which are more  or less, directly or indi-
 rectly, the consequence of sexual intercourse, in whatever way affected."
   Venereal diseases thus defined, he arranges in two orders.
   Order I. contains diseases  depending upon common  causes, independent of
 any special agent, reproducing themselves daily, and under all possible condi-
 tions ; consisting of simple  affections, in a word, non-virulent.  We call them
 syphiloid diseases.
   Order II. contains diseases depending upon a special principle, distinct from
 all the ordinary morbific causes; affections which  give  rise to special  effects
 called virulent. We call them syphilis.
   This second order has three distinct stages.
   1st Stage includes primary symptoms, which are the immediate effect of the
 morbific cause occurring on the spot where the virulent agent has been  depos-
 ited.  Example, chancre.
   2d Stage comprehends secondary symptoms, which  are the consequence of
 absorption into the system of this virulent cause.  They are hereditary, but  not
 capable of transmission by inoculation.  Example, certain affections of the skin
 and mucous membranes, iritis, &c.
   3d Stage comprises  tertiary symptoms, not capable  of being transmitted by
 inoculation, nor hereditary, but subject to pathological transformations and alter-
 ations of the submucous and subcutaneous,  or of the fibrous or osseous, tissues.



                                   II.

 HISTORY OF THE  THEORIES  ENTERTAINED  ON THE NATURE
               AND ORIGIN OF VENEREAL  DISEASES.

   It may be thought by some  superfluous to dwell  upon these subjects, inas-
much as they have been already  treated of in the previous part of this historical
sketch.   The  perusal  of this  section will,  however, I trust, prove that such is
not the  case, as the notice  taken of them was only incidental, and they still
require further elucidation.
   In the sacred writings, from the slight allusions made to these affections,  no
one will be surprised to find that these points are barely dwelt upon; but there
is  apparently no reason to believe that they were supposed to differ from other
diseases, except in  consequence of the manner in which they were contracted;
in fact, they seem to have  consisted  of simple inflammatory  affections, which
yielded to ordinary means.
   Whether the affections described in the Proverbs were mere inflammatory dis-
eases, or maladies of a  specific nature, is a question which I shall not now stop
to  examine.
  The various affections of the genital organs, of which mention is made by
Hippocrates, Celsus, and other ancient writers, as they are  not stated to have 
24
INTRODUCTION.
 followed sexual intercourse, can not be noticed  here;  neither will it be neces-
 sary to state the various theories which these fathers  of physic entertained on
 their cause—such as too great continence, a dyscrasy of the humors, &c.
  In the year 437, as mentioned in a former part of this introduction, a disease
 of the genitals which followed connexion was  supposed to depend upon the
 judgment of Heaven. In the 13th century, as we learn from  the writings of
 Gulielmus de Saliceto and John of Gaddesden, the disease, although attributed
 to contagion from foul women, was supposed to originate in hot humors, which
 find their way out of the body through the womb.  A little later the disease
 was  stated to have  arisen in consequence of persons being affected with the
 leprosy;  and we may offer  it as  a probable  conjecture, that under this  term
 were included affections which would now be called venereal.
  Such were the opinions entertained regarding  the disease we have sketched
 in the previous pages, up to  the  end of the  fifteenth  century;  in fact, many
 authors of great repute believe that, up to this period, no such afiections as
may be called venereal had existed. Whether these opinions be correct I  shall
 leave to the consideration of my readers, as they are now in possession of the
 data  on which to decide, and I shall at once pass on to  the opinions entertained
 at that period on the nature and origin of venereal affections.
  Those  authors who wrote at the latter end of the fifteenth  and commence-
ment of the sixteenth century, were convinced that venereal affections, which
 at that time assumed such severe forms, owed their origin to the fatal influence
 of the stars, to the conjunction of Venus  and Mars, or of  Jupiter and Venus.
Among this class may be enumerated the names of Torella, Maynard (Peter),
 Fracastorius, &c.; and hence we may infer the influence  that astrology and
 the planets were supposed to exercise in producing disease, even by the best-edu-
 cated physicians of the day.   There were, however, others  who treated as idle
 fancies these supposed stories of astrologers, and the malign influence which the
 air was supposed to  produce; thus, the venereal  disease  being  generally ac-
 knowledged to be a contagious malady, the same causes were stated to  develop
it as  are  now considered to give rise to epidemics.  These   opinions, however,
 gradually lost ground, and a more  special cause was sought after, as the nature
 of the means and ordinary sources of contagion became more generally known;
 among others, they (venereal diseases) are again  attributed to leprosy, to ulcers
in the womb, to poisoned wells, to the use of lime in bread, &c.
  Van Helmont, in 1640, believed that the disease first sprang  from unnatural
 connexion between a man and  a horse laboring under the farcy, which occurred,
 as he believed, about the time of the siege of Naples.  Dr. Linden thought that
it had its origin " in sodomy sometimes committed between  men and monkeys,
 or the satyrs of the ancients."
  Having given the principal hypotheses, I shall pass  to the opinions of more
 modern authors, not, however, omitting to state that the major part of the au-
 thors believed that  the diseases which they  described were new, and not
 known previously to the taking of Naples.
  That learned and laborious  author, Astruc, was of opinion that venereal dis-
 eases were not known in Europe  previously to the year 1493, when, he states
 they were brought into Spain by the followers of Columbus, on their return af-
 ter the discovery of America.   The same author quotes various passages  from
 contemporary writers to prove the correctness  of his opinion, and states that 
INTRODUCTION.
25
venereal diseases were endemic in the Antilles, and  especially in the island of
St. Domingo, whence they were  directly imported.   In  subsequent pages he
cites various passage for the purpose of proving that they are of native growth,
and that the following places may be  considered as  so many seed-plots of the
venereal venom :  viz., the kingdom of Peru; New Spain;  Florida; the midland
part of Africa under  the line; the island of Java;  the Molucca islands; the
country of China.
  As to the  immediate source of the diseases in these countries, Astruc attribu-
ted them to  the nature of the diet, to  immoderate promiscuous intercourse, and
the virulent acrimony of the menstrual flux.
  Having explained in this manner the original appearance of the venereal dis-
ease, Astruc informs us that it was communicated by sexual intercourse to the
Spaniards, who imported it into Europe;  thence it spread  among the  Neapoli-
tans.  Soon afterward he traces it among the  French, who contracted it  from
lying with infected women at the  siege of Naples, and it soon afterward spread
over the other countries of Europe.
  In 1752, Sanchez* wrote a book to contradict the opinion which the writings
of Astruc had made popular, and came to the following conclusions :—
   1st.  That the venereal disease was  known in France previous the arrival of
Columbus.
  2d. That  the Spanish army could not have given the disease to the French
troops, as it did not come in contact with them.
  3d. That  it commenced in Italy, at the beginning of the year 1493, as an
epidemic.
  Hunter declines giving an opinion on the origin of venereal diseases, as he
thinks  it could  be of little practical benefit. Having previously noticed at
length his division of the diseases, and the opinion he entertained on  the  spe-
cific nature  of the virus, which caused both gonorrhoea and syphilis, I  shall not
here allude  to them.
  Broussais and his followers, as I stated before, denied that the venereal dis-
ease depended upon a virus.  M. Richond, in  1826,  published a work, entitled
" De la  Non-Existence du Virus Vencrien."  Practitioners of this school be-
lieve that venereal diseases depend upon  simple inflammatory affections, result-
ing from the mode of the peculiar vitality of the organs primarily affected, and
of their sympathetic power over certain parts of the economy.
  They believe that the diseases in question  may arise spontaneously, and in-
stances are given by them in which this is said to have occurred.
  Having now traced the principal opinions (from the earliest times to the pres-
ent day) which have been entertained on the origin and nature of venereal dis-
eases, I shall, in as concise a manner  as possible, give my own opinions, which
I have every reason to believe are those of M. Ricord; but as the professor of
the Hopilal du Midi has not yet published on this subject, I am unable to quote
his words.
  Venereal diseases, according to the  definition which I have already  given of
the term, have probably existed from the  most remote ages, or at least the  non
virulent class of such affections.  Proof of this has not only been adduced from
history, but  I have likewise the following reasons for the belief: At the pres-
             * Sur l'Origine de la Maladie Venerienne.  Paris, MDCCLII. 
26                         INTRODUCTION.

ent day we find that all these non-virulent affections* may be developed sponta-
neously, and that we  can produce them at will; hence  I  conclude that it  is
more than probable that they existed long before they were described, because
the same agents were then in action to produce these  affections as  at  present.
Thus I admit the spontaneous origin of all non-virulent diseases, and that when
once developed they may be propagated by contact, under circumstances which
I shall hereafter allude to.
  In respect to the second order of venereal diseases, or virulent affections,] I can
only now assert (and must refer to the subsequent chapters for proof), that we
are not acquainted with any cases (nor do any such exist on record) which
prove that syphilis, properly so called, can arise spontaneously ; all the experi-
ments made to produce it de novo have completely failed; and a careful inves-
tigation of the disease proves, on the contrary, that it has been contracted from
a person who has himself contracted it of another, and it is in this way that the
disease is now propagated.  I thus deny most  positively the spontaneous  origin
of this form, or of syphilis, properly so called;  the exact laws and  periods  at
which it ceases to be contagious, as far as my observations  extend, will be
mentioned hereafter.
  When this disease began (for necessarily it must have had an  origin) I,  in
common with ma/iy previous writers, admit my ignorance.   I can trace it (as I
have done) as far back as the year 1494, and on this point there is little  differ-
ence of opinion; previously to that year authors ate not agreed:  for my own
part, I believe that a disease similar  to syphilis was known previously  to the
year 1494, as may be gleaned from the authors I have cited;  but I am as  firmly
induced to believe that the exact date of its outbreak is unknown, and that we
are in ignorance of those circumstances which  first gave it birth, or in what
country it first made its appearance; in this respect the same lack of informa-
tion reigns  as in  a vast number  of other diseases, the origin of which we are
equally unable at the  present day to ascertain.   I believe that the disease has
had various phases; at one period it has assumed a very mild character, in con-
sequence of attention to cleanliness and peace.  On  the other hand, in time of
war and famine, it has assumed  aggravated forms depending upon evanescent
causes; and the disease, though always smouldering, will break out again, and
rival in intensity those forms described by Fernel and Fracastorius, should the
world become the scene of that condition of society which  existed in the  six-
teenth century.  In proof of this, I need only cite Dr. Ferguson's account of
the disease as it attacked our men in the Peninsula, and gained it the name of
the Black Lion of Portugal.
  Having given, then, my own opinions, which will be more fully developed  in
the succeeding pages, I turn from this theoretical part to describe practically a
disease on which the.author and  reader will more certainly  agree.

  * By the term non-virulent affections I mean diseases, the consequences of sexual inter-
course, depending upon common causes, and not on any special one ; as, for example, gon-
orrhoea, &c.
  t By this term are meant those affections which depend on a special principle, distinct from
til the ordinary morbific causes.                                                 / 
A
COMPLETE  PRACTICAL  TREATISE,
                       &c, &c,  &c.
           PART  I.
SYPHILOID  DISEASES.
                       CHAPTER I.

                     BLENNORRHAGIA.

  For the purpose of bringing the subject of venereal diseases in a
clear and methodical manner before my readers, I  shall  adopt the
arrangement of M. Ricord, pointed out at pages 22, 23, of  the Intro-
duction.
.  Order I.—Comprehends the non-virulent venereal affections, called
syphiloid by M. Ricord.
  Definition.—By the term  syphiloid diseases are meant  those af-
fections which follow sexual  intercourse, reproducing themselves
daily, often contagious, but not depending upon a special cause—non-
inoculable.
  Under  this order is included blennohrhagia, and its consequences;
excoriations, herpes, eczema, and all other affections the result of sex-
ual intercourse, not included under the second order, or virulent affec-
tions.
  Blennorrhagia, from B\ewa, mucus, and 'Pso, to flow, signifies a
discharge from  mucous membranes, consisting usually of mucus, and
depending upon inflammation of that membrane, being to the urethra,
vagina, or conjunctiva, what bronchitis is to the bronchi, with this
difference only, that blennorrhagia most usually depends upon, or is
contracted in, sexual intercourse.
  Gonorrhoea.—The disease here spoken of, under the term Men- 
28
BLENNORRHAGIA.
 norrhagia, has  been successively  known by a  variety of names.
 Among others, authors have employed the term gonorrhoea, derived
 from Vovn, semen, and ^&>, fluo, it being supposed that the disease de-
 pended upon a discharge of semen.
   The impropriety of employing the term gonorrhoea, at the present
 day, will at once become evident;  in  the first place, it is objectiona-
 ble, inasmuch as the  discharge which attends  it  does  not contain
 semen,  and  it is by no means applicable as a general term (in the
 manner I  have proposed to employ the word blennorrhagia) to the
 affections  of mucous membranes.   Thus, when the  disease affects
 the uterus, under causes other than those of contagion, we fear we
 should be  altogether misunderstood if we spoke of gonorrhoea of the
 uterus.  By choosing  another  term,  I hope gradually  to wean the
 minds of practitioners from the idea  that gonorrhoea, as they call it
 (blennorrhagia, according to my views),  is  always the consequence
 of contagion, although they are unable to distinguish it, except by the
 cause.
   Chaude pisse is  the  term employed  usually in France  in  non-
 medical language, derived from chaude, hot, and pisser, to urinate;
 but though graphically describing one of the symptoms very frequently
present, still it is objectionable, as many patients, particularly females,
do not  complain of  scalding in making water, when the affection is
confined to the upper part of the vagina.
  Puorrhcea is the  name given  to  the  disease which we are de-
scribing, by a French writer : he wishes  to  imply, that the affection
gives rise  to, or  is accompanied by, a discharge of pus.  Now, al-
though it happens that pus is mixed with the discharge,  still it alone
does not constitute the affection,  for I  shall presently show it to  con-
sist of muco-pus, and the  quantity of the latter secretion will differ
greatly.  The inconvenience, therefore, of using such  a term will be
at once  apparent.
  Arsura is another term that old writers employed to designate this
disease, as they  supposed it to be a species of purgation to man, and
replaced menstruation  in the female, which in their opinion was the
outlet of bad humors.
  Clap.—This term, now commonly employed in England, is derived
from the French term clapier, meaning a depot of matter, or anything
that is filthy.  The impropriety of using  such a  term in this work
 need not be dwelt upon.
  Mucite.—The physiological school in France  applies  this term
to blennorrhagia, implying a simple  inflammation of the  mucous mem- 
BLENNORRHAGIA.                     29
brane.  The propriety of adopting this term will be considered here-
after.
  Catarrhal inflammation is another term by which this disease
has been known, and Capuron has spoken of it as a venereal catarrh,
not implying, by that term, that it depends upon a principle distinct
from  inflammation, but wishing to use  the  term venereal as I have
done in speaking of venereal affections, viz., that the disease is a con-
sequence of sexual intercourse.
   Catarrhal primary syphilis.—In the valuable work on the Ve-
nereal Disease, by  the late Mr. Wallace, I find blennorrhagia de-
scribed under this term.   Notwithstanding such an authority, I  think
no term could be more improper,  as it brings us back to that period
when gonorrhoea and syphilis were supposed  to arise  from one and
the same virus.
   Brenning is the last term of which I shall speak ;  and it is here
mentioned, more to  complete the history of the synonymous terms,
than  with  the  intention of  recommending it as a general one to
describe the disease  in question, arising as it  does  from so many
causes.
   After a careful consideration of the  terms which are and have been
in use, I come to the conclusion  that the use  of the term blennor-
rhagia presents the fewest objections,  although, like the others, it may
be  cavilled at.   In the following pages, then, it will be employed, and
although derived from B\swa, mucus,  and 'Ps&j, to flow, still it is not
intended to express that the discharge, which is a consequence of the
disease, consists only of mucus ; it  is rather a muco-purulent dis-
charge, as any one may readily satisfy himself.
   In making use of this term, let not the reader consider that the dis-
ease  depends upon  anything specific, or different from common in-
flammation ;  for, after a close study of uncomplicated cases we can
find no reason for agreeing with those authors, who seem disposed to
admit a blennorrhagic virus, or, in other words, to distinguish gonor-
rhoRa from leucorrhcea.
   Blennorrhagia is  then defined to be a simple inflammation of the
mucous membrane, a consequence more or less direct of sexual inter-
course, not necessarily, although often, contagious ; this last character
depending upon a morbid secretion of the stimulating matter, which,
acting on another mucous membrane, will occasion a blennorrhagia,
but will (on inoculation) produce no disease of the cellular tissue into
which it is introduced.  In fine, blennorrhagia differs in no respect
from other inflammations of mucous membranes, otherwise than  in its 
30
BLENNORRHAGIA.
 usual situation,  and in the manner in which it is contracted.  Blen-
 norrhagia thus considered may occur in nearly all the mucous mem-
 branes.  In the male, the urethra or prepuce may become diseased j
 in the female, the vagina, uterus, &c.; and  in both sexes, the con-
 junctiva and rectum.   The affection,  as far as my personal observa-
 tion has gone,  does not  attack  either the buccal  or nasal mucous
 membrane.
   The  epithelium alone may be the seat of the affection, or the sub-
 stance  of the mucous  membrane may participate  in it;  lastly, the
 follicles may become affected, or the  sub-mucous  cellular tissue be
 simultaneously or consecutively attacked.  (See pi. I. &IL,figs. 1,2,
 3,4.)
   Causes of Blennorrhagia.—The causes of blennorrhagia, con-
 sidered in reference to mucous membranes  generally, may be divided
 into two classes, the predisposing and exciting.
   Predisposing  Causes.—Under  the  head of predisposing causes,
 age may be cited  as an important  feature.  Infants are found to be
 more predisposed  to the affection  than adults, cceteris paribus;  and
 this predisposition seems to depend upon the  delicate state of their
 mucous membranes.  Who that has seen the treatment of new-born
 children, is not acquainted  with the fact  that they are particularly
liable to blennorrhagic affections of the eyes, glans, and prepuce, from
 causes that would fail to give rise to the complaint in adults ?
   The  sex has  likewise its influence as a predisposing cause ; it is
an indisputable fact, that the female is more liable to discharges of a
blennorrhagic character than  the  male.*   In Paris,  says M. Ricord,
woman  may be said to have habitually a discharge,  call it what you
will, leucorrhoea, gonorrhoea, fileurs blanches, &c.: it affects all ages
and all stations.   " Were I called upon," adds  the same author, " to
estimate the proportion of discharges in the  male and female, I should
say that it is  a hundred times greater in the  little girl  than in the boy ;
a thousand times greater in the adult female than in  the male."
   The  temperament  plays  its  part,  likewise,  as  a  predisposing
 cause.  Every individual who is subject to  congestion, or an cedema-
 tous state of the mucous membranes, is predisposed to blennorrhagia •

  * M. Lisfranc, in his clinical lectures, is in the habit of stating, that, being called one
 day into the country, to perform an operation on a washerwoman, he amused himself
 out of scientific curiosity, during  the time his assistants were preparing the necessary
 apparatus, in examining the linen of the Parisian ladies, a load having just arrived (for
 his patient did  the  washing on  a large scale). He  found that evident symptoms of
 blennorrhagic discharges were present upon nearly all. This may give the reader an
 idea how common the disease must be in the French capital. 
BLENNORRHAGIA.
31
hence the lymphatic temperament is a strong predisposing cause.   It
may be here  stated, that  preceding blennorrhagic  affections predis-
pose the  individual to  future attacks;  hence people are sometimes
said to be subject to a blennorrhagic diathesis :  but such  a term has
been abused ;  it is no more correct  than to speak of a sore throat dia-
thesis.  Daily observation, nevertheless, proves  that any portion of
the body which has been  the seat of disease is, cceteris paribus, more
liable to become a second time affected, than one which has not been
previously affected.  This applies  especially to mucous membranes,
as a tumid state of parts, and a liability to a  return of the hypersecre-
tion, remain long after the cure of the blennorrhagia.
   Locality.—Habitation is another predisposing  cause :  in a cold,
moist climate, or in damp situations, blennorrhagic affections are more
common than  under opposite  circumstances.
   The  season of the year is not without  its influence.   In spring
and autumn, discharges from  mucous membranes are more common
than in summer  or winter.
   Hygiene is  daily found to  predispose, more  or less, to the same
effect.  Under this general term mention should be made of the in-
fluence of clothing.  Light and imperfect clothing may be considered
as one of those causes which predispose females in the higher ranks
of life to discharges of a blennorrhagic nature.   They will usually,
whatever be their station, sacrifice  comfort to appearance ; hence the
mignon shoe and the open-worked stocking  are worn, in spite of the
cold feet they produce : a chilliness of  the extremities follows the
insufficient quantity of woollen under-garments, and  gives rise  to
what are called white discharges.  The peasant-girl, who protects
herself from  the cold by woollen  petticoats and worsted stockings,
observes M. Ricord, is not subject  to leucorrhoea.  Hence we may
draw the practical lesson of strongly recommending warm  clothing in
cases of blennorrhagic affections.
   Having passed in review the principal predisposing causes, let me
now speak of those that may be considered more directly to  act  as
efficient or exciting causes.
   Exciting  Causes.—Food of a stimulating, heating nature, as well
as salt  provisions,  act  as exciting causes. Beer, of all beverages,
has been more especially accused  of this effect, but on  insufficient
grounds ; it is, however, certain, that of all beverages  it is the one
which will the soonest bring back a  discharge when taken during
convalescence.   In Germany, the  students  who drink beer, though
of a weak kind, to great excess, know this so well that they avoid it 
32
BLENNORRHAGIA.
 most particularly when laboring under blennorrhagia, and I had occa-
 sion to see cases where the discharge was recalled by even one glass
 of that liquid.  They consider their red wine of the greatest benefit,
 and find that a bottle  of their strongest  Rudesheimmer does not so
 much harm as one glass of beer.
  Among other articles of food, asparagus has a tendency to produce
 blennorrhagia ; hence its  use should always be forbidden to patients
 liable to the affection  in question.  There are, in fact, certain persons
 who can not eat that vegetable without having an urethral discharge
 on the following morning.
  The use of cantharides is often followed by the  same effect.
  It has been stated  that horse-exercise will produce, in the female,
 this affection. Frequent and long-continued sexual indulgence, or too
 severe continence, are likewise said to act as exciting causes, and so
 I believe they may, when predisposition exists.
  While, on the one hand,  M. Jourdan thinks that onanism is one of
 the most  common causes, M. Ricord  entertains a different opinion.
 Far from supposing that masturbation is always followed by blennor-
 rhagia,  I  imagine it to be a strongly exciting cause.  The following
 case shows  that there exists some reason for this opinion.  During
the period I performed the duties  of Externe, under Professor Vel-
peau, at La Charite, a mother brought into the hospital a little girl of
three years of age,  affected with  a white  swelling  and a discharge
from the vagina.   She stated that the infant was in the constant habit
de s'amuser, as she called  it, and  when left alone, repeated continu-
 ally this mal-practice.  She further traced  the habit, so early com-
menced, to a plan which nurses in France have of tickling the genital
organs of children who are peevish.   This, for the moment, quiets
them ; but infants repeat  these manipulations  even at a very early
 age, as  this  case proves.   On inquiry, I found that this was not an
isolated case, and leads in after life to most vicious propensities.
  Local irritation, or mechanical causes, such as bougies,  pessaries
 calculi,  or any substance that individuals introduce  into the vagina
 rectum,  or urethra, will act as causes of the  disease.  On this sub-
ject, M. Ricord states, that a  woman was brought  into the wards of
 Dupuytren, complaining oF great pain  in the vagina.   On examina-
 tion by the toucher,  that eminent surgeon was not a little astonished
 at finding his finger opposed on all sides by a wall of porcelain, when
 after sundry efforts, a  large jam-pot was pulled out, which this female
 had introduced so far that  she herself was incapable of withdraw-
 ing it. 
BLENNORRHAGIA.
33
  Enemeta have been accused of causing blennorrhagia, probably on
insufficient evidence ;  but their  employment  may recall a discharge
when it is getting well.
  There are certain pathological or morbid states of the constitution
which occasion the disease in question.   Thus  scrofula, gout, can-
cerous affections, various skin diseases, secondary symptoms, partic-
ularly the  mucous tubercle, have undoubtedly this  effect.*  M. Ricord
related a case, during the last winter, of a female who was affected
with an herpetic affection running along the whole length of  the va-
gina ; the disease lasted eight days, and gave rise to a discharge which
ceased with the eruption.
   Labor may be considered as not an  unfrequent cause of blennor-
rhagia ;  the lochia, instead of disappearing after  the usual time, be-
come irritating, and give rise  to chronic discharges.
   Inattention to Cleanliness.—There is  no one cause, perhaps, among
those I have previously mentioned, which gives rise to blennorrhagia
so frequently as inattention to cleanliness.  Women, more especial-
ly, are liable to  much  blame  on  this score;  they wash every other
part of the body, but, unhappily for their own comfort, as well as that
of their  husbands,  they seem to be averse to let clean water reach
the vagina.   Such neglect of cleanliness  is  not  found in the  case of
prostitutes  only, but is  met  with in many other women.   Certainly
those who have the direction  of young females would do well  to rem-
edy this  inattention.   M. Ricord states that all ranks would be bene-
fited by sundry hims on this subject.
  Menstruation has its influence in producing the affection in ques-
tion.   Of  this fact no people were more aware than the Jews ;'  and
we find it strictly forbidden in the Mosaic law to have  connexion with
a woman about this period, and no doubt it arose out of the fact that
such intercourse was found to propagate blennorrhagic affections.

  * A good illustration of this happened in one of the patients at the venereal hospital
during the last winter.  A man came in  suffering under various secondary symptoms,
particularly the mucous tubercle (condyloma) around the anus. He drew my attention
to a discharge which proceeded from the umbilicus.  On examination, a mucous tuber-
cle was distinctly recognised in this position, and M. Ricord took the opportunity of
showing it to his class : no doubt many of my countrymen will remember well the case.
Now here is1 the secretion from the tubercle giving rise to a blennorrhagic discharge.
Had such a case occurred in the vagina, most ipersons would have considered that the
gonorrhceal or leucorrhoeal discharge, as it would there be called, gave rise to second-
ary symptoms, whereas the converse is true. Moreover, as mercury is of the greatest
advantage in curing secondary symptoms, and was here employed with advantage, so
would such treatment be cited as a further proof that  gonorrhoea  and syphilis are one
and the same affection.
                                 3 
34
BLENNORRHAGIA.
   Worms.—Intestinal worms  exert an  influence  in  producing  the
disease; as  they may act by occasioning a  sympathetic  action  be-
tween the rectum and vagina—irritation in the one organ is felt gen-
erally in the  other;  or again, by the passage of the worms from the
anus to the vulva.   M. Ricord states that he has seen a case where
he could distinctly trace the blennorrhagia to this cause.   I have met
with several  cases of blennorrhagia in children, which show the  im-
portance of medical men being acquainted with this fact.    The  fol-
lowing may prove interesting.  A woman brought  a female  child to
the hospital, which  she had left very much to itself, as she was
obliged to go out to  work during the day; and observing a discharge
on its linen, questioned it, and said that she believed a boy had given
the disease  to  the  child.   On further interrogation, this  was by no
means so evident; the mother had asked the child if she did not play
with such a boy,  and the  child replying in the affirmative, she con-
cluded the boy had ravished her child.  A dose of scammony brought
away a great quantity of worms,  and the  child got perfectly well.
Renal and vesical affections, as well as haemorrhoids, will act in the
same way in producing discharge from the male  and female organs
of generation.
   Reflections on the foregoing Causes.—Having now passed in re-
view those agents which can be rationally considered as predisposing
and exciting causes of blennorrhagia,  1  may observe that, thus con-
sidered, it presents nothing that is specific ;  it may arise under the
most varied circumstances and causes.   Its existence in the male or
female, therefore, is of itself no proof of libertinism ; it may occur in
the most modest as  well as in the  youngest child.   Hence, in medi-
cal jurisprudence, the necessity of being guarded in our opinion,  and
the surgeon, in family disputes on the subject of contagion, should be
especially cautious, and always  lean to the weak side.*   Thus the
opinion of Tod, viz., that blennorrhagia depends upon a specific virus
  * I have  at present under my care a case illustrative of this, and how much good a
medical man may do in arranging those family disputes arising from blennorrhagia. A
very respectable looking female applied to me for a discharge of twenty months' stand-
ing, which she asserted her husband had given her.  On examination, a large ulcera-
tion of the neck of the  uterus was observed. This patient stated, that twenty months
before she had miscarried, and the discharge had been increasing ever since ■ and as
she had observed stains on her husband's linen, she was sure he had gone astray, and  *
that she had contracted the foul disease from him.  He denied the accusation, and ac-
cused her of infidelity, and they led a most unhappy life.  In about  three weeks after
this female was cured, the husband soon got well, and they are now perfectly satisfied
that the affection in the one was the consequence of the miscarriage, and the clap in the
other a consequence of the previous affection in the female. 
BLENNORRHAGIA.
35
is no longer tenable.  But this leads me to speak of contagion in ref-
erence to blennorrhagia.
  Contagion.—I  have previously avoided,  except in  the definition,
even alluding to the possibility of this  affection  being  contagious, in
order that I might comprise  that  subject in a  separate paragraph.
Every one well knows  that  it is by contagion that this disease most
frequently extends itself ;  and some have imagined that it is only in
such a way as this that it can be contracted.  This opinion has, how-
ever, been shown to be incorrect.
  Whenever, then, the word contagion is used, let it be understood
to mean, that if the muco-purulent secretion from any of the foregoing
causes  of  blennorrhagia comes in contact with another portion of
previously healthy mucous membrane, either in the same individual
or in another, it will, in many cases, but not in all, produce a similar
affection ;  not, however, in virtue of anything specific in the muco-
pus, but as a  consequence  of  simple irritation—like any chemical
irritant, in fact.
  But  it is not always enough to bring the secretion in contact with
a healthy mucous membrane, in order to produce blennorrhagic affec-
tion.  There are various  circumstances which must be combined, to
produce  the effect,  although we can not always  seize upon them.
Every individual  exposed  to contagion  is not affected, any more than
when  exposed to a draught of  air he  should be seized with coryza,
although his neighbors on the right and left may be attacked by it.
  In some cases  we arrive at, or suppose we know, the cause of this
circumstance.   Thus we may say that habit, or, as the French call
it, acclimatement,  may account for the impunity or manner in which
some individuals are exempt from the affection.  The following case
will illustrate our  position—we borrow it from a collection of memoirs
published by M. Ricord.   A companion to an'elderly lady was in the
habit of receiving a lover who  was a  very old friend ;  and during a
long intimacy contracted no disease,  although this lady, his mistress,
suffered under a discharge.   It  happened that a second lover pre-
sented himself, who was previously perfectly free from  disease.   No
sooner, however, had  this young man enjoyed her favor,  than  he
found himself attacked with a discharge, although the original lover,
notwithstanding frequent intercourse, was  never seized with any af-
fection.  The second lover got cured of his complaint, and although
he visited this lady afterward, he did not contract any  fresh  disease.
But a third Lothario was,  like his predecessor,  subject to the same
penalty for her first favor,  and was in his turn rendered exempt from 
36                     BLENNORRHAGIA.
a second attack.  On examining the female, M. Ricord found there
existed a catarrh of the uterus, which was more or less purulent, and
a granulated appearance on the surface of the neck of the uterus was
very apparent.*  Now in  this  case  it appears  that habit prevented
the original lover from contracting a blennorrhagia, although exposed
in the same manner as the other two, who in their turn became  in-
sensible to a  second infection.   In this respect  habit may have its
influence, as in cases of certain  fevers which are said  not to attack
the natives, but only strangers, who become, after a time, unaffected,
although exposed to the same influences.
  Although contagion is one of the most frequent causes of blennor-
rhagia, surgeons must not be too credulous, otherwise they will be
liable to be often deceived.   Women will frequently hatch up a story
as to the manner in which they have contracted  a discharge.   It is
not uncommon for nurses,  for  example,  to account for  a discharge
which they may be  subject to,  by saying they have contracted it from
the child they  have  taken in to nurse, wishing  to make  you believe
that it is through the milk they themselves have become affected.   If,
on examining such children, no disease of the mouth or genital organs
is found, the surgeon may flatly contradict them,  as such a means of
contagion is impossible.
  Before quitting the subject of contagion, I should say a few words
on  certificates, a subject  which annoys  very frequently a medical
man.   In consequence of judicial inquiries, or family feuds, a female
presents herself and  asks the surgeon for  a certificate to the effect
that she is not subject to a contagious disease, or  is not in a condition
to  communicate any discharge, under which she  herself is laboring,
to  another person.
  M. Ricord recommends that the surgeon write  one to the following
offect, having previously carefully examined  the woman  with a spec-
ulum, and finding no ulcerations :—
  " I certify, &c,  that-------presents no symptoms of a  syphilitic
disease, but has a catarrh of the vagina, uterus, &c, and may proba-
bly [or not, as may be] communicate the disease to another."
  No surgeon can  be warranted in stating more.
   Epidemics of Blennorrhagia.—Blennorrhagia, in the preceding
paragraph, has been considered as a  sporadic disease, but it is repre-
sented by some authors as occurring epidemically.  One of these so
called epidemics,  says  M. Ricord,  fell under my notice during the
building of the Magdalene.   An epidemic  existed among the masons
         * Bee plate  II., fig. 3, which represents a similar appearance. 
BLENNORRHAGIA.
37
and occurred to so great an extent that, when a mason presented him-
self as an out-patient, I immediately told him he worked at that build-
ing, and came to consult me for a clap;  and the  poor fellow thought
me a prophet, so sure was I to be right in my  statement.   This sup-
posed epidemic simply depended on the collection of a great number
of workmen together, who lived in common with a few women suffer-
ing under blennorrhagia.   Such is the explanation of these so-called
epidemics,  and the word can not be more unfitly used as applied to
such cases.
   It will not, perhaps, be out of place here to say a few words on the
period that elapses between exposure to the  causes, and the occur-
rence of the  blennorrhagia.  The period is usually some few days,
but will depend upon the greater or  less reaction which takes place,
as well as  other circumstances, for a certain  space of time  always
passes between the last connexion and  the appearance of the dis-
ease.
   Some authors have observed cases which occur so long after con-
nexion, that they have been induced  to believe in what is called in-
cubation.   Among others, Bell cites a  case to prove this point.  A
person went on board a ship, where he could have no means of con-
tracting gonorrhoea (adds Bell), and  on the fiftieth day after being at
sea, a discharge from the urethra appeared and continued some time.
Here, then, is a case  of  gonorrhoea which was  contracted on shore,
and broke  out at the end of fifty days ; the intervening time was the
period of incubation.
   Now, giving Bell all the credit for veracity, it does not seem neces-
sary that we should come to his conclusion.  Might not the man have
contracted  the discharge by certain mal-practices ?  But even this
was not necessary.  It has been  above  stated  that various  causes
will produce the disease, as well as contagion, particularly scorbutic
complaints.  Is it not more rational, then, to suppose that these very
rare and exceptional cases depend  on some cause above alluded to,
rather than to believe that incubation exists, or  that gonorrhoea may
be concealed in the system, to break out when  it  pleases its good will
and pleasure 1
   I believe, in fine, that  blennorrhagic affections are produced soon
after the causes which excite them come into action.   Circumstances
may retard them  two  or three days :  in this respect they resemble
other diseases.
   The  Symptoms of Blennorrhagia.—A blennorrhagic affection
may be ushered in by loss of appetite and the other signs of an in- 
38                     BLENNORRHAGIA.
 flammatory disease, constituting the general symptoms.  These are,
 however, often absent.
   The local symptoms consist in heat, a tension of the part, followed
 by increase of the natural secretions, which  soon  afterward tend to
 diminish, and may altogether cease, giving rise to that form which
 has been vulgarly called dry clap.   It does not, however, remain long
 in this state,  for the secretion again becomes not only increased, but
 altered, taking on a  muco-purulent character, and the pus will pre-
ponderate in proportion to the severity of the inflammation of the cel-
lular tissue.   The discharge changes in color; at first it is milky,
then more or less gray or green, or, in proportion as  blood  is mixed
with it, it will have various shades.   To these circumstances the pa-
tient will pay great attention.  The odor, as Avell as the thickness of
the discharge, will vary much.
   The course of the  affection will  be either acute or chronic ; how-
ever,  the  symptoms  have usually a tendency  to progress until about
the twelfth or twentieth day.   From that  period it as gradually de-
creases in severity.   From  being purulent, the discharge assumes  a
muco-purulent or simple mucous character; and lastly, only an aug-
mented but natural secretion remains.
   The terminations of the  affection may be various.   Soon after its
invasion, the  blennorrhagia may terminate suddenly, either  under the
influence of  treatment,  or  without  any reason that we  can assign:
such may be  called delitescence.   It has been  supposed that the dis-
ease, after existing a certain length of time, may be  cured locally and
suddenly, but at the risk of being driven into  the system and break-
ing out afresh in some other part; in other words, that  a metastasis
of blennorrhagia may take  place, analogous to that which occurs in
rheumatism.   M. Ricord states, that  after a careful consideration of
cases where  the affection is supposed to be driven into the system,
and cases of  this kind have  been observed in his hospital from time
to time, he is by no means convinced  that  a blennorrhagic  affection
is cured  in  one part of the body, merely to break out in another.
From what he has  observed as happening occasionally, he is induced
to believe that some  other affection may come on during, or coinci-
 dent with, a blennorrhagia ;  which  disease, acting on revulsive prin-
 ciples (as a blister or  seton would), may  moderate  or  cure the blen-
 norrhagia.  For instance, should a patient, during a gonorrhoea be
 seized with any other affection, say fever, that may have the  effect
 of producing such a revulsive action,  that the  discharge will for the
 time abate.   I have  seen this  happen pretty  often ;  but such  is not 
BLENNORRHAGIA.
39
the opinion usually entertained.   Persons believe, for example, that
a gonorrhoea quickly suppressed by treatment will give rise to ophthal-
mia, swelled  testicle, and rheumatism.   On the contrary, I think it
more probable that any one of the foregoing diseases may arise du-
ring the  course  of a gonorrhoea, and, if violent, will act as a revul-
sive ; but the  original complaint, instead of being  cured,  is  only
ameliorated for the time : it will return to its  former severity.  In
this respect blennorrhagia resembles other affections of the  system ;
and it is of use, in a practical point of view, to know that these affec-
tions are rather  coincidences  than caused directly by blennorrhagia
driven into the system.
   Resolution.—The most ordinary termination of blennorrhagia is by
resolution;  that is to say, a gradual diminution in the symptoms and
secretions takes place.
   Such  has been  always considered as the most favorable  termina-
tion ; but of this I shall again speak under the head of treatment.  It
will be there seen that I  do not think a gonorrhoea should be allowed
to go on unchecked, for a cure by delitescence is preferable.
   Continuation under the Chronic Form.—Surgeons  have  usually
stated that the affection may terminate in a chronic form.  Such lan-
guage is, however, not correct,  as their  so-called termination is un-
doubtedly but a continuation of the disease under a  chronic form. M.
Ricord  observes,  he was  consulted by a military man for  a  gleet
which he had been subject to for thirty years.   Could it then be said
that the blennorrhagia terminated thirty years ago,  as he had suffered
ever since that period ?  The  acute stage of the disease may then
terminate, or pass into a chronic one, which depends on various alter-
ations of the tissues, consisting  sometimes in hypertrophy, with indu-
ration, or with softening of the mucous or sub-mucous tissues.
  Pathology  of  Blennorrhagia.—The  lesions  of the  mucous
membranes which result  from blennorrhagia are  numerous ; yet very
few specimens are preserved in even our best museums of pathologi-
cal anatomy.  Works  on the  venereal  disease  are equally deficient
in information on these points.  In books on this subject, one writer
has copied  another, and  seems to have dissected books rather than
bodies ; hence, since the time of  Morgagni, how few^new pathologi-
cal illustrations have we on the disease,  and how  seldom do we see
the urethra opened in post mortem examinations !  For these reasons
I shall describe the subject in  the following pages at some length.
Hunter  states it  as his opinion, founded  on the examination of the
urethra  of two men who were hanged while suffering under gonor- 
40
BLENNORRHAGIA.
rhoea, that this disease is attended with no changes of the mucous
membrane.   Other writers, in copying him, have been contented with
this view, although they forget that a mucous membrane, wherever it
is placed, is subject to certain diseases in common.  Why should the
urethra, then, be more exempt than other similar  membranes ?   Ob-
servation of the genito-urinary mucous surfaces during life, as well as
after death, have clearly proved,  that either acute or chronic inflam-
mation will produce  such alterations in it as are not generally stud-
ied, much less known.  By means of the  speculum, the state of the
female organs, in cases of blennorrhagia of these parts, has been suf-
ficiently demonstrated ;  and from the analogy of the tissues, it might
have been supposed  that  the same morbid appearances  would be
found in the male,  could we observe his urethra.  Gonorrhoea,  how-
ever, seldom terminates fatally.   The following appearances I can
speak of, from direct observation,  as occurring in the vagina, &c.
   In acute stages of blennorrhagia, the mucous membrane is simply
redder  than usual in its whole extent,  exactly resembling what takes
place in balanitis, or what is commonly called gonorrhoea praeputialis.
(See plate III, fig.  1.)   In some cases this redness, accompanied by
a  good deal  of local swelling, puts  on an  erysipelatous character,
which  has induced Fabre to term it gonorrhee seche, as it gives rise
to very little discharge.
   In other instances  there exist distinct patches  of reddened cuticle
or epithelium, surrounded by a healthy appearance  of the mucous
membrane.  These patches are  covered  with little  pieces of de-
tached  and softened cuticle, or spots,  as seen in  the drawing (plate
III., fig. 3).   All species of discharges may accompany these morbid
states,  and require  to be removed  before these appearances are dis-
tinctly brought into view.
   In some places there may be erosion of the epithelium, and distinct
granulations may be observed emerging from the body of the mucous
membrane, as seen in plate L, fig. 2.  Ulcerations of all characters
may be met with in any point of the  internal organs, as most  Eng-
lishmen who  have attended M. Emery's  clinique have had ample
means  of observing, and as may be seen in plate II., A. fig. 1. When
the disease is in a  chronic state,  I have often observed the mucous
membrane paler than usual, but presenting at certain points a tume-
fied appearance,  and  stripped of epithelium, or covered by pale gran-
ulations similar to those observed in  cases of chronic inflammation
of the conjunctiva.   This condition of parts is very liable to bleed
under  slight  causes.   In some cases I have witnessed distinct vege- 
BLENNORRHAGIA.
41
tations in the whole course of the vagina, as well as at the orifice of
the urethra.  In plate III., fig. 2, vegetations are seen sprouting from
the urethra of the male.  This is the second case which I have ob-
served during the last winter.
   M. Ricord states he  has,  in two  cases (examined after death),
found  distinct  ulcerations,  with an indurated base, situated on the
mucous membrane,  an inch and a half within the carunculae  myrti-
formes.  The plate showing ulcerations of the urethra in the male
will be given in a wood-cut,  in the second part of this  work.  In
neither of these  cases was there any analogy to cancer or scirrhous
disease.
   In addition to  the  changes* above mentioned, distinct induration,
or cicatrises, and other morbid appearances, may occur; but any fur-
ther description must be reserved for what we shall have to say on
stricture.
   With reference to the termination of blennorrhagia, it will be often
found very uncertain, as every one well knows ; hence the tendency
of patients to accuse unjustly  certain women of giving them the dis-
ease, whereas a warm bath or a too copious dinner will recall a com-
plaint which was  on the wane.
   Blennorrhagia may not only return, but recur at regular intervals.
I have seen a few cases of  this kind, which I may call periodical, as
they were accompanied with intermittent fever, and seemed to depend
upon irritation about the neck of the bladder.   Certain other causes,
also, may influence  the return of blennorrhagia ;  thus certain patients
have an annual gonorrhoea, which follows the carnival.  In  these
cases, drinking and dancing reproduce the discharge, if there  is any
predisposition.
   These periodical attacks of blennorrhagia,  again, depend upon
causes which we  are not able always to ascertain, independently of
sexual indulgence.  " I have," says  M. Ricord, " seen  more than
one  person attacked with gonorrhoea annually, in consequence of eat-
ing asparagus, and, on leaving off this vegetable, the discharge has
ceased.
   Complications.—In the  previous pages,  blennorrhagia has been
described as it may occur; but  in a variety of cases it is  not such a
simple disease : numerous accidents arise during its course, and will
be here described under the head of complications.  The local swel-

  * The illustrations which are annexed place these lesions now beyond a doubt, and
I have had too many opportunities of showing their existence in England, to suppose
that they are confined to Paris, and do not equally exist in this country. 
42
BLENNORRHAGIA.
 ling may be so great that  the  urine may be prevented from passing
 along the canal, giving rise to retention depending  upon an inflam-
 matory stricture.   The  lymphatic  vessels may become likewise in-
 flamed, and buboes or swelling of  the  lymphatic glands result, as
 occurs after an irritation in any part of the foot.   These buboes may
 be the result of a direct extension of the inflammation along the lym-
 phatic vessels to the glands, or  may depend  upon sympathy,  or  that
 law of the animal  economy which  causes  the one extremity of a
 canal or tube, when irritated, to swell or sympathize with the other
 extremity, without the intervening  part of  the tube or canal being
 sensibly affected.  These last  are  properly  called sympathetic bu-
 boes.
  I have seen haemorrhage occur during the  course of a blennorrha-
 gia, which, like other haemorrhages from mucous membranes, may
 depend upon  simple exudation from the surface, or upon the rupture
 of vessels around ulcerations, or from a varicose state of the  venous
 system of the part.
  Fresh exposure to contagion, as well as any excess in diet, by ex-
 aggerating  the severity of  a previously existing  blennorrhagia, will
 act as a severe complication, by increasing the morbid condition of
the mucous membrane.
  Chancre is a frequent complication.   It keeps up the irritation, and
gives rise to a secretion, which, from its position, we  can not always
remove as soon as it is formed.
  Constitutional syphilis has been above stated to be a frequent cause
It may likewise be a complication, as will appear in subsequent chap-
ters.
  I shall hereafter describe one of the  most  frequent complications,
namely, epididymis, or what is usually  termed swelled testicle ;  but
it can not find a place here, as we  are describing only what is gen-
eral in regard to the affection, without reference to locality.
  Notice has previously been taken of rheumatism occurring during
the  course of a  blennorrhagia.  Authors generally  are  not  agreed
upon the relation between these two affections ;  and having no fixed
opinion,  I therefore  speak  of it as a complication,  observing, that
rheumatism may come on  during the time that a patient is suffering
 under blennorrhagia.  I am, however, induced to  believe that blen-
 norrhagia is not the exciting cause, though it may be a predisposing
 one, of rheumatism.
  The Diagnosis of Blennorrhagia.—From what has been above
 stated, it will appear at once that the diagnosis of blennorrhagia is 
BLBNNORRHAGIA.
43
easy,  characterized as the disease is by a muco-purulent discharge.
There are, however, several points which are deserving of attention,
as distinguishing the position, intensity, &c, of the affection.
  The character  of the  discharge  will often give the  surgeon some
notion of the exact situation  of the  disease.   When  he observes a
glairy secretion, resembling the white of egg, he is justified in stating
that the neck of the uterus is affected ; when the  discharge is com-
posed of muco-pus, he may be assured that it arises from the urethra,
vulva, or vagina, &c.  Some assistance may be derived likewise from
chemical tests, to decide whence the  secretion  issues, as it is found
that the  muco-pus of the  vagina is acid, whereas that coming from
other  sources is alkaline.
   When  the mucous membrane  is alone inflamed, the secretion is
formed almost solely of mucus ; when, however, the sub-mucous tis-
sue becomes affected, we observe the secretion  to assume a more or
less purulent character in proportion as this tissue  is  affected.
   The existence of blood, mixed with muco-pus, will generally lead
the surgeon to expect an ulceration of the  canal, which he can not
examine.  But here there are many sources of error, as blood may
be poured out in consequence  of  excessive  inflammation.   Usually,
however, I  have been  able to distinguish, or at least to suspect, the
existence of a chancre, from the appearance of the discharge, when
it has a grayish or  reddish tint, and is  of a thin consistence;  and
inoculation has frequently  proved these  surmises to be correct.  I
shall not here stop to point out the error of those who consider that,
because  blood is mixed with the blennorrhagic secretion, the disease
was contracted from a woman during a menstrual period.
   Lallemand  of Montpellier has, in  his late  work entitled " Les
Pertes Seminales," laid  great  stress on the existence of semen in
these  discharges  of  a  chronic character.  A  careful  examination,
however, should be made, before it is asserted that the spermatic fluid
is present, as what is often called  semen is nothing  more than the
prostatic fluid, which is  to be  distinguished from the former by its
containing no  animalcules,  when  viewed  under the microscope.
When semen is present in the discharge, we may usually affirm that
blennorrhagia has reached the opening  of the vesiculae seminales,
and, by the  irritation it produces, gives rise to the  ejaculation of se-
men,  which becomes mixed with the  secretion.  The  acute may be
distinguished from the  chronic stage in the urethra, by the former
being accompanied with pain in making water,  and the secretion be-
ing purulent; whereas the latter is  accompanied by no scalding in 
44                     BLENNORRHAGIA.

making water, and the secretion is mucus.  It will hereafter be found
that the existence of the one or the other stage occasions a great dif-
ference in the treatment.
  A very important point of diagnosis may be drawn from the exist-
ence of the complication of chancre, as it enables the surgeon to de-
cide whether a blennorrhagia is of a virulent or a mild character.
  This point has been very much contested ;  and although the ex-
pressions virulent  and mild  are often met with, yet no two medical
men are  agreed upon the use of these terms.   I shall, before explain-
ing my own opinion upon this point,  say a few words on the various
suppositions which have been brought lately forward.
  Supposing that a male or female is laboring under a blennorrhagia,
the question to be decided is, whether it be a virulent or a mild affec-
tion.   Some surgeons state that, before coming to an opinion, we must
wait for the occurrence of secondary symptoms ; if they appear, it is
a sufficient reason to call  the blennorrhagia which has preceded, a
virulent complaint.   This  opinion is just;  but we would ask, of what
use is  a diagnostic sign  which can be only given at so late a period,
and when we have arrived  at the diagnosis it is of no further use to
us, as  probably the blennorrhagia is cured 1
  Other authors  have considered the existence of buboes as the dis-
tinguishing character of the two  forms of the disease ;  but, as will
hereafter be shown, no  dependance can be placed upon this sign, for
any simple irritation on  the foot, &c, will give rise to buboes ; there-
fore the mere circumstance of buboes, without reference to the pus
they secrete, demonstrates nothing.
   Some, again, state that a virulent blennorrhagia  follows connexion
with a suspicious subject;  whereas a mild affection may follow con-
nexion with  a modest woman.  These  distinctions, founded on  the
consideration of the causes, can not be adopted.   Is the opinion on  a
subject like  this to be  based on the supposed or presumed morality
of one woman  over  the  other ?  Does  not daily experience  show
(says M. Ricord) that girls of the most tender age, as well as persons
holding high social positions, can and do contract virulent complaints,
and may communicate these to persons who have  connexion with
them 1   Let not the  fact of a disease being contracted from a more
or less (apparently) virtuous woman be the means of founding a diag-
nosis.
   Little dependence can be likewise placed on the opinion of those
 who state that the green color, as  well  as the presence of blood in
 the discharge, or the breaking out of the disease a long time  after 
BLENNORRHAGIA.
45
connexion, can enable us to distinguish a virulent from a mild blen-
norrhagia.
  Not long since, at the Academy of Medicine, it was stated that the
duration of the disease may serve as a distinguishing feature  of the
two forms.  A virulent complaint was stated  as likely  to last forty
days,  and a mild one twenty.   This, however, is a very erroneous
opinion, as will presently be shown.*
  The acute nature of the complaint, and the existence of ulceration,
has  been also  cited as proving the existence  of a virulent affection.
This will likewise be shown to be incorrect.
  Induration of the canal, pain on pressure at a particular point, and
the possibility of  taking  the impression  of an  ulceration with the
porte empreint, or bougie armed with wax, have been cited as so many
pathonomonic signs of the  virulent form.   It will hereafter be found,
however, that these form but a probable diagnosis, as induration is by
no means a constant character, and any  simple ulceration will give
rise  to pain, and an  impression may be occasioned by folds  of the
mucous membrane.
  I  believe that  authors have had ample reason for separating blen-
norrhagia  and  its  discharges into two forms, which they have called
virulent and mild ; but I have before  stated, that, previous to M. Ri-
cord's investigations, they had completely failed to state on what cir-
cumstances they depended,  nor  could they by any one symptom dis-
tinguish one form from the other.   As this  is of great importance, I
may be excused if I dwell  somewhat longer on  it, particularly  as
many other facts that I shall hereafter describe, depend upon the clear
comprehension of this subject.
  The previous views of authors show how much difference of opin-
ion existed on this subject  when  M. Ricord undertook  to show that
the  cause of a virulent blennorrhagia depended upon the complaint
being complicated with a chancre.   In women, more especially, he
found that what was called a virulent  gonorrhoea depended upon the
existence of ulcerations,  which could  not be discovered by an exam-
ination of the external organs of generation, but which the use of the

  * M. Puch, onp of the surgeons of the Venereal hospital, has stated to me that he can
distinguish a mild from a virulent blennorrhagia by the period which elapses between
the appearance of the discharge and the  previous connexion. For the observation of
a great number of cases of a mild blennorrhagia proves that the usual period is from a
few hoars to as many days; on the contrary, in a virulent affection,  the interval be-
tween connexion and the first appearance of the discharge is from seven to fifteen days.
That this is often the case, no one will doubt; but, if relied  on, it may lead to many
errors in practice. 
46                     BLENNORRHAGIA.
 speculum clearly proved to exist.  But did all ulcerations  give rise
 to a virulent gonorrhoea ? was the next question to be solved.  At the
 time this eminent surgeon was investigating the subject, he often had
 occasion to treat the woman from whom some of his male  patients
 had contracted  the  disease,  and he  found that there were various
 forms  of  ulcerations,  the  secretion of which caused simply a mild
 gonorrhoea.  There existed others, however, which caused sometimes
 chancres  on the glans penis and prepuce ; on other occasions, viru-
 lent gonorrhoeas.  In vain did he try to distinguish these ulcerations
 by their physical characters.   It was only by inoculation that he was
 enabled to prove why sores  similar in appearance gave rise to such
 different consequences.  Inoculation soon showed him that there may
 exist an ulceration of a specific character, which will be described in
 its proper place, and called chancre ; but there likewise exist ulcer-
 ations of a simple nature, the result of an  inflammatory state of the
 mucous membrane,  which were frequently the  consequence of a
 blennorrhagia.   From  this  moment,   that which  was  previously
 doubtful became clear, and an inquiring and observing mind like his
 was not long in deciphering what had been the  opprobrium  medi-
 corum.
  From what the speculum showed clearly to  exist in the vagina, he
 naturally concluded that  similar appearances  might exist in the ure-
 thra of the male, but which, from its small size, it was impossible  to
 demonstrate.   However,  one  opportunity of examining the urethra,
followed soon after by a second,  put him in possession of two cases,
which  he showed to the Academy of Medicine, in which chancres
 existed in the whole  course of the urethra.  (See cut on page  169.)
 He   thus discovered the key to this hitherto difficult labyrinth, and
 concluded that the only diagnosis between virulent and mild blennor-
rhagia is derived from  inoculation.
  The experiments, frequently repeated, of inoculating with the se-
 cretion of a simple  mild blennorrhagia, produce only a slight irrita-
tion, which subsides in a few hours ; whereas, if the complaint  is
virulent, or, in other words, depends  upon,  or  is complicated with, a
 chancre which is concealed,  or which can be brought into view by
 the speculum, the secretion introduced under the skin, in a similar
 way as in the former experiment, will  produce a  vesicle,  pustule,
 and  chancre, as seen in the drawing (plateIV.,fig, l, a> h, and c).
 This, then, I call the  certain pathonomonic diagnosis of a virulent blen-
 norrhagia.  A rational  diagnosis may be drawn from the rosy, thin,
 serous, or rusty color of the  discharge,  provided such be present, as 
BLENNORRHAGIA.
47
well as from an indurated spot in any point of the canal, accompanied
with fixed pain, &c.
   Should buboes  follow, which  on inoculation give rise to the char-
acteristic pustule, it may be asserted confidently that the blennorrha-
gia is a virulent one.  The occurrence  of secondary symptoms,
which only follow in a few cases, gives  a  further diagnosis  of the
same fact.
   It is, however, the rational diagnosis that the  surgeon must usually
depend upon, as  inoculation can not always be  proposed, or he may
find patients object to submit to it.  He must, however, remember
that it is but  a  rational one, and on  such data be cautious how he
risks his reputation by giving an opinion.
   The Prognosis of  Blennorrhagia.—The prognosis, with refer-
ence to the probable duration  of the disease, will depend in a great
measure on the mucous membrane which is the  seat of the disease.
It is proved by experience  that,  when  the  conjunctiva  or urethra is
affected, a cure will not  so readily ensue as when the prepuce or
glans penis is attacked.  When the uterine surface suffers, the sur-
geon may feel assured that the complaint will resist treatment  longer
than when the  vulva or vagina is affected.
   The same principle  holds good in  relation to the portion of the
canal affected.   It will be found that  the disease will be more diffi-
cult to cure in proportion as it has gained the deeper portions, or such
as are the farthest removed from the external openings.   Hence it is,
that blennorrhagia of the vagina or prostatic portion of the urethra
are so intractable to treatment.
   If the blennorrhagia has  existed but  a  short time,  the cure will
probably be speedy,  and the more  amenable will it be to plans of
treatment, and vice versa.   An acute attack  of  the disease will be
cured  easier and  more speedily under treatment than the chronic
form.
   The prognosis  of the surgeon  will be much modified by the cir-
cumstance of his patient having or not having been previously attacked
with blennorrhagia.  If he has previously had a  blennorrhagic affec-
tion, the present complaint  will be probably less  severe, but more re-
bellious to our means of treatment.
   It is evident that the occurrence of the  various complications will
modify considerably the prognosis.   On this point I shall not  insist,
reminding my reader only that improper hygiene and  treatment are
very liable to  produce  them, especially the formation of abscesses
along or around the parts affected. 
48                     BLENNORRHAGIA.
   Under the head of prognosis, it may be as well to consider a few
 of the questions which patients put to surgeons, more especially as it
 will enable me to state some important facts, and attempt to destroy
 some popular prejudices.
   A patient will sometimes ask the surgeon  if the treatment he  is
 about to prescribe will give rise to  a stricture or a swelled testicle.
 It is a very common  error to suppose that the treatment will occasion
 either of these  complaints ; and this, like many other rjopular errors,
 has taken  its source in medical writings, which have stated that a
 blennorrhagia speedily cured  will give rise  to various  other com-
 plaints.   M.  Ricord  says, we may state distinctly that no ill conse-
 quences are to be feared from any treatment, provided it is not grossly
 improper.  If (pursues that surgeon) I were disposed to be aphoris-
 tic, I  might say that the ill consequences will be few, in proportion
 as the cure is speedy; and I defy any one to produce a case cured
 in twenty-four  hours from its  commencement, which has been  fol-
 lowed by any ill consequences.   There are prejudices against speed-
 ily curing a  blennorrhagia, and I  may  be  told by some surgeons,
 " after a practice of full thirty  years, I am of an opposite opinion."
 But I ask, may not such a practitioner have labored under a mistaken
notion during  thirty years ?   Is implicit belief in a fact, for that space
of time, a proof that  that fact  is true ?  Has not an old author said,
and very truly,  " experientia fallax ?"
  In addition to the questions relative to prognosis which the surgeon
will be called upon to answer, he may have to reply to the following:
 Shall  I, or shall I not, be subject to  secondary symptoms ?   To  an-
swer this question, a surgeon must of course ascertain if  the blennor-
rhagia be virulent or  not.  If it is a mild  affection, he may, with
 every assurance, quiet the fears of his patient.
  If there  be reason to suspect that he is suffering under a virulent
form of the complaint, it does not necessarily follow, even then, that
secondary symptoms  will  ensue ; for if the chancre can be cured pre-
viously to the third day of its existence, no such symptoms ever will
 appear,  and the shorter  the subsequent duration of the chancre, the
less probable  will be the  chance of infection; and if no induration
 attend it, most probably no secondary symptoms will follow.   In my
 opinion, however, too great caution can not be used ; tell  your patient
 that the complaint is complicated with chancre, otherwise he may lay
 to the score of  your  treatment  effects  which really depend upon the
 existence of the chancre, or his own neglect.
  Under the head of prognosis, I must consider the greater or less 
BLENNORRHAGIA.
49
 probability of transmitting a blennorrhagia.   On this score, patients
 are  usually  very inquisitive, and surgeons  should  be particularly
 guarded in any opinion they may give.  Whately asserted, that as
 long as a discharge was merely white, there was no fear of commu-
 nicating it.  Bell states,  that if the secretion consists of mucus, we
 need entertain no fear on this head.
   M. Ricord considers that when the secretion is reduced to a thready
 mucus, which is transparent like  vermicelli, contagion is not  to  be
 dreaded.   On  the contrary, as long  as the secretion is purulent—a
 fact to be ascertained by  simple inspection, or by means of the  mi-
 croscope, whatever may have been the duration of the disease—it is
 capable of causing a similar complaint in any mucous membrane with
 which it comes in contact.
   Should, therefore, any pus be present in the secretion, the surgeon
 ought never to sanction sexual intercourse ; if the secretion be  not
 purulent, let him wait some days  before he gives his permission, to
 see if it does not become so.  Impress strongly on your patients  the
 necessity of abstaining from sexual  intercourse  as soon as any pus
 appears mixed with the secretion.  Patients will sometimes ask  the
 following question : "I am obliged to have connexion with my hus-
 band ; now, doctor, I  am suffering under a discharge—what  com-
 plaint will he contract  from me V   Inoculation will alone answer the
 question,  and  the  surgeon will at once be able to tell the probable
 consequences.   The  same question  relates to marriage; " and pa-
 tients," says M. Ricord, " present themselves to me to know whether
 they may marry, for often their fortune may depend upon a marriage.
 I persuade them  against  it, if they have a simple gonorrhoea,  but if
 it be a virulent complaint, I wash my hands completely of the affair.
 If they still persist, I tell them  that  they may give a gonorrhoea to
 their wives which, unless cured previous to confinement, may cause
 a loss of eyesight to the  child : called, however, afterward to cure
 the lady, I attempt to explain the affection which she has contracted,
 by speaking of the fatigue of the honeymoon, as well as the dejeuner
 a la fourchetle,  and in the interim cure both parties, of course forbid-
 ding connexion.  Such is the part that a medical man often has to
play, and many disputes in married life may be thus avoided, and the
surgeon must, in these  cases, lend  himself to deception."
  The  Treatment of Blennorrhagia.—In studying the history
of the treatment of blennorrhagia, it is curious to  see how it has dif-
fered at various periods, being modified by the notions which medical
men of the day entertained on its  nature and causes.  When it was
                                4 
50                      BLENNORRHAGIA.
a prevalent idea that blennorrhagia depended upon, or consisted in, a
loss of semen, such remedies were prescribed as  surgeons supposed
capable of checking spermatorrhea.
   At a later period, when humorism was in vogue, the discharge was
supposed to  consist of pus ;  and as it was thought to chase the bad
humors from the body, care was taken not to check the discharge—
the  supposed outlet  of various disorders.   When we consider that
medicine was but little advanced at this period, we are  not surprised
that this  doctrine should have kept its ground for a long time ; but is
it not astonishing that these prejudices are still entertained by many
enlightened men,  although they  reject the ancient doctrines of the
humoral  theory ?   It  is  lamentable  to find that many of the practi-
tioners of  the nineteenth  century are not more advanced than were
those of the  fifteenth,  and obstinately resist any line of treatment
which has  for its object the cutting short a disease, for fear of conse-
quences which they can not describe.   " My treatment," says M. Ri-
cord, " is opposed completely to this opinion.   I allow a discharge to
continue  no longer  than I can help.   It is never my intention to pro-
long the discharge ; if it continue, it is in spite of my treatment, which
has been ineffectual in checking it."
   When, about  the time of Fernel, blennorrhagia was first  arrayed
under  the  class  of syphilitic  diseases,  and confounded with them,
mercury  of course was used  in the treatment of both complaints,
which were considered synonymous, and many and  severe were the
cases of  salivation which resulted from such a confusion.*
   Notwithstanding  the  distinctions which modern practitioners have
introduced, and although  it is  generally believed that the two affec-
tions differ in toto,  still  at the present day many surgeons prescribe a
course of mercury  either during or after  a blennorrhagia; some con-
sider that  small doses  of  mercury are advantageous as a species of
alterative treatment.  I  shall have occasion to condemn this line of
practice  at a future period.
   Sydenham, who, in other respects,  all must so  much admire, was
in the habit  of prescribing purgative medicine, and, from his state-
ment, appears to have met with  great success ; but from my personal
experience (says M. Ricord) I can not corroborate his opinions.
  * I lately saw, in the hospital of St. Bartholomew, a case which must formerly have
been very  common.  An ostler had suffered from clap.  Several weeks previous to
coming to  the institution,  he  went to  a quack living in the city, who recommended
Leake's pills, composed of mercury, and an aperient occasionally; his mouth became
sore, and his clap got worse.  This charlatan then recommended him to apply to a
public institution. Under proper treatment he rapidly recovered. 
BLENNORRHAGIA.
51
   Tod and  his  school have  much eulogized the use of diuretics,
 under the supposition that  frequent micturition might make the dis-
 eased humor pass out of the system.  M. Ricord, in his appreciation
 of this treatment, has  found  no  other  effect result, except that of
 causing an acute attack of  blennorrhagia to pass to  a chronic one,
 which is  by no means desirable.   These various plans of treatment
 had successively held their sway in the medical world, when Bell
 proposed that a direct or local treatment should be resorted to ;  but
 useful as these means may be  in some few cases, it will be soon ap-
 parent to the surgeon that no one universal panacea can be recom-
 mended.   Blennorrhagia, like all  other  diseases, will and must be
 treated according to the indications present.
   Having attempted to establish the fact that at its commencement a
 blennorrhagia is a local affection, that the number and severity of the
 accidents which follow depend not only on the severity, but likewise
 on the duration of it, I should state that it does not at once acquire its
 greatest severity, and, moreover, that it is not one of those  affections
 which run a certain course, or last a certain time.   Lhave attempted
 to prove that suppuration is not necessary to chase  the peccant hu-
 mors from the body, and that  we  have no occasion to allow the dis-
 charge to continue during an indefinite period.
   I have  shown that the fear of driving the discharge  into the system
 by a rapid cure, or that of its causing certain accidents, is chimerical,
 and the opposite  proposition has  been  established,  that the sooner
 the patient is cured, the less  he  is exposed to these accidents.  It
 follows, then, that the  surgeon should attempt by  his treatment to
 prevent the development, and to diminish the intensity of the symp-
 toms when he has been  unable to check them at the onset, and in all
 cases to shorten the period of their duration as much as  possible.  We
 may now  divide the subject of treatment in the following manner :—
   1. I shall  speak of the prophylaxis, or the preventive means.
   2. Of the  abortive* treatment.
   3. Of the  curative treatment.
   Prophylaxis,  or Preventive Means.—It follows, as  a consequence
 of the knowledge of the causes, that it is impossible  always to pre-
 vent the occurrence of the disease,  as it may arise spontaneously un-
 der circumstances  over which the patient has no control; yet he may
 be able, in the  greater  number of cases, to prevent the  occurrence of
 the affection  by avoiding the causes that, as above stated, give rise to
  * By the term " abortive" treatment, I wish to express such means as cut short the
disease before it can be completely established. 
52                      BLENNORRHAGIA.

it;  or, if the surgeon can not persuade a patient to avoid them alto-
gether, at least he may often be able to induce him to take such pre-
cautions as will render the occurrence  of the disease less probable or
less severe.
  Such precautions, then, I now proceed to describe.
  1. As  they relate to persons already  affected, so that they do not
communicate it  to  healthy individuals who may in any way expose
themselves to the contagion.
  So large a number of females suffer under discharges, that, were
the  surgeon very cautious, he should, perhaps, forbid connexion alto-
gether ; for  M. Ricord states, that ninety-nine women and a half in
every hundred, during some part of the month, suffer  more or less
from blennorrhagia.  It is impossible, however, to forbid connexion
altogether.  But supposing a woman to be subject to an habitual dis-
charge, she may,  by taking certain precautions,  prevent those who
have connexion with her from  contracting it.  She should abstain
from  all  heating or irritating dishes  or beverages; and she should
employ frequent injections  of a slightly  astringent or cooling nature,
especially previous to connexion.
  2. The precautions to be taken by a sound individual who exposes
himself to the contagion,  should consist in not prolonging the vene-
real act,  and in making water immediately after it ;* but the means
which place the patient  most indisputably beyond the possibility of
contracting blennorrhagia, is the use of the  condom.   " This practice,"
says M.  Ricord, " is not  sanctioned, it is true, by nature, yet Astruc
has long since recommended it, and in practice there are many cases
in which the surgeon is  forced to prescribe connexion once or twice
a week,  as he would do aperient pills.  Although,  therefore, a prac-
tice not to be lightly sanctioned, I must recommend it in some cases,
for without it the  mucous membrane  of the urethra would infallibly
inflame."
   These, then, are the only means which a surgeon can depend upon
or  recommend,  to place his patient out of danger of contagion.   The
host of  other specifics which  charlatanism has invented, I shall not
here stop to enumerate.
    The Abortive Treatment.—It has been stated above, that one of our
 principal objects  should  be  to shorten the period of the duration of
 blennorrhagia, and to check it at the onset.   This we should attempt
 to effect in two ways,  either by general, or local and direct means.
   * The use of injections into the urethra is prejudicial, as they serve only to push the
 contagious matter farther into the canaL 
BLENNORRHAGIA.
53
The following, or the abortive treatment, is, however, only applicable
previous to the occurrence of the symptoms of acute inflammation—
that is to say, during the first few days after the disease has declared
itself.
   The general means will consist in  abstaining from all irritating or
heating food ; not, however, that we prescribe an entire abstinence.
A moderate use of nutritious diet should be recommended, as we be-
lieve  general debility, of itself,  tends greatly  to produce a discharge
from mucous membranes.  Small quantities of fluids should be taken,
and warm baths or any relaxing  agent  should be strictly forbidden,
unless there be reason to expect that the complaint depends upon an
irritability of  the skin  or the quality of the urine ; in these excep-
tional cases alone, baths and copious drinks should be allowed.
   In  addition to these precautions, rest  and quiet of the affected parts
must  be strongly recommended.
   Internally, the surgeon should prescribe  the use of the anti-blen-
norrhagic remedies, which seem to  act by their revulsive action on
the intestinal canal, such as cubebs, copaiba,  and  turpentine.   The
doses in which they should  be administered will be further alluded
to, when mention is made of the particular forms of the complaint.
When I say that their  action is or ought to be a revulsive one, I do
not wish to be supposed to  recommend  their  use so as to produce
gastritis.   On the other hand, however, these  preparations should be
given in sufficiently large doses, and  at short intervals, so as to pro-
duce  a sudden effect on the  system.   Various powerful quack medi-
cines owe their efficacy as anti-blennorrhagics to  this mode of action.
The surgeon,  however, in the use of these  means,  must not discon-
tinue  them  too quickly, but gradually  diminish the dose.   By such
means the cure will be found to  be permanent.
   Externally,  various  revulsive  remedies  have been in vogue.   In
some  cases, the Russian or vapor bath,  which acts by determining to
the skin, will completely cure a patient in a  very short time.   Blisters
have  likewise been  employed  with  the same view, but, generally
speaking, they are prejudicial.
   Direct or local means have been  employed  with the object of cut-
ting short the  affection ; under this head I may mention compression.
This  treatment has  succeeded  in some few cases, but, generally
speaking, it is not only useless, but prejudicial.  It is only in urethral
blennorrhagia that we can employ it; and here it produces erections
by day and pollutions at night, which again  occasion congestions, the
forerunners of inflammation. 
54
BLENNORRHAGIA.
   Local baths  are likewise  to be  avoided, as they tend to increase
rather than to diminish the secretion.  However, ice and cold washes
(provided no reaction follow) may  be attended with  great  benefit.
Separation of the  surfaces of the mucous membrane will be  among
one of the direct  means from which the surgeon  may derive much
advantage ;  for, as we  have previously observed, one  diseased mu-
cous surface reacts on  the other, and augments the mischief.   In ad-
dition to  these means, great attention must be paid to cleanliness;
but, generally  speaking, the  greatest dependence  should be  placed
upon injections of  various astringents or  tonic substances, the nature
and strength of which will  be spoken of again under the head of
regional forms of blennorrhagia.
   Provided, however, these means fail in curing the patient, or if the
surgeon be  consulted at a late period, when  symptoms of acute in-
flammation  are present, it will be in vain,  and even dangerous, to
pursue any longer the treatment above  spoken of, as  it would tend
only to augment the mischief.  It therefore must be  given up ; and
this leads me to speak of the third division.
   The Curative Treatment.—The first stage, or the acute form, par-
ticularly if the  inflammation  be severe, may  require general or local
bleeding; usually, however, M. Ricord recommends leeches, taking
care to employ them in sufficient quantities, and never applying them
on those parts where the skin is doubled  on itself and maintained by
a loose cellular tissue,  such as on the scrotum, eyelids,  or penis ; for
although twenty cases  might be cited in which no ill consequences
have arisen, still the twenty-first is liable to be followed by gangrene
or erysipelas; and as  equal  advantages  follow their  application on
the surrounding parts, namely, the groin, perineum, or temples, the
surgeon should never  expose his patient to the danger of these acci-
dents.   In virulent blennorrhagia, especial care should be taken that
the leeches are not applied on a depending  part of the body, other-
wise, if the secretion falls, or comes in contact with the leech-bites,
inoculation will result, and a distinct chancre  will be formed on every
leech-bite.  I  saw a case of  this kind at the female venereal hospi-
tal, where thirty chancres existed on the perineum, in consequence
of the application of thirty leeches, prescribed by a  sage femme.
   Leeches  sometimes will produce  an  erythematous irritation  and
swelling of the neighboring  glands";  therefore it will be well for the
surgeon to  apprize his patient that this  is probable.   Poultices and
rest will,  however, soon cure this affection.
   Baths.—In the preceding  section  I have  condemned the  use of 
BLENNORRHAGIA.
55
baths; but in this, the  acute stage, they are of the greatest benefit,
when employed of such a temperature as is agreeable to the patient's
feelings.  Provided no reaction  comes on, the patient may continue
in the bath for half or three quarters of an hour.  In other cases their
use should be omitted.   Local bathing  is prejudicial, as tending to
cause congestion of the part.
  Injections are in some cases useful:  in the vagina they wash away
the secretions; but in a  narrow canal  like  the urethra,  they cause
great irritation.
  Diluent drinks may be freely employed, as they tend to render the
secretions less irritating.   The  composition of  them  must depend
upon the taste of the patients, as it is the water they contain which
is beneficial.   The  use  of diaphoretics should be strictly forbidden,
for reasons  stated above.
  The state of the digestive organs should be attended to, as all mu-
cous membranes sympathize with the stomach; constipation or diar-
rhoea must, therefore, be avoided.  In addition, the horizontal posture
should be prescribed ;  strict attention to diet, avoiding everything that
can excite, particularly beer, asparagus, &c.
  This terminates what I have to say on the treatment of acute blen-
norrhagia.  I now, therefore, turn to the chronic form, which is called
blennorrhoea.
  Treatment of Blennorrhea.—The first point in the treatment
is to omit the antiphlogistic remedies, as they have become useless
the instant  that  acute inflammatory symptoms have  subsided.   In
their place  the surgeon should prescribe those remedies which were
recommended under  the head of abortive treatment.  Warm baths
must be now avoided ; the  diet should  be more  nutritious, but  not
stimulating.   In  addition, a general  revulsive treatment, combined
with  a  local  or  direct one, should  be prescribed ;  for  experience
proves that,  although a cure may take place when either mode is em-
ployed singly, still, when conjointly employed, they  act more surely
and effectually.
   The revulsive general treatment consists in  the  employment of co-
paiba,  cubebs, turpentine, purgatives, diuretics,  astringents,  tonics,
iodine, and  cutaneous revulsives.  I have arranged them in the order
of their efficacy.
  Copaiba is placed in the first rank,  for this oil has enjoyed a repu-
tation for  being a specific, or at least  of having a special  action on
blennorrhagic affections.   It is,  in fact, one of  the  most powerful
agents-that  we employ in the treatment of  this disease.  By some 
56
BLENNORRHAGIA.
surgeons it has been given in all stages of the  complaint,  and many
r ave vaunted its virtues in the acute stage.   M. Ricord states that he
feels convinced it may occasionally be useful in this stage,  but that it
is usually inefficacious.   The result of my experience on the admin-
istration of this substance (continues M. Ricord) leads me  to the fol-
lowing conclusions on its therapeutic effects.
  In the acute stage of a blennorrhagia, it produces no amelioration;
on the  contrary, it  often gives  rise to ill consequences  which we
should avoid, and in  some cases aggravates the disease  itself.  Ad-
ministered in the  acute  stage, it has this further disadvantage, that,
if it produce no good effect, the surgeon is deprived of one of his best
agents, as the stomach gets out  of order and will not bear it at a later
period.
  The action of copaiba  is manifested  in certain effects on the stom-
ach,  intestinal canal, skin, urinary organs, and, in some few rare
cases, on the nervous system.
  The effects of the remedy  are first evident on the stomach, as it
produces a disgust;  vomiting often follows, and this occurs to such
an extent  that we have  known persons feel  sick on coming into a
room where the oil is kept.  In cases where this unpleasant effect is
produced, the surgeon may feel convinced that no  good  will result
from continuing the preparation, as it will only tend  to  occasion in-
flammation of the stomach, without diminishing the discharge.   In
cases of gastritis, which come  on especially in persons  predisposed,
the other mucous surfaces  will  become  sympathetically affected or
inflamed.
  Usually the action on the intestinal canal is but slight—particularly
confined to the small intestines.  Sometimes, however,  colic  and
diarrhoea follow.   This we consider, when present in a slight degree,
to be a  good sign,  as it by no means betokens  inflammation, but
shows that the revulsive action is taking place ;  still the surgeon
should watch carefully that inflammation does not  succeed,  or run
too high.
   It has been stated that copaiba has a decided action on the urinary
organs.   It seems as if the specific good results arise directly from
the action on the urinary organs ; for,  unless  absorption take  place,
 and the oil pass off by the urethra,'the same good effects are not ap-
 parent ;  and a further proof is,  that this preparation is especially use-
 ful in gonorrhoea.   Given in the other forms, it appears  to produce
 little or no effect, viz., in blennorrhagic ophthalmia, blennorrhagia of
 the rectum, vagina, &c. 
BLENNORRHAGIA.
57
  On the skin,  the  action of the remedy is no less apparent, produ-
cing various eruptions, most frequently one which resembles measles,
or nettle-rash;  eczema likewise sometimes follows its administration,
as it does after  eating seafish.
  To produce these complications—for such may these eruptions be
called, there must exist some predisposing cause, which usually con-
sists in a stomachic derangement: a moist state of the atmosphere,
exposure, &c.   These  should be carefully avoided during the time
that the patient is taking copaiba ;  this is the more necessary, as the
surgeon will be blamed for their occurrence.
  The eruption is usually preceded by a general lassitude and drow-
siness, and sometimes  by shivering, accompanied with a general itch-
ing or irritation of the skin.
   The eruption will continue as long as the use of the copaiba is per-
sisted in.   Let the surgeon only cease to employ  it, and in a few
days every trace of the skin affection will disappear.  Such an an-
nouncement to your patient will free him from much anxiety.  I have
observed  these affections to occur epidemically, particularly during
spring and autumn.  These have, by some authors, and Gibert among
the rest, been stated to depend upon, or bear a relation to gonorrhoea,
as  secondary symptoms do to syphilis ; but we shall not here stop to
prove the  absurdity of such an opinion.
    Lastly,  it has been stated that copaiba sometimes acts in an unu-
 sual way  on the nervous system.   During the same month, M. Ri-
 cord states, he has known the administration of enemata, containing
 six drachms of copaiba, followed, in the case of a female, by an apo-
plectic attack  ; in another  case, likewise a female, by hemiplegia,
which ceased on  the breaking out of a rubeolic eruption over the
whole body.
    The dose of copaiba must  vary according to circumstances; for-
 merly, surgeons were  in the habit of prescribing only a few drops;
 however,  Bell, Swediaur,  and others, have  given  the oil in much
 larger quantities—that is to say, in doses of from 3j to fj; and this
 last-mentioned quantity has been given without any ill consequences
 following.  My practice (says M. Ricord) is to begin with a drachm,
 and  gradually augment it  until some visible good or bad effect fol-
 lows ; but I think that the dose should never exceed §j in the twen-
 ty-four hours,  for fear of ill  consequences.   If  we believe certain
 practitioners, one would be  led to suppose that this remedy is more
 efficacious when  administered by the  rectum,  as  an enema, than
 when taken into the stomach.   M. Lisfranc, especially, is one  of the 
58
BLENNORRHAGIA.
French surgeons who relies greatly on this form of administration.
I have personally watched the treatment, but can not say I have been
persuaded that it  is a  preferable plan, as it required a larger dose,
and a longer time to cure the patient;  and the quantity employed was
enormous.
  I think that, as  the  beneficial effect is particularly marked  on the
small intestines, and not on the rectum,  the  copaiba should be given
by the mouth;  and this brings me naturally to consider the form un-
der which it may be administered.
  Daily experience proves the truth of the following proposition, viz.,
that the efficacy of the preparation will depend upon the greater pu-
rity in which it is given ; hence the superiority of those in which the
oil is simply held in suspension.
  On  the other hand results the inefficacy  of many preparations
which apothecaries have invented to cover the smell and taste  of this
drug.  Among these, I may speak particularly of its combination  with
magnesia; a means of solidifying  the oil, and thus administering it
in pills.  These hard balls pass through the intestinal canal without
any effect.
  Latterly, the copaiba capsules  have been introduced  into practice.
They consist of a  little  shell  of gelatine or gluten, which encloses a
small quantity of copaiba.  The inventors assert that oil thus given
produces no  unpleasant smell  or taste,  nor  do eructations  follow.
This, however, is not true  ; the taste and  smell are  rendered less
disagreeable, but, generally speaking, the characteristic taste  of co-
paiba remains in the mouth after taking them,  though not to so great
a degree.  Many individuals  are unable to swallow them, or the little
shell may burst, or at once  become dissolved in the stomach, and then
all the unpleasant effects of copaiba remain.
  The capsules of M. Mothes are not so objectionable as the rest;
they are smaller, and the  oil is mixed with a very small quantity of
magnesia : hence they have not the same tendency to break, but pass
on into the duodenum,  where the oil escapes  without occasioning
eructations.
  The dose is usually six or  eight capsules in the twenty-four hours.
  As  long as the  copaiba  gives rise only to slight colic or diarrhoea,
without any accompanying symptoms of  inflammation, these  symp-
toms may be  allowed to proceed, provided the blennorrhagia gets bet-
ter under its  use ;  but should no  amelioration follow,  the diarrhoea
must be checked by combining the copaiba with opium, or some as-
tringent preparation, such as  the rhatany, &c. 
BLENNORRHAGIA.
59
  Constipation should be  relieved by gentle cathartics; when  there
is  no effect  on the  urinary organs, it will be well to order a little
nitric aether ;  if the stomach be irritable, great advantage may be de-
ived from the use of the bicarbonate of soda.
  In employing, then, copaiba, we  ought  not to use exclusively any
preparation, but prefer one or the other according to circumstances.
  I  will now speak of another preparation, which has evidently anti-
blennorrhagic properties, namely—
  Cubebs.—In appreciating the value of the powdered cubebs, it should
be stated that it yields only to copaiba in efficacy; and notwithstand-
ing  the objections that have been  urged  against this remedy, I con-
sider its use of great benefit.                          ,
  On the stomach, cubebs acts like the pepper tribe generally in ex-
citing that  organ.  Its curative  powers are exerted more especially
on the small intestines; but, instead of producing  diarrhoea, like co-
paiba, cubebs  occasions  constipation.   We must, therefore, combine
it with purgatives.   In some cases, this powder irritates the stomach
to such a degree that gastritis ensues.  The surgeon should be aware
of this,  and leave off administering it on  the occurrence of the first
symptoms.  This is one  of the reasons  for preferring copaiba; an-
other is, that  cubebs is  very liable to adulterations, which are not
easily detected.  M. Ricord  states in his  lectures that he has met
with two very serious cases where he suspected an adulteration ; the
dose given did not exceed six drachms, and the two patients obtained
the powder from apothecaries in different parts of Paris ; yet, an hour
after taking the medicine, vertigo, trembling of the limbs, dilatation
of the pupil, together with convulsions,  occurred.—In one case, ery-
sipelas, followed by gangrene of the thigh, came on, and the patient
sank in twenty-four hours.  The remainder of the  cubebs was ana-
lyzed, yet  no  adulteration could be detected ; the papers, however,
were not  observed to be greasy, as they usually are.   On the other
hand, its cheapness, the fact  of the  stomach  supporting its use,  as
well as the  smell being less  penetrating in the room in which it is
kept, and, lastly, no eruptions following its  employment, have  made
it a  standard  remedy at the venereal hospital,  and  in  private prac-
tice  with  M.  Ricord.   Notwithstanding, I believe copaiba  to  be
the  more efficacious of the  two remedies  for the cure of blennor-
rhagia.
   The  dose is usually from a 3j. to ?ii.  of the powder; but among
the  out-patients of M. Ricord, I have rarely seen more than 3iij. pre-
scribed during the twenty-four hours.  He finds from experience that 
60
BLENNORRHAGIA.
 it is better to begin with this quantity, as the stomach feels at once
 the  effect  of it,  and does not habituate itself to its use, as happens
 when we order smaller doses and gradually increase them.
   The mode of administering this remedy is usually in powder, and
 when taken it  should be mixed with water.  In this state it is  far
 more efficacious than in combination with other ingredients ;  its  ac-
 tion seems more direct.   M. Ricord has  found that the tincture,  de-
 coction,  or pills, are very inferior to the powder  alone.  Of late,
 chymists have  contrived to  enclose cubebs in capsules of gum, and
 the plan is a very good  one.  The combining cubebs with copaiba
 is bad, as  the  effect generally is not so well marked, and we should
 prefer reserving the  one remedy for cases which are rebellious to  the
 other.
   It seems to act  particularly on the urinary organs, as it gives a
 very peculiar smell to the urine ; and it is especially in blennorrhagia
 of the urethra that its good effects are visible.  Cubebs and copaiba
 may, then, be said to be anti-blennorrhagics par excellence, although
 other preparations have been equally vaunted.
   The administration of turpentine, in the opinion of some surgeons,
 is attended with good effects ; but it should be ranked among the  ad-
juvants to a cure, rather than as a remedy.
   Tonics.—In  the chronic stage,  complicated with a lymphatic tem-
 perament or scrofulous constitution, the best results will often follow
 the administration of bitters and tonics, in conjunction with a reason-
 able quantity of wine and nutritious diet.   Vapor baths, shower baths,
 and sea-bathing, are adjuvants which  no  surgeon should  neglect in
 chronic cases.
   Blisters, placed as near the diseased parts as possible, particularly
 when the discharge  depends upon a change of structure of the mu-
 cous membrane, deserve well the attention of the practitioner.
   Here I terminate my observations on the general treatment of blen-
 norrhagic affections,  and shall now direct the attention of my reader
 to what may be called—
   The Direct Treatment.—This consists  in  checking  the discharge
 by local applications, which form  a numerous list,  comprising solu-
 tions of lead, zinc, the protoioduret of iron, sulphate of alum, corro-
 sive sublimate, and particularly nitrate of silver.
   As I shall have occasion to speak of these various preparations at
 a later period,  in  describing  the  treatment of the  various regional
 forms, I shall now pass them over, reserving the description of each
 of their properties and doses until then.   Leaving the description of 
BALANITIS.
61
blennorrhagia, I shall pursue the plan I have previously laid down,
and describe the disease as it may occur in one or the other sex, and
in the different mucous membranes.
                    I

                         CHAPTER  II.

                 BLENNORRHAGIA IN THE MALE.

   The forms of blennorrhagia peculiar to the male are balanitis and
 gonorrhoea;  affections of very great importance to the surgeon, and
 which I shall successively describe at some length.

                         SECTION  I.

                           BALANITIS.

   Synonymous Terms.—English writers  have  described the  com-
 plaint here spoken of, under the name of balanitis, by the terms gon-
 orrhoea prseputialis, bastard clap, external gonorrhoea, &c.  Of late
 years it has been generally known in France by the name of balanite,
 the equivalent term for which I shall employ in the following pages.
   Definition.—Balanitis consists in inflammation and patchy excori-
 ation of the glans penis  and lining of the prepuce,  accompanied by a
muco-purulent discharge.
   Causes.—The predisposing cause of balanitis is undoubtedly the
existence of  the  prepuce, for  we do  not meet  with the affection in
persons who  have been  circumcised.
   The exciting cause can be usually traced to the application of some
 irritating secretion, such as the menstrual  fluid, blennorrhagic matter,
 &c.; but, although frequently of venereal origin, this affection often
 depends upon other causes than impure connexion.  I have frequently
 occasion to see it in boys who are inattentive to  cleanliness, and al-
low the secretion of the  glandulae  odoriferae to  accumulate between
the prepuce and glans.
   I  have been able to  trace it to a discharge from the urethra, pro-
duced  by stone in the bladder, or by the passage of  instruments.
The surgeon  should be aware of these facts, otherwise he may fall 
62
BALANITIS.
into the error of attributing to infection the simple effect of inattention
to cleanliness.  I might  cite more than one instance where this has
occurred.  " The prepuce," adds M. Ricord,  in one of his  clinical
lectures, " is an appendix to the genital organs, the use and object of
which I could never divine ;  in place of being  of use, it leads to a
great deal of inconvenience, and the Jews have done well in  circum-
cising their children, as it renders them free from one of the ills of
humanity.   The prepuce is a superfluous piec^ of skin  and  mucous
membrane, which serves no other purpose than acting as a reservoir
|ar the collection of dirt,  particularly when individuals are inattentive
to cleanliness."
   As I stated above, the disease may affect  either the prepuce or
glans ; part only, or their whole surface, may  be the  seat of the  in-
flammation.  It is particularly liable to occur in the neighborhood of
the fraenum.
   The symptoms of the  affection are the following :  a slight  itching,
which is soon after succeeded by heat and pain of the part, attended
by an increased secretion of the glands, which becomes more or less
purulent.   The prepuce soon swells, in consequence of a tumefaction
in the  cellular tissue, which so largely enters into  its composition,
and this swelling may occur in a very short period.  Not unfrequently
an inflammatory or erysipelatous condition succeeds this oedematous
state, and may be confined to the prepuce only.
   Usually no pain is felt in making water, nor does  any chordee ex-
ist.  In a few cases, however, when the urine passes  over  the  in-
flamed prepuce, a scalding  is felt, and in erection the  glans may
become too large for the swollen parts around ; a pain like that expe-
rienced in chordee may occur, and it is very difficult, when phymosis
exists, to decide whether  the balanitis is accompanied with gonorrhoea
or not.
   Balanitis is usually acute in its progress, but it may become chron-
ic. Its termination is commonly favorable ; however, gangrene some-
times ensues, as well as erysipelas, more especially if the  surgeon
applies leeches on  the diseased and oedematous prepuce.  The  sur-
face of the  glans and prepuce frequently becomes irregularly excori-
ated, resembling a blistered surface,  as seen in plate III.
   Complications.—Balanitis, however, is not always the simple affec-
tion I have here described.   In some instances abscesses may form,
in consequence of  the  collection  of matter  between the  glans and
prepuce, which is  swollen  or  narrow, or a circumscribed inflamma-
tion of the cellular tissue of the prepuce result, terminating in abscess. 
BALANITIS.
63
In either case, these collections of matter will point at the upper part
of the penis, and gangrene will often attack the prepuce, and, destroy-
ing it, the glans penis will become exposed, as seen in plate V., fig. 3.
Gangrene rarely commences at any other point than this, and may
destroy the whole penis, or be limited to the prepuce, as was the case
in the individual from whom the drawing was taken.   This tendency
of the prepuce to become gangrenous  at its upper part has been vari-
ously accounted for.  Some  suppose  it to depend upon the greater
number of vessels  in this situation ; but it more probably arises from
the friction against the trowsers, to which it is subject in all the
movements of the  body.
   A very frequent complication is chancre, which, masked by a nar-
row prepuce and purulent discharge, leads the surgeon to believe that
the patient is suffering under simple balanitis.
   Secondary symptoms may become  also a complication.   Thus the
mucous tubercle occurring on the prepuce, which is already the seat
of a balanitis, will increase the disease ; it will likewise  be one  of
the causes of it.   Hence we have what is called, improperly, a syph-
ilitic balanitis,  for the complications produce or exaggerate balanitis,
not in virtue of any specific poison, but as  a  consequence of the  se-
cretion, which  is  very acrid.  Eczema, particularly in  old  people,
will constitute a  complication,  and,  like  vegetations, will  be  more
difficult to cure, in proportion as the  surgeon is unable to expose the
glans.
   Balanitis, without any complication of chancre, may cause a bubo.
This, however, is rare, and we seldom find that  buboes arising from
this cause  suppurate ; they are  merely sympathetic, and when they
do  suppurate, never give rise to virulent sores capable of being inoc-
ulated.
   Secondary symptoms never arise as a consequence of simple bala-
nitis.  Such is the result of M. Ricord's  researches on  inoculation.
I have never heard a case of simple balanitis cited which was fol-
lowed by secondary  symptoms.   M. Cullerier, who supposes that a
simple gonorrhoea may give  rise  to them, says he has never seen a
case  of balanitis which he could trace as the cause of constitutional
syphilis.
   M. Puch, one of the surgeons  at the Venereal hospital, considers
that simple balanitis may produce  a chancre, and thus induce second-
ary symptoms.  He  inoculated  a patient  affected  with simple bala-
nitis, unaccompanied  by chancre,  but in whom vegetations  existed.
The characteristic pustule was observed, and he  had the kindness to 
64
BALANITIS.
show me the case, and concluded that simple balanitis, without ulcer-
ations, may give rise to syphilis.   This conclusion I can not adopt,
for the following reasons :  He  admits, himself, that  it is  an excep-
tional case to see the inoculation succeed ;  he has observed it in two
cases.  M. Ricord has never met with similar results.   It is, there-
fore, natural that we should seek an explanation of it in some circum-
stance beyond a simple balanitis.   I believe that many circumstances
may explain this occurrence.   The patient, before entering the hos-
pital, had connexion, and as his prepuce was long, the syphilitic virus
may easily be supposed to have remained within its folds  without
producing  chancres, as the  glans was  covered  with  mucous and
smegma ;  for we find that the virus does not produce its effect until
it  comes  in contact with  the  mucous membrane  or skin, or till an
abrasion  results,  or it is introduced into a follicle.   The  virus may
remain on the prepuce  inert, provided there is a secretion which pro-
tects it, in the same way that it may be kept in glass tubes, and yet
at the end of the eighth day produce a chancre.  I believe, then, that
the true explanation of these  exceptional cases depends upon some
such cause.
   The diagnosis of balanitis  is very easy,  provided the surgeon can
uncover the glans, and see  in what state it  is ; but when phymosis is
present, the practitioner is often at a loss to know whether a simple
balanitis exists, or if it be complicated with a  gonorrhoea, chancres,
or vegetations.   In these cases,  an induration may  often be felt on
the prepuce, and, on interrogating the  patient, it will  be found that a
chancre existed before  the phymosis took place; but if no induration
exist, and if the patient have not examined the penis, our diagnosis
will be very imperfect.   Still one  means is  within our reach—it  is
that of inoculation.
   The prognosis will depend upon the complications present, for sim-
ple balanitis presents nothing unfavorable.
   The treatment of balanitis  in uncomplicated cases  is very simple.
It consists  in washing the parts, and separating the prepuce from the
glans by means of a piece of lint; this alone  will usually suffice to
cure the patient.   When all other local applications have been tried
I have seen patients, whom other practitioners  have had under their
care for six months without benefit, consult M. Ricord, and this sim-
ple treatment cured them in  a few days.   The piece of lint may be
about an inch and  a half long, and half an  inch in breadth.  Having
washed and dried  the affected parts, apply this piece of lint between
the prepuce and glans at its base,  and then draw the formerover the 
BALANITIS.
65
glans, taking care to change the lint two or three times in the twenty-
four hours.
  When an inflammatory condition of the parts exists, it will be well
to pass  a stick of caustic  over  them, simply to whiten the surface,
which should be previously dried by lint;  and during the subsequent
days the surgeon should order a wash containing—
                      Liq. Plum. Subac.  3i.
                      Aq. Distill.        Jviij.
and dry lint to  be  constantly kept between the glans and prepuce.
  When balanitis  is  complicated with chancre, of course  we must
employ the treatment  which the latter complaint  may  require,  and
which will be  described in the second part of this work.
   The complication of phymosis presents some difficulties, as it is
often impossible to act directly on the diseased parts. The first thing
to be borne in mind is, that we must not operate on the prepuce when-
ever we  can avoid  it,  particularly if the phymosis be  not habitual.
Instead of slitting  up the prepuce, M. Ricord's  plan is to wipe away
all the secretion, and introduce a stick of nitrate of silver between the
glans and prepuce, and cauterize  slightly the parts.  The immediate
consequence is considerable augmentation of pain, which may last for
half an hour, but on the following day the amendment is very marked.
Baths, and injections containing opium, are useful,  but not so advan-
tageous  as  cauterization : it is the best antiphlogistic remedy with
which I  am acquainted.
  If the surgeon, however, be consulted at a later period, when the
gangrene is imminent,  or has already commenced, the prepuce should
be freely slit up without delay, so as to expose the part; and com-
presses of cold water, or solutions of opium, should be constantly ap-
plied.
  The indications  for  cauterization, or for  incision, are sometimes
obscure.   When,  however, the discharge consists of thick pus, we
should cauterize, and the patient thus preserves the prepuce, for in a
few  days he  is able to uncover  the glans ; moreover, if there be a
chancre,  an incision is very prejudicial, as it  most probably will in-
oculate the divided surface.
  The indication  for slitting up the prepuce consists in a discharge
of ichorous matter, or when the skin is of a dark livid color. If the sur-
geon do not operate in these cases, nature herself will form an opening.
  In cases of balanitis, the surgeon should be particularly cautious
that the glans is not left uncovered, as inflammation and swelling may
occur, and paraphymosis result.
                                5 
66
GONORRHCEA.
                        SECTION II.

                         GONORRHOEA.

  The next form of blennorrhagia I am about to describe, as it exists
in the male, is gonorrhcua.
  Synonymous Terms.—M.  Ricord calls it urethral blennorrhagia;
some French writers denominate it venereal catarrh;  in  England it
is vulgarly known by the name clap,  derived from the French word
clapier, signifying a filthy abscess ; and  in France the common peo-
ple  call it chaude pisse.
  As the term  gonorrhcua is generally  accepted,  I shall employ it,
rather than change the name of the affection, and at once proceed to
treat of the conditions which tend to its development.
  Causes.—The unnatural size of the male organ, as well as  a large
meatus, tend to augment the chances  of contracting a gonorrhoea.  A
relative disproportion between the genital  organ of the male  and fe-
male will be a very frequent cause of the development of gonorrhoea.
  It is probable that the introduction  of  the gonorrhceal matter takes
place previous  to  ejaculation,  and that it is the expulsive force with
which the semen issues that washes away the contagious matter;
for, unless such were the case, I  am convinced that gonorrhoea would
be still more common than it is.
  During erection, and previous to ejaculation, the meatus has a great
tendency to open.  The round form  of the glans further promotes
this tendency, as it is pressed laterally when passing the vagina, and
this naturally separates the  lips of the  meatus.  Some writers, not
content with this explanation, believe that gonorrhoea does not occur
from the introduction of the pus, but they suppose that absorption from
the external part takes place,  and that the virus is directly carried
into the  glands of morgagni, which are situated just within the  fossa
navicularis.
   I have sufficiently, I hope, under the general head of blennorrhagia,
spoken of the direct causes of the affection ; I  shall not here there-
fore, return to the subject, but at once describe the situation of gonor-
rhoea.   Every part of the urethra has been successively considered
as  the seat of the disease ;  in  addition to the  fossa navicularis, the 
GONORRHOEA.
67
vesiculae seminales and the prostate gland have been by different wri-
ters pointed  out  as the parts from which the secretion takes place.
My own opinion is, that any part of the urethra may become affected,
but the exact point will in a great measure depend upon the time the
affection has lasted ; undoubtedly the  fossa navicularis is the point
most frequently affected, as Cockburn stated long since.
   The symptoms  of gonorrhoea consist  in pain felt in the course of
the urethra, particularly at the fossa navicularis.   As M. Jourdan has
observed, this point seems the rendezvous of all the morbid sensations
of the  penis, so this sign alone can not be of great value ; but when,
together with pain, the surgeon observes a muco-purulent discharge
coming from the ureth#, he may at once infer that gonorrhoea exists.
The pain which is felt is sometimes slight  and of an agreeable kind
—if this term may be applied to pain ; whence the belief that gonor-
rhoea proceeded from the vesiculae seminales.  More frequently, how-
ever, the pain is severe ; patients speak of their urine scalding them,
or that they feel needles pricking them, especially when the urine is
loaded with salts,  or when it  is passed in a large stream.  In the
acute  stage of gonorrhoea there is  frequently a difficulty in making
water,  a circumstance which arises  in  part  from fear of  the  pain
which  accompanies the passage of the  urine, and in part, likewise,
from the swollen  state of the  mucous membrane and the narrowness
of the  canal.
   These  symptoms do not exist long without chordee, sometimes of
so violent  a  nature that  authors  have spoken  of a distinct variety
(chaude pisse  chordee),  in consequence of  chordee  being  the most
prominent symptom.
  This chordee depends upon an inflammation of the corpus spongi-
osum, and a secretion of plastic lymph into its interstices.   It conse-
quently loses its elasticity, and in erections can not follow the corpora
cavernosa in their varied movements ; hence the curvature in different
directions,  either  downward, laterally, or otherwise.  Chordee will
be severe in proportion as the penis naturally varies in size between
the quiescent  state and  during  erection ;  hence,  in persons whose
penis  enlarges but little in  erections, chordee is  seldom  present.
Chordee is likewise a  symptom which is more severe in proportion
as the  gonorrhoea has gained the deeper portions of the mucous mem-
brane ;  when the  affection is confined to the orifice of the meatus, the
chordee is  proportionably slight.
  Various  morbid  sensations, such as  cramp, pains in the testicle, a
feeling of  tension in the groin, pricking in the perinaeum, frequent 
68
GONORRHOEA.
desire to make water, sometime  incontinence of urine,  or tenesmus
of the bladder, are present, and may add to the severity of the case.
   These  symptoms  increase  in proportion as the gonorrhoea gains
the deeper portions of the canal; hence, Bell has described varieties
which depend upon  the presence of one  or other of the foregoing
symptoms.  He  has  distinguished gonorrhoea of the bulb, prostate,
neck of the  bladder,  and bladder itself.  Instead of admitting these
distinctions,  I shall  consider them only as signs that the gonorrhoea
has reached certain portions  of the  canal; for example, the pain in
the perinaeum causes  us to suspect that the prostate participates in the
disease—tenesmus, that the bladder is inflamed, and so on.
   The Diagnosis of Gonorrhcua.—Every tyro in medicine will at once
distinguish what he calls a clap,  by means of the  symptoms  above
described ; but such a  person may not be  aware that a surgeon can
not always decide at  once whether a man is suffering under  a gonor-
rhoea or not, provided no discharge be observed,  and the lips of the
urethra be not inflamed, and no stains seen on the linen.  M. Ricord
gives the following instance of the occasional difficulty.   He was or-
dered by a magistrate to give an opinion whether  a prisoner, said to
have violated a girl, was laboring under gonorrhoea or not.  The ac-
cused presented no swelling of the lips of the meatus ;  on pressure,
no discharge came from  the urethra,  and there  existed no traces of
any secretion on the shirt.  When  interrogated,  he stated he had
made  water  six hours previously to the examination.  As M. Ricord
had some suspicion, he ordered him  to pass his  urine at once, and
desired one  of the jailers to watch his prisoner.   In six hours after,
M. Ricord returned,  and then found undoubted marks of an existing
gonorrhoea.   The  prisoner confessed that he had made water previ-
ously to the  first examination, and had taken care to remove the se-
cretion as soon as formed, by a piece of lint which he concealed for
that purpose.
   The diagnosis of gonorrhoea of  the various portions of the urethra
I have above spoken  of, and shall not repeat what was then said ex-
cept to observe that these distinctions are of importance, as they lead
the surgeon  to  foretell  the probability of this  or that  complication
arising;  for instance, a swelled testicle, or inflammation of the blad-
der ; and the patient is not thus taken by surprise,  and does not ac-
cuse the surgeon of bad treatment.
   The prognosis must  be drawn  from the general and local symp-
toms, which it is unnecessary for me here to refer to.
   The complications which may occur are numerous.   We may in 
GONORRHOEA.
69
the first place,  find abscesses in the fossa navicularis, and they exist
more frequently than surgeons think.   They commence in the small
follicles, which exist in great abundance in this portion of the canal.
Inflammation of the prostate gland is  another complication.  Hemor-
rhage comes on sometimes as a consequence of rupture of the urethra
when individuals wish  to overcome  a chordee, a practice formerly
recommended,  and occasionally followed  by the  unenlightened.
Swelled testicle,  as well as buboes, are  among the complications
which I may mention here, but I shall treat of this subject in full at
a future period.  With respect to buboes accompanying a mild gon-
orrhoea, they are very rare ; we may estimate their occurrence once
in a hundred cases of gonorrhoea ;  they seldom suppurate, and  are
never of a  specific nature ; they disappear under simple treatment.
In scrofulous patients buboes occur,  not in proportion to the severity
of the gonorrhoea, but in  virtue  of the lymphatic diathesis ; and bala-
nitis is not an unfrequent complication.
   Chancre may likewise occur in any part of the urethra, giving rise
to what the French call a chancre larve.   Of the existence of this
complication, any one who has seen much practice  must have had
ample proof.
   M. Ricord has kindly furnished me with a drawing of a urethra in
which chancre is seen in its whole extent.  (See cut, p. 195.)  Such
 cases, however, are very rare  ; he  nevertheless  possesses two  ex-
 amples.  I shall not here stop  to reconsider the manner in which the
 virus is introduced into the urethra,  as it is similar to that described
under the head of  Introduction of Gonorrhoeal Matter,  with which it
is often combined.   A knowledge of this fact, viz.,  that chancre may
 exist concealed from view, is of the greatest practical importance; it
 at once explains a host of difficulties that previously did not admit of
 solution; it points out  the  difference between  a virulent and mild
 gonorrhoea, and explains those rare cases of secondary symptoms
 which follow,  with various other points which it  would  be out of
 place to discuss here, but which are fully treated  of in the second
 part of this work.
   Chronic Gonorrhoea, or  Gleet.—The acute  stage of gonor-
 rhoea, either in consequence of non-treatment, or when treatment is
 injudiciously employed,  may degenerate into  a chronic stage, which
 is known by a diminution of the scalding in making water.  The dis-
 charge, which was previously purulent, becomes mucous, though it
 continues  abundant.  In other cases, no running is observed during
 the day, but in the morning  the  lips of the meatus  are found glued 
70
GONORRHOEA.
together, and a very small quantity of discharge escapes ; on the linen
it leaves a stain like that  of gum.  In some persons, no other traces
of a discharge are found than  various mucous flocculi, which resem-
ble little bits of vermicelli; they seem to come from the follicles in
the urethra and prostate,  and are a very plague to hypochondriacal
patients who are. haunted with  the venereal  disease;  and as they
daily examine their urine, the  existence of a thread of mucus of the
size of a millet-seed causes them to post off to their surgeon to show
him what they have found.
  All the acute symptoms have passed, as well as redness of the lips
of the meatus ;  but chordee often remains, for it will be readily un-
derstood that the cause  of this symptom is not so easily got rid of as
the others, and it often requires a  considerable  period before the penis
can regain its natural elasticity.
  In chronic cases of blennorrhagia, when  the affection  is seated
near the entrance of the vesiculae seminales, nocturnal pollutions are
frequent, attended with  considerable suffering ; here the chronic in-
flammation causes the pollutions,  and they react on the mucous mem-
brane, thus forming a vicious circle, out of which it  is very difficult
to rescue the patient.   M. Ricord states,  that patients come to him,
who, during the time that they  are rapidly recovering from gonorrhoea,
without having committed any excesses, find  the affection  suddenly
return as bad as  e^er.    On interrogating them, he often finds that the
only explanation which can be given of the aggravation of the symp-
toms, exists in the occurrence  of  nocturnal pollutions.
  Another frequent symptom of chronic gonorrhoea, is a difficulty in
making water.   Thus,  after any  slight excess in  diet,  &c , the pa-
tient will be suddenly seized with a difficulty or impossibility of pas-
sing urine.  This  depends upon a spasmodic  stricture ;  in other
cases, upon an inflammatory state of the mucous membrane, brought
on by exposure to cold,  or overdrinking ; such causes irritate further
the canal, and tend to keep up the discharge.
  In place of a  stricture, an opposite state of the mucous membrane
may exist; for instance, a want of contraction, or relaxed state of the
mucous membrane, the result of a long-continued  gleet.  The urethra
loses, in part, its contractility, and when the bladder has emptied itself,
there remains a small quantity of urine in the canal, which the urethra
can not dislodge, but which dribbles away, when the penis is in a de-
pendent position, by the  mere force of gravity ;  this naturally stains the
shirt, and ought not to be mistaken for  gonorrhoea, although the irrita-
tion which this urine produces in the canal occasions that affection. 
GONORRHOEA.
71
  Impotence is again a result which sometimes follows a chronic gon-
orrhoea.  I do not, however, wish to  say that  impotence is always
due to this cause, as it may depend upon various circumstances.  In
the chronic stage of gonorrhoea, impotence depends upon the absence
of erections, yet pollutions occur.  Impotence in the acute stage is
due to a swelling of the canal of the urethra, which prevents emission,
although erections occur.
  Lastly, impotence may depend upon  moral causes ; and I believe
that such is the cause in nine out of every ten cases of persons who
consult the surgeon.  Thus timidity has made more than one man
impotent; and in such cases it is only relative to certain women,  not
to all.
   Hunter's prescription for impotence is about the best a surgeon can
recommend—that our patient sleep with the woman with whom he is
impotent, and make a resolution not to have connexion with her.
  While on this subject,  and as I can not  revert to it, I may here
state, that the best treatment  for nocturnal pollutions, which occur to
so great an extent in some young men that they never have erections,
and whose health and spirits suffer considerably in  consequence, con-
sists in prescribing  an  enema of cold water, before  going to bed, con-
taining a small quantity of  laudanum, together with the use of nutri-
tious  diet; but  no food should be taken for at least four hours before
going to sleep.   Instead of continence, the fault of such young men,
let  them  indulge once or  twice a week, and they will be suddenly
surprised at finding that pollutions cease, and their health improves.
   The Treatment of Gonorrhoea.—I  shall treat of  this subject as I
have done that of blennorrhagia in general, viz., speak of the various
plans to be followed in the abortive and curative treatment.
  The Abortive Treatment.—At  the commencement  of  a discharge
from  the urethra, and previous  to any redness around the orifice, or
pain felt in making  water, the surgeon will frequently be able at once
to cut short  the affection and cure his patient;  under other circum-
stances, this plan will not avail.   It consists, in addition to the gen-
eral means spoken of under the head of abortive treatment of blennor-
rhagia, in employing, during the  succeeding forty-eight hours, twelve
injections of nitrate  of silver at regular intervals : the strength of  the
solution of the salt  should be two grains to the fviii. of distilled wa-
ter.   Let the injections be  then left off, and cubebs or copaiba be
given in the doses above spoken  of.  If the cases be recent, and  the
disease not too far advanced, this treatment will succeed, fifty times
in a hundred cases, in checking the disease,  and there is no fear of 
72
GONORRHOEA.
 occasioning  stricture or swelled testicle  at this period of the com-
 plaint.   Under this treatment the running will at once cease ; but to
 complete the cure, it will be necessary to continue the cubebs, dimin-
 ishing gradually the dose.  No further recourse should be had to in-
 jections,  as  a  continuance in  their use  would only tend to keep up
 irritation.  At  the end of fifteen days the surgeon may allow his pa-
 tient to resume his usual habits.
   The  direct  treatment consists  in  the employment  of injections.
 Of all those I have seen employed, no doubt exists in my mind that
 by far the greatest benefit is derived from the nitrate of silver.   The
 strength of the  solution should be two grains to eight ounces of dis-
 tilled water.  To employ this properly, the following directions should
 be attended to : During the forty-eight successive hours, twelve in-
jections  should be thus used :  let the  patient place himself  on the
 edge of a bed or chair, and having previously charged a glass syringe
 with the solution of nitrate of silver, let him hold it perpendicularly,
 introducing  it perfectly parallel with the urethra ; if he now ge.Dtl~
push on the injection, the fluid will easily enter the urethra, and come
in contact with every portion of the  canal; no  pressure is  required
on the perineum, as the force employed is not likely to push the fluid
far into  the canal.   As  to its reaching  the  bladder, and the danger
that  attends  it, I can assure my readers this is chimerical, as any one
must be convinced who has  ever attempted to inject the bladder ; to
effect that, a  catheter must be employed, and a strong syringe.  Even
supposing the solution to reach the bladder, the smallest quantity of
urine will decompose the  nitrate of silver.  I have seen, purposely,
not only injections, but the solid stick  of nitrate of silver, introduced
into  the bladder without any ill consequences following.
   A glass syringe is recommended,  and we should  be careful to tell
the patient that a pewter instrument decomposes the  salt, and renders
it less efficacious.   Should we inform  him that the solution is one of
those preparations which  act on pewter, he would  refuse to employ
it, on the  score that, if the  solution  acted on  metal, it would,  as a
necessary consequence, injure the urethra.
   The liquid should be injected  cold, and a common-sized  syringe,
only half  filled, will be  sufficient,  as the urethra does not hold more
than that quantity.
   Soon after the injections have been employed, there will appear a
reddish-looking discharge.  This should not  prevent the patient from
continuing the twelve injections,  at intervals of four hours, notwith-
 standing any slight pain which may occur.   A slightly purulent, rosy 
GONORRHOEA.
73
discharge, is a very favorable sign,  as it shows that the disease will
rapidly yield.
  We  have dwelt at some length on the cases for which injections
are suited—on the period,  the  strength,  and manner of employing
them—because we have the firm conviction that  they have not been
hitherto  correctly appreciated;  they have been either too freely
praised, or too absolutely rejected, without sufficient trials.  ,
  Various  other injections have been recommended, and Mr. Carmi-
chael, particularly, some years ago, proposed another method, which
differs materially from the one we have just spoken  of.   He advised
that injections of nitrate of silver, containing ten  grains to the ounce
of water, should be used.   He  purposely caused an inflammation, to
destroy the  special catarrhal one, and stated that gonorrhoea might be
cured by this means.  He  further  treated the inflammation of  the
urethra which he had occasioned, by antiphlogistic means, and on the
disappearance of the inflammation he states  both complaints were
cured.
  M. Ricord, in speaking of the merits of this treatment, says that
such means will cure a great number of cases, but  the surgeon plays a
game of double or quits :  if the disease be not cured, its violence is
increased in a relative proportion, which is not unattended with dan-
ger ; hence, he has long since desisted from employing injections in
the acute cases of gonorrhoea.
  With respect to the method  of employing injections, we can per-
sonally speak of  their great advantage, having seen them employed
in a great number of  cases  during the last three years, and in no one
case have we seen either stricture or swelled testicle follow their em-
ployment in the treatment of the affection  at its commencement.
  This, however, we are well aware, is not the general  belief.   In-
jections are, in the opinion of some of the great surgeons, very inju-
rious ;  they are  the "source of the  complications which  occur after
gonorrhoea.  In reference, then,  to such objections, I shall say a few
words, not  that I suppose  they relate to the special treatment here
recommended, but to the use of  injections generally.
  In  tracing back the history  of injections, we  shall find that, by a
very singular coincidence, they were first generally employed a short
time before  the investigation into the causes of stricture took place j
hence it naturally resulted, that, as injections were then in vogue, the
cause of stricture was assigned to their use, as hardly a case occurred
in which an injection had not been employed.  This was  rendered
more probable by the  astringent property of the injected liquid. 
74
GONORRHOEA.
   Surgeons seemed .to be contented with this explanation, and hence
may be the prejudices which exist at  the  present time.   But we
would ask any reflecting person—because an injection has been used
previous to the occurrence of a stricture, is  it to be considered as a
cause, any more than than the cubebs powder ?  Are we justified in
saying, post  hoc, propter hoc ?  We  answer, positively, no.  In a
great number of cases of stricture  which we have examined, no in-
jections have ever been  employed.  In  a great many  others, injec-
tions  have been used, it is  true ;  but  are  we surprised that in an
affection such as a  gleet of two years' standing, every remedy has
been  in  turn employed to no effect ?  Would it not, then, be more
consistent to  consider that the organic changes which produce stric-
ture are occasioned by the long duration of  a chronic  inflammation,
which, from positive evidence, we know to be capable of producing
induration and hypertrophy of all the tissues in which it occurs, rather
than to believe the very problematic one that the use of injections
occasions them ?  Let us ask  any one of our opponents, what proof
have  they  that injections produce  stricture ?  The only reply they
can give is, that they have followed the employment of injections;
ergo,  they are caused by injections.  Such a line of reasoning is not
allowed in other branches of pathology ;  we hope, therefore, the same
strictness of language will be* held here, and that the urethra will no
longer be allowed to form an  exception  to pathological laws, or re-
main  the field of ignorant charlatans.
  Our reasons for entertaining the opinion that undue blame has been
thrown upon injections, are the following :—
  1.  No one can  doubt but that strictures arise where no injections
have been used.
  2.  In cases where they have been employed during (we may with
safety say) the first  month of a maiden gonorrhoea, no stricture has
been  found to follow.
  3.  In the chronic cases of gonorrhoea which have lasted  months
and even years, and where  injections have been employed in  vain,
strictures will follow, not in  proportion to  the  injections, but as a
consequence of the chronic inflammation which has been allowed to
exist.
  4.  Instead of  causing strictures, we believe, and hope to prove, in
speaking of that subject, that the proper use of injections will remove
one of the forms which depends upon a softening and hypertrophy of
the mucous membrane.
  5.  From the  beneficial effects which follow  the employment of 
GONORRHOEA.
75
nitrate of silver in checking inflammation of the conjunctiva or of the
prepuce, we believe that this substance will have the same effect on
the urethra, and, by curing inflammation, check one of the most fre-
quent causes of stricture.
   In these observations, we  allude of course to  the employment of
injections in proper cases, and  with judgment;  for in the hands of
quacks, they, like any of  our most valuable  remedies,  may produce
great mischief, but the blame must be thrown on the abuse,  and not
on the use, of the  preparation.
   On a late occasion, M. Ricord stated that he looked forward to the
time when the action of nitrate of silver will be better known : from
good effects to be derived from it in  cases  of balanitis and vaginitis,
he should be disposed to employ  the solid  substance  in the abortive
treatment of gonorrhoea ;  but in hospital practice patients do not pre-
sent themselves  early enough, and in private practice a surgeon risks
too much to commence such a treatment,  particularly as  the patient
derives so much benefit from injections.
   Treatment of the Acute Stage of Gonorrhoea.—Occasionally, in spite
of our treatment, or in the case of a patient demanding our assistance
at a  period too late for us to entertain  the  idea of cutting short the
complaint, the inflammatory stage will set in.
   In such instances, the treatment must be guided by general princi-
ples, and consist in a  severe antiphlogistic regimen.   The practice
which we  have  seen the most  effectual, is, to  apply twenty-five
leeches to the perineum ;  the daily use of a warm bath ; to prescribe
diuretics, as well as large quantities of mucilaginous drinks, and to
recommend the use of a suspensory bandage.  The employment of a
bougie or any instrument must be strictly forbidden.
   Chordee.—By the foregoing means  we  shall  relieve the most ur-
gent symptoms ;"but we must not stop here—we must attend particu-
larly to the erections, and treat the  chordee.   With this object in
view, the patient  should  be enjoined to keep quiet, and avoid female
society; let him lie on a straw or hair mattress,  and  not  indulge in
feather-beds or much bed-clothing ;  cold lotions  to the penis are of
advantage,  and if  chordee occur, the patient should put his feet on
the cold floor.   However, our greatest dependance should be placed
upon camphor ; it  is one of the most powerful sedatives with which
we are  acquainted.  In enemata, camphor may be beneficially ad-
ministered in doses of from ten to twelve grains, mixed with the yolk
of an egg, a grain  of opium, and about  four ounces of water.  When
lavements are given,  they should be prescribed an hour before going 
76
GONORRHOEA.
to bed, when they most probably will  be retained.  Camphor is, at
the Venereal hospital, often administered in the form of pills, made
of—camphor, 3 grs., opium, \ gr., mucilage, q. s.   Two' such pills
may be taken before bedtime, and the dose increased until the de-
sired effect is produced.
   Retention of Urine.—The next symptom which the surgeon has to
treat, is the  retention of urine which sometimes occurs.  The anti-
phlogistic means above recommended  are usually sufficient to rem-
edy the evil—not, however, always.  Of course we should  attempt
to distinguish a retention of urine from a non-secretion of that liquid,
as well as from dysuria.   In  the latter case,  repose  and a simple
mucilaginous drink will suffice;  diuretics should never be employed,
and warm baths have likewise the effect of increasing  the mischief,
by causing a further swelling of the mucous membrane.   In the case
of retention of urine, which may last a few minutes, and is occasioned
by spasm, warm poultices  applied to the hypogastric region usually
produce relief;  there is no occasion to employ a catheter, as it only
aggravates the complaint.
   When the retention of urine has lasted many hours, and the means
you have used are inefficacious, recourse must be had to the catheter,
if the bladder be distended, but it must be introduced with great cau-
tion.  If the instrument has passed freely, it should be withdrawn;
on the  contrary, if  any obstacle  has  been overcome, the catheter
should be left in the bladder,  and fixed in the usual way, and the sur-
geon must continue the antiphlogistic treatment.
   Abscess.—In  cases where abscesses of the  urethra, prostate, or
fraenum, take place, they must be opened upon their first appearance,
or a fistulous opening will occur  should they burst.
   When an abscess forms in or about the prostate, the diagnosis is
often difficult; but as there is dysuria,  a sound being introduced may
cause the abscess to open internally ;  however,  the  surgeon can not
calculate on this, and therefore an external opening  should be made
as soon as the presence of fluctuation is perceived.
   Hemorrhage.—Another complication of the  acute stage of gonor-
rhoea, which the  practitioner is  called upon to treat, is, haemorrhage
from the urethra.  It is not very common, but we have observed some
few cases of it.   The  causes we have previously stated to be the
rupture of a chordee, or else the  act of coition during  the  inflamma-
tory stage.
   In such cases, repose in a horizontal posture generally suffices at
the same time that, by mucilaginous drink, the urine is rendered wa- 
GONORRHOEA.
77
tery, taking all the precautions to avoid erections by the means de-
scribed, and administering iced drinks.   Our sheet anchor, however,
is a cold lavement,  and a horizontal posture upon a straw mattrass ;
excessive cold is  prejudicial, as the urine is passed with difficulty.
If, in spite of these measures,  the haemorrhage do not cease, com-
pression must be had recourse to by means of a towel twisted up and
placed under the perineum,  or, again, direct pressure may be made
on the urethra.  These, however, are  but temporary means ; for, as
the coagula  form, the stream of urine washes them away.
  Notwithstanding these circumstances, this species of pressure usu-
ally suffices.  M. Ricord  states he has found  it of great  advantage
lately in the case of a young man who, in bathing, ruptured the ure-
thra.   The  severe haemorrhage which followed was checked by com-
pression, and it  was  not  necessary to  have  recourse to any other
treatment.   All cases are not to be thus treated  ; simple compression
may fail in  checking haemorrhage.   The only means which are left
for  the surgeon is, to introduce a catheter of a moderate size, with
great care, otherwise a false passage will be made.  The simple in-
troduction will usually suffice to check the bleeding ; or compression,
by means of straps of plaster, may be added.  By such means the
surgeon is sure to check haemorrhage ;  but he  must qarefully watch
the case, as, from the altered volume of the penis in a quiescent state
and in erection, gangrene may come on, and sloughing succeed, as
happened in a case of the kind we are describing, at the Venereal
hospital, some years ago.
  Inflammation of the Neck of the Bladder.—The  next complication
to which we shall now call the attention of our readers, is inflamma-
tion of the neck of the bladder, or, according to the classification of
Bell, his fourth phase of gonorrhoea.  The symptoms are—tenesmus,
a frequent and earnest desire to make water, and great pain attends
the passing the  last few drops, which are mixed occasionally with
blood or pus.
  The  treatment must consist in antiphlogistic means, together with
enemata, composed of four  ounces of infusion of poppies with twenty
drops of laudanum.  Inflammation of the bladder may become a com-
plication of gonorrhoea, and  produce  all the usual symptoms of ca-
tarrh of that organ ; but it would be here out of place to enter into
further  details.  We must refer our readers to the works of surgical
writers.
   Chancre.—With respect to the treatment of chancre in the urethra,
it will in no way modify the treatment of acute gonorrhoea;  when 
78
EPIDIDYMITIS.
that is passed, it must be treated  as chancres usually are.   To avoid
repetition, we must refer our readers to the chapter on chancre.
  Buboes.—The treatment  of buboes  is very simple, as they do not
depend upon a specific cause ; they very readily disappear under the
use of antiphlogistic means, such as leeches and poultices.  It is a
circumstance worth noting here, that sympathetic buboes occur when
gonorrhoea is in the acute stage ;  on the contrary, when they arise as
a consequence of a chancre in the urethra, and are therefore virulent,
they commence at  a late period, when  the chancre is getting well.
But on this  subject we refer our readers to the subject of virulent
buboes.
  Among the complications of gonorrhoea in the male, perhaps one
of the most important  is that affection known by the term swelled
testicle.  I  shall  consequently devote the  following section  to its
consideration, believing  that it has  not received that attention from
pathologists or surgeons which it deserves.
                        SECTION  III.

                         EPIDIDYMITIS.

  Synonymous  Terms.—In the older writers we find the term hernia
humoralis frequently made use of.   Astruc, in 1740, wrote on  " De
Tumore Testium Venerea, sive Hernia Venerea."  Hunter, in 1784,
employed the term " swelled testicle."   B. Bell,  in 1793, treats of
the affection under the chapter " Of Swelling in the Testicle."  Swe-
diaur, in 1809, speaks of " tumeur des testicules."   Sir Astley Cooper,
in 1830, described the affection, terming it " acute inflammation of the
testis, or testitis."   M. Lagneau,  in 1831, heads his  chapter, " Testi-
cule Venerien."   Mr. Wallace, in 1833, writes on the " disease of the
testicles" (complication of catarrhal syphilis).  Sir B. Brodie, in 1833,
calls  it " acute inflammation of the testicle,"  but  tolerates the  term
hernia humoralis.   In  1836,  M.  Desruelles described  the affection
under the  term " or-chile aigue."  In  1836,  M. Rochoux first called
the disease " vaginalite."  M. Velpeau,  in  1839,  calls  it " orchite."
M.  Ricord,  in  1839,  has  denominated it  " epididymite  blennor-
rhagiqueb" 
EPIDIDYMITIS.
79
   Symptoms and Course of simple uncomplicated Cases.—During  the
 existence  of  gonorrhoea, it  not unfrequently  happens that a patient
 who is observant of his complaint, feels a pain in the perineum,  ac-
 companied or preceded by a dull aching sensation  in the groin, and
 along the course of the spermatic chord, ultimately becoming fixed in
 the back part of the scrotum, and he can often cover the painful part
 with his finger.  He remarks that the gonorrhoeal discharge is some-
 what diminished.   When subject to nocturnal emissions, such  a  pa-
 tient will feel great pain for some hours afterward ;  but  at  this stage
 his linen presents no marks  of blood ; the seminal discharge appears
 natural.  When the  surgeon sees the patient at this early  stage,  the
 finger detects a distinct swelling confined to the epididymis, which is
 sometimes hard and painful on pressure; there is little or no redness
 of the scrotum,  and the spermatic chord is often free from any thick-
 ening, although usually the vas  deferens can be felt more distinctly
 than in the healthy state, and a feeling of pain is  expressed when
 pressure is made in its course.  In such a case, if  proper  treatment
 and rest be enjoined, the disease proceeds no further, and the patient
 rapidly recovers.   As the surgeon rarely sees the case at  this  early
 period, if, from inattention to such  slight inconvenience, the  patient
 uses  exercise,  or  goes about  his ordinary occupations, the conse-
 quences soon  become apparent; the  swelling in  the  scrotum  in-
 creases, great pain is experienced on making the slightest movement,
 and the patient supports the testicle with his  hand, so  great is his
 fear of motion, which  aggravates the pain in the course of the chord.
 At this stage he is often awoke by great augmentation of pain  from
 nocturnal  emissions, and he is surprised at seeing his linen stained
 with semen mixed with blood.   There is, however, occasionally some
 alleviation to the suffering after  an emission.
   M. Ricord states that he has seen pus intimately mixed with the
 seminal fluid.   I have witnessed considerable augmentation of suffer-
 ing to the dull aching pain in the perineum when the patient goes to
 stool.   A careful examination of the scrotum, at this stage of the  af-
 fection, will show that there  is not alone redness of the skin  with
 great augmentation  of  heat, but that effusion has taken place into the
 tunica vaginalis.  If the surgeon, with the left hand, embrace firmly
 the affected half of the scrotum, so as to render tense the testicle
 covered by its envelopes, and, with the fore-finger of the  right hand,
 gently but suddenly press on the centre, a distinct feeling of fluid will
be experienced, and the elastic body of the testicle will be felt below
it.  Should a lancet be thrust into this point where fluctuation exists 
80
EPIDIDYMITIS.
a clear or slightly turbid serum, varying in quantity, will often escape,
and  the  size  of  the tumor will sensibly diminish.   When  the  fluid
thus contained in the tunica vaginalis has  escaped,  the greater por-
tion  of the remaining swelling is found to depend on the epididymis,
which is hard and painful, and can be felt distinct from the testicle; this
appears to constitute the disease, at least in the majority of the cases.
Effusion  may not be confined to the tunica vaginalis ;  we often see
the  subcutaneous cellular tissue infiltrated with serum, and become
oedematous or phlegmonous ; inflammation may result,  and distinct
abscesses form.   However, when intense suffering has preceded, and
the fluid has been allowed to escape, the testicle may be found hard,
having lost its proper  elastic feel, and it seems to form a nodulated
body which we are  unable to distinguish from the epididymis.
  The general or constitutional symptoms  at the commencement are
slight, but in the stages of the complaint last described they may be
very severe, and have been occasionally confounded with hernia.*  A
furred tongue,  hard pulse, pain in the abdomen, vomiting, constipa-
tion, &c, are  all  met with in the severer forms.
  Pathological Anatomy.—Patients laboring under this affection rare-
ly die, as will be presently  seen ; but  it  occasionally happens that
surgeons have an opportunity of observing the conditions to which
the coverings  and parts of the   testicle are reduced by the disease,
when a patient has been carried off by some affection of a more fatal
kind.  I  cite below two instances of this disease where patients la-
boring under the complaint died—one in consequence of typhus fever,
the other from an acute inflammation of the brain ; and I may add,
that  all the cases observed since, by various persons, have confirmed
the view here  taken of the  pathology.  In a simple case which M.
Ricord presented to the Academy of  Medicine in Paris, the epididy-
mis was  affected alone.   In another  case, where  severer symptoms
had been observed,  the tunica vaginalis  presented traces of  pus and
false membrane.  In the most severe forms, plastic lymph was effused
among the seminiferous vessels.   Mons. Gaussaile, late interne of M.
Cullerier, at the Hopital du Midi, has given the  two  following cases,
which are to be found in  the 27th volume  of the Archives de Mede-
cine, for October, 1831, p. 189.
   Case 1. The epididymis was double the usual size, and hard.  The
testis of the  same  side  presented twice  its ordinary  volume ;  this,
however, was  found to depend in great part upon an  accumulation of
  * See Potts's works, and case, page 83, occurring when the testicle was confined in
the inguinal ring. 
*
                          EPIDIDYMITIS.                       81

 a thick turbid serum, somewhat  bloody, which flowed out when the
 tunica vaginalis was opened; the size of the testis immediately sub-
 sided.  The tunica albuginea seemed thicker than usual;  its surface
 presented a large number of minute vessels spreading themselves
 out in various directions on its surface.   The substance of the testis
 presented no  appreciable change;  its consistence  was  somewhat
 firmer than usual, and the color deeper.
    Case 2.  The vesiculae seminales larger  than usual, and firmer to
 the finger ; on the  left  side they were much injected, and of a dark-
 red color, containing a large quantity of a yellowish-white  substance,
 which was  somewhat granular.   Both the vasa deferentia presented
 similar traces of inflammation, and were filled with this same matter.
 The epididymis of either side was voluminous  ; the  surface  resem-
 bled the color of lees of wine, but this discoloration did not extend
 to the testis.   The testicles had their ordinary volume ; some vessels
 were observed ramifying on their surface.   A small  quantity of red-
 dish serum was found in the tunica vaginalis.
    Causes of the Affection.—These may be of two kinds—the predis-
 posing, or direct and exciting causes.
    Predisposing Causes.—Under  this head  may be included fatigue,
 violent exercise, repeated sexual intercourse, and any circumstance
 producing excitement of the organs : authors have mentioned partic-
 ularly excitement of the animal  passions.  Daily observation shows
 that various trades predispose to  the affection ; we meet with it much
 more frequently among weavers, turners, grooms,  and those whose
 testes  are  liable  to  friction.   Among  other  predisposing  causes, I
* should mention an habitual flaccid condition of the scrotum ; for it is
 a point on which any one may convince himself, that a strong cre-
 master  and  firm scrotum  is rarely met with in individuals suffering
 under this affection.  This is  corroborated by  the fact  that the left
 testis is more frequently affected  by the disease  than the  right, which
 is sustained by the seam of the trowsers affording it an adventitious
 support. Wet, damp weather, seems to act in the same  manner in
 predisposing to the affection, and may afford an  explanation of the1
 epidemic nature of the complaint at some seasons of the year.  Such
 are the principal predisposing causes of the affection.
    The direct and exciting cause consists  in  inflammation of the ure-
 thra.   Observation shows that this may take place by direct continu-
 ation of the inflammation along the vesiculae seminales and vas defer-
 ens to the epididymis ; or, it would appear, by virtue of a law common
 to many mucous surfaces, extremities of canals may  become sympa-
                              6 
82
EPIDIDYMITIS.
 thetically affected, the intervening surface not perceptibly participa-
 ting in the inflammation.  Of the fact there can be no doubt, that the
 epididymis is often affected,  the chord remaining perfectly free from
 disease.
   This cause, viz., inflammation of the canal  of the urethra, however,
 seems to act in  a manner  that, a priori, we should not expect; for
 the epididymis  is rarely affected during the first week, or during the
 period that the  inflammation is most acute ; from the third, fourth, and
 fifth week, this  affection is most frequently met with.   I take the fol-
 lowing  account from some  statistical tables  made by Mr. Gaussail:
 during the first week, three cases ; second  week, four cases ;  third
 week, five cases ; fourth week, sixteen cases ; fifth and sixth weeks,
 thirty-nine cases ; two months,  two cases ;  three months,  one case.
 Now, as in the  first fortnight the inflammation, although very severe,
 has not reached the deeper portions of the canal, being confined usu-
 ally to the corpus spongiosum, it is probable  that this is the  reason
 why, at the early periods  of the affection, the epididymis  escapes.
 Such a supposition, however, is  of some practical utility, for, if true,
it leads to the practice of attempting to prevent the occurrence of the
affection of the testicle, by putting a stop, by all  active means in our
power, to the inflammation before it has reached the prostatic portion
of the canal; it may induce, moreover, the surgeon to inform the pa-
tient who consults him about the fifth week, that  an affection of the
scrotum is imminent.
   Complications of the Affection.—The extension of the disease  from
the epididymis  has been above spoken of, and I here collect the com-
plications together in the order of their relative frequency.  The epi-
didymis may be primarily or  alone affected ;  then the chord becomes
inflamed ; next, the tunica vaginalis, giving rise to all the symptoms
of acute hydrocele, which has been of late,  in France, supposed to
play so large a  part in the affection I am now treating of.  The next
most  frequent  complication   is  oedema of the scrotum and  chord.
 Lastly, the testicle may become implicated, causing the disease prop-
erly called orchitis or testitis.
   Terminations of the Affection.—When the epididymis alone has
been affected, provided the case is seen early and proper means are
 employed, that  organ will speedily recover its  normal structure and
 functions.  It often happens, however, that  a hard, nodulated mass
 remains, which resists all the usual methods  of treatment, but which
 in time, will become diminished  in size, and  the  perfect'function of
 the organ be  recovered ; however, for  months  after, great pain  may 
EPIDIDYMITIS.
83
be felt during sexual intercourse, and relapses may recur as a conse-
quence.  The effusion  into  the tunica vaginalis may, in some few
cases, distend it to  such  an extent that it will form a hydrocele re-
quiring an operation  ; in other  cases,  effusion  of pus or coagulated
lymph may take place, and induce all the consequences which follow
such  lesions ; these terminations are, however, rare.   The cellular
tissue of the scrotum may regain its former condition, or the inflam-
mation may become phlegmonous  and abscesses form, or induce a
chronic thickening of the whole scrotum, which alters its appearance
considerably.  Lastly,  the  testicle may present the hard irregular
mass above spoken of, and suppuration of it occur ;  when the slough
separates,  the seminiferous vessels become  unravelled, and appear
as so many shreds at the opening ; and not  unfrequently a fungous
growth makes its appearance, a condition  of the testicle which has
been  so ably described by Mr. Lawrence.  Lastly,  the disease may
cause the development of,  or occasion, any  latent disposition to tu-
bercular  disease  in  the  epididymis or testis ;  and I have met with
numerous malignant  affections which the patients themselves attrib-
uted to an affection of the  scrotum following gonorrhoea. Here, how-
ever, there must have been some previous predisposition in the con-
stitution, which is thus  fostered by the excitement produced by the
disease in the epididymis.
   Diagnosis.—It would require more space than I can devote to this
section, to point out the  means of diagnosis between this affection and
all those  diseases with which it may be confounded.   For this infor-
mation, I must refer my readers to works on surgery.   The cases of
difficulty which I have met with, have been under circumstances such
as the following.   A similar  instance  will  be found in Potts's work
on hydrocele :—
   A young man, twenty-four years of age, was in the habit of amu-
sing himself, while a boy, by pushing his testicles into the abdomen;
one day the left testis did not descend as usual.   Two months previ-
ous to his  admission, he  contracted a  gonorrhoea, which discharged
profusely ;  he continued, notwithstanding,  his employment, that of a
wheelwright—a business which requires great  bodily exertion.  In
about a fortnight after, he felt.a painful sensation in the left groin, or
a colic, as  he expressed himself,  in the loins  ; and this becoming
worse, he entered the Hbpital du Midi, a month after the commence-
ment  of  his complaint, suffering under  great pain in the inguinal re-
gion of the left side, which was  greatly  inflamed, and pressure on this
part produced that peculiar feeling,  but in a greater degree, which is 
84
EPIDIDYMITIS.
 excited when the testicle itself is compressed.  On examining this
 patient, no testis was found on the left side of the scrotum ; but, on
 passing the finger into  the  left inguinal  canal, a rounded body was
 distinctly felt, resembling the testis in shape,  and the patient stated
 that he experienced a similar kind of pain as that felt when the tes-
 ticle on the opposite side was squeezed.  Notwithstanding the vom-
 iting which existed—the constipation of some days' standing, pain
 referable to the abdomen, and a quick, hard pulse—the case was im-
 mediately considered to be the affection I  am describing, varying only
 in the  situation of the testicle within the canal.  The treatment was
 such as I shall presently describe, and the  patient did well, and left
 the hospital in a few weeks.   I shall  make no  comments on this
 case—it speaks for itself; and I believe  there are few  surgeons but
 would  be able to distinguish these symptoms from hernia, although I
 do not  know that the diagnosis, or rather the occasional complication,
 is mentioned, except in  Mr.  Potts's work on hydrocele, who states
 that this error was committed by a practitioner who sent  for him to
 operate on a case of supposed  hernia, which turned out to be one of
 hernia  humoralis.   Should, however, a strangulated hernia occur in
 combination with this affection, there might be some doubt, and the
 operation, if attempted, would be rendered difficult.
   The diagnosis of affections of the different parts contained in the
 scrotum, which become successively diseased, next requires our  at-
tention, particularly as the complications above alluded  to have not
been noticed by English writers, or  at least only hinted at.  On the
 subject of tumefaction of the epididymis I shall not dwell, as from the
 time of Swediaur, in 1809, authors, with hardly an exception, have
 admitted that that organ participates the first in the affection.   Thus,
 Sir A. Cooper says,  in  his valuable Treatise on the Testes,  that a
 swelling of the epididymis is  a third effect of inflammation.  He
 further says, " This portion of the epididymis (globus major) is more
 frequently diseased than any other part of the testis or epididymis."
   Sir  B. Brodie, in his lectures,* says :  " It (swelling) generally be-
 gins in the epididymis,  and then extends to the rest of the organ."
   On the diagnosis of effusion into  the tunica vaginalis, I must beg
 to dwell at some length, for, although it is admitted by Sir A. Cooper
 to exist frequently,  still I do not think  sufficient attention has been
 paid to the subject by the profession, and, in fact, practitioners are
 seldom agreed upon its existence.  Fluid, when effused in small
 quantity into the tunica vaginalis, can not be easily detected, and may
                * Medical Gazette, vol. xiii., 1833-34, p. 219. 
EPIDIDYMITIS.                       85
be mistaken for a swollen state of the testicle itself—a thing of every-
day occurrence ;  and this is a circumstance, I believe, which has in-
duced English surgeons to speak of the affection as an acute inflam-
mation of the testicle.  My readers will therefore see, that the diag-
nosis of effusion into the sac, from inflammation of the testis  itself, is
not a mere quarrel about terms, or one of those fine-drawn diagnostic
distinctions, but is a matter of great importance.  When fluid is pres-
ent in the tunica vaginalis, the surgeon may satisfy himself of its ex-
istence in any of the following ways.  I copy M. Velpeau's plan of
detecting it, from the French dictionary :—
   " If a considerable collection  of fluid exist, there will be a trans-
parent state of the tunica vaginalis as late  as the eighth day; should
it be turbid, or the tunic thickened, the next best means  is to seize
the testis at its root between the two fingers ; the thumbs should then
be pressed on the two extremities of its anterior part, and the follow-
ing sensations will  be experienced :  the  sudden  pressure will pro-
duce the sensation of a layer of fluid  which sinks into a cavity, but
is soon checked by a more firm and regular surface ;  the  other finger
will  feel, at the same moment, an undulation which raises it." When
the serosity is abundant, it will often be detected by its  transparency.
But  perhaps  the simplest way is to puncture it with a lancet, an op-
eration attended with no danger;  the escape of the fluid,  though pro-
ductive of no very good effect (except in cases where the  tunic is
very much distended), has never been, in a great, number  of cases
that  I have   seen so treated by M. Ricord, attended with any ac-
cident.
   Swelling of the testicle may,  as Sir B. Brodie states, be usually
supposed to exist, from the severe pain  felt by the patient when the
glandular structure of the testicle becomes inflamed within the cavity
of the fibrous, unyielding tunica albuginea;  such a rational diagnosis,
however, has not been  considered sufficient by  the surgeons above
quoted.   Having punctured  the  tunic,  and allowed the  serosity to
escape, they then feel for the testicle, which, if  inflamed, has, from
reasons  above  stated, lost its peculiar elastic feel, and may be felt
hard and inelastic, either partially or generally.
   On the diagnosis of effusion into the cellular tissue of the  scrotum,
I  must beg  to say a few words.  GEdema may follow as  a conse-
quence of various affections.   I have lately seen a case  of eczema
of the scrotum, with great oedematous swelling of the subcutaneous
cellular tissue, and so hard that it required some time before I could
decide  if the testis  was free from disease ;  rest, cleanliness,  and 
86
EPIDIDYMITIS.
 proper treatment, however, enabled me to clear up this point.  I men-
 tion the case, as its nature was mistaken.
   One.word  more,  and  I have done with the subject of diagnosis.
 The  oedematous   swelling  of  the  scrotum,  when  attended  with
 phlegmon, may bring on abscess ;  it becomes very important to open
 such abscesses early, and their diagnosis  deserves some consider-
 ation.
   The  characters of such an  abscess are the  following :  The skin
 becomes adherent to some part of  the epididymis or testes ; an indu-
 rated circle is formed around it;  in its  centre a distinct fluctuation
 may be felt, and this point is covered by the distended skin, which is
 of a darker color than that of the surrounding parts.   In fine, the bis-
 toury should  never be used unless  these signs are present, otherwise
 we may run the risk of wounding  the testicle,  mistaking its  elastic
 feel for matter supposed to be contained in an abscess.
   Prognosis.—That this  is  favorable, the preceding  pages  will, I
 think, attest;  consequently there is no occasion for my dwelling more
 upon it.   But it will be necessary to say a few words on the proba-
 bility of the occurrence of the complications, or of the speedy termi-
 nation of the  complaint.   Seen  at  an early period, particularly when
 there is no swelling of the chord, the surgeon may usually assure his
patient that the disease will be speedily relieved.   If the gonorrhoeal
 discharge be  slight,  or very severe,  provided the patient takes no
 care, the same chance exists of the occurrence of the affection, or a
return  of  it.   I may  here state,  that a  virulent or mild gonorrhoea
 seems  to  influence little  the prognosis ; this,  as previously shown,
will depend upon other circumstances.   The  chance of  suppuration
of the testicle taking place is very  slight, unless the treatment be very
 injudicious.   The effusion into  the tunica vaginalis will, as Sir Ast-
ley Cooper has so justly observed,  be speedily absorbed, and seldom
 degenerates into  chronic  hydrocele, or requires more than palliative
 treatment.
   The patient is often anxious to learn if the testicle will recover its
 proper functions,  and the assurance  that  this will occur, and that
 atrophy of that organ is not probable, will give him a degree of confi-
 dence not experienced except in cases of this affection where  pathol-
 ogy shows that the  most important part,  the  testis, usually escapes
 altogether.  However, the surgeon should inform him that induration
 of the epididymis may remain for some months.
   When  nocturnal pollutions occur mixed with blood  the same con-
 solatory prognosis can not be held out; and when there is a  scrofu- 
EPIDIDYMITIS.
87
lous tendency in the patient's constitution, the surgeon should take
care how he holds forth sanguine  expectations  of  a permanent or
speedy recovery, otherwise his treatment may be blamed, and his
prognosis found to be incorrect.   Let him in  such a case share the
responsibility with another.
   The Treatment.—As every surgeon should have in view  the pre-
vention of  the disease, the indications for effecting  this must neces-
sarily follow from a consideration  of the  causes which have been
shown above to  produce it.   I may mention, that a speedy cure of the
gonorrhoea, previous to the third or fourth week, and the employment
of a suspensory bandage, are the most effectual means of preventing
this complaint, and they should never be omitted.  When the disease
has become developed, either in consequence of neglect or inatten-
tion on the part of the patient, or from recourse not being had to sur-
gical advice, the following means will be found the  most effectual in
preventing its further extension, and relieving the complications which
have occurred.  Rest  in the  horizontal position is among the first and
most efficient remedies : merely  keeping at home is insufficient; re-
pose on a  bed or sofa  becomes indispensable ;  and the other means I
am about  to mention will afford  little benefit, if the patient  can not
lay up for  a few days. In the acute form of the  complaint, when
there is great constitutional disturbance, abstraction  of blood from the
arm will often be  called for,  followed by a local application  of leech-
es. On this subject I must  beg  to say a few words : leeches should,
as a general rule, never  be  applied on  surfaces which have a sub-
stratum of loose cellular tissue, such as the scrotum, eyelids, vulva,
 &c.   I can recal to  my recollection various instances of the very
worst  effects—such as erysipelas,  oedema, ulcerations, and gangrene,
following the application of  them to these surfaces.  It is true, that
 in nine out of ten cases these consequences  may not happen, but the
 careful  surgeon should avoid even  these exceptional ones,  particu-
 larly when he  is aware that all the  good effects, without the ill con-
 sequences, will follow their  application on the groins or perinaeum;
 and let not the practitioner be thrifty of them—a few often do more
 harm  than good in acute inflammation, and the patient does not save
 either time or expense.  Patients, as Sir Astley Cooper has so well
 remarked, are often, from their social position, unable to apply leech-
 es, or they may be procured with difficulty.  Under  such  circum-
 stances, the surgeon may  with a lancet puncture  the  scrotal veins,
 and withdraw the requisite quantity of blood, the patient standing be-
 fore him ;  cold and the  recumbent  posture will immediately check 
88
EPIDIDYMITIS.
the bleeding.  On the subject  of local applications,  the feelings of
the patient may be consulted ;  cold washes, or warm poultices, may
be prescribed.  I need not say that aperient medicine must be given
in cases  of  constipation, and  a strict antiphlogistic regimen recom-
mended.   The employment of the tartar emetic in nauseating doses
is undoubtedly of benefit  in  lowering the circulation, but alone it
should not be relied on.  In twenty-four hours the acute symptoms
will usually  have passed away, if the  epididymis  alone be affected;
and it is then necessary to employ compression of the affected part,
in the manner I shall presently describe.  The surgeon may now
turn his attention to the cure of the gonorrhoea by the ordinary means,
which it is not my intention here  to  enumerate ;  in  doing  this, the
cause  being removed, the effect will speedily disappear, and not be
liable to return.
  When  the acute stage is complicated with considerable and rapid
distension of the tunica vaginalis, occasioning much pain, great relief
will be instantly given by puncturing  that  membrane.  I have like-
wise seen this symptom quickly relieved by the application of a blis-
ter which embraces the half of the scrotum,  after the previous anti-
phlogistic treatment has been had recourse to.   When  the  chord is
much swollen, poultices and frictions must be persevered in for along
time, and compression should never be recommended.
  In cases of abscess, I need not state that they should be opened as
early as possible.
  Method of employing Compression.—Compression is made on the
testis by means of strips of plaster.   The  emplastrum vigo  cum mer-
curio, of the French codex,  is  the preparation, that M. Ricord em-
ploys,  cut into strips  about half an inch wide; but  other  adhesive
plasters answer equally well;  the less  irritating they are, however,
the better.
   The manner of employing them is as follows : embrace the affect-
ed testicle in your closed hand, drawing it,  at the same time, away
from the  other;  then  pass  a strip of plaster  around the chord, just
where it  is  in  connexion with the testicle, to prevent the testicle
escaping out  of  the  scrotum ; this being  done, the  scrotum of the
affected side will be adapted closely to the  testicle,  which presents
an oval shape; the strips of plaster may then be  applied in circular
layers along the testicle, until  all but the lower part is included ; the
latter may then be compressed by smaller and shorter strips,  placed
at right angles with  the circular  ones,  which they thus maintain in
their place.   The testicle is thus equally compressed, and the strips 
EPIDIDYMITIS.
89
of plaster should be drawn tolerably tight.   The patient will usually
complain of some degree of pain during and immediately after the
operation ;  far from  discouraging the surgeon, this should lead him
to believe that the compression is well applied.  When, however, the
pain has not abated at the end of an hour,  the surgeon  may usually
be assured that no good can result from this treatment;  the compres-
sion should be discontinued, and antiphlogistic means  had recourse
to.   If the cases of compression be well selected, and the indications
followed, it will be necessary to withdraw the plaster in a few hours
after, for the  size of the testicle will have subsided considerably,  and
the shell of  adhesive  plaster will become quite lax; it  must be re-
moved, and  other strips  applied in the same  manner as the former,
which may require removal in succession.  I have witnessed cases
cured  in twelve hours by these means, both in the hospital of La
Charite, and  in the Hopital du Midi; and I can most confidently rec-
ommend it in the subacute stages of inflammation, and in the sympa-
thetic affections of the  epididymis.
  It is, however, very prejudicial in all cases where inflammation is
gaining ground, or when it has  already become very severe; it is
useless when there  is  great effusion into the tunica vaginalis, pres-
sure then having but a  slight effect on the epididymis.  When, how-
ever, the  fluid  has  escaped, compression becomes a very valuable
adjunct; it  should never be employed when the chord  is affected
with acute inflammation, as we are unable, from its position, to com-
press it completely;  and I may here repeat, that  there  is no means
so useless or prejudicial as  inefficient  or unequal pressure.  If the
strips be not reapplied  when they become loose,  a reaction will take
place which  it  becomes very difficult  to counteract; therefore  the
period of reapplication  should be carefully watched.  The surgeon
should be aware that this treatment,  like many others, may be abused;
and I may mention, that gangrene of the  scrotum has come on from
the non-observance of  the above  rules.   I have, however, never ob-
served any ill consequences  follow the judicious employment of com-
pression, notwithstanding I  have seen it used in two hundred cases.
I may be expected to say a few words on the  supposed modus oper-
andi of compression ;  although, for the practical surgeon, it is suffi-
cient to know that it is beneficial,  and  in  what cases  it should be
employed.  Compression  here,  as  in many other cases, has been
supposed to  act by retarding arterial  action,  and not permitting so
much blood to  come to the part; support, it is said, is given to  the
veins, and if inflammation depend upon  or be followed by an enlarged 
90                       EPIDIDYMITIS.
state of the vessels, it is not surprising that compression should be of
benefit.  Pressure, moreover, not only is stated to prevent the further
deposition of fluids and solids  among the tissues, but it is supposed
to excite absorption of such matters as are effused and  not yet be-
come organized.   Whatever view we may take  of the  subject, no
difference of opinion, I repeat,  can exist on the benefit to be derived
from the treatment which I hope I have dwelt sufficiently long upon
to induce English surgeons to practise it.
   The annexed engraving will better explain the  manner of employ-
ing compression.   Fig. 1 shows the strips of plaster  passed around
the chord and testicle ; figs. 2 and 3,  the strips placed at right an-
gles, to  maintain the circular ones, and compress the lower part of
the swelling.
   Chronic Stage of Gonorrhoea.—I shall now,  having treated of the
most important complications of gonorrhoea, in pursuance of the order
laid down, return to the consideration of the treatment of the chronic
stage of gonorrhoea.
  It has been above stated, that this period is easily recognised by
the absence of pain in making water.   Chordee may, however, still
exist.
  At this stage we  should employ the same means as recommended
for the abortive treatment of it;  thus, the use of warm baths, which
were strongly recommended in speakino- of the treatment of the acute 
EPIDIDYMITIS.
91
stage, must now be entirely laid aside.  The  patient should be put
on a mild but nutritious diet, prudence being observed as to quantity,
and care being taken that no excess of any kind follow.  The most
perfect tranquillity of the genital organs  should be observed.  The
surgeon must likewise employ  cubebs and  copaiba in the proper doses,
which alone will, in a variety  of cases, suffice  to  cure this chronic
stage.  The same rules, in the  administration of these two substances,
must be followed as were laid down in a previous section.
  Although M. Ricord is fully persuaded  that  gonorrhoea may be
cured by these means, still he  recommends them to  be combined with
a direct  local treatment,  or, in other words,  to employ injections in
the way we have detailed already,  preferring, above all others, those
containing the nitrate of silver;  not, however, as M. Carmichael rec-
ommends,  in the proportion of twelve grains to the ounce, but in the
more modest proportion of a quarter of a  grain  to  the ounce of dis-
tilled water.   Whatever results follow, and even  in spite of an in-
creased discharge,  or  a secretion tinged  with blood, we recommend
that, during the following two days, six injections be employed daily ;
stop at the end of that time the injections, but continue the cubebs,
&c.  The aggravation of local symptoms, which  the injection has
occasioned, will soon  pass off, and, usually speaking, the discharge
will altogether cease.   A relapse, however, often follows  any excess
in diet, &c.;  in such a case, we must repeat the injections with the
same restrictions, and  continue the general treatment some time.  M.
Ricord usually prescribes the  cubebs during the following nine days,
gradually diminishing  the dose.
   During the succeeding three weeks, neither baths, wine, nor women,
must be indulged in ; after that time, the patient may gradually return
to his usual habits.  It occasionally happens that  the injections of
nitrate of silver do not produce a  sanguinolent  discharge, and  the
running continues  in spite of this treatment; the surgeon, finding this
to be the case, should  enjoin  his patient to recommence the twelve
injections, increasing  the strength  of the  solution to the amount of
one, two, or three grains  to the  ounce, and  so on progressively, until
the usual effects are produced.
   When the discharge is of  very old standing, it may be necessary
likewise to continue daily the  injections for some time, particularly
if under their use the muco-purulent discharge gradually ceases ;  but
as soon as such an effect is produced, it will be well to leave off the
injections instantly, as  their employment would only tend to  recall
the running.   The  object the surgeon should  have in view is thus 
92
EPIDIDYMITIS.
 usually obtained, and, guided by these principles, he will generally
 succeed.
   In some few cases, injections with nitrate of silver fail of their de-
 sired effect; we may then replace them by others, containing sul-
 phate of zinc, in the proportion of six grains to Ij. of water, combined
 with a*few drops of laudanum.
   In spite of this treatment, or in consequence of its  not  being fol-
 lowed up,  a  gleet will remain.   The  discharge appears only in the
 morning, gluing together the lips of the meatus.  It is generally con-
 sidered of little consequence, still it annoys some patients very great-
 ly.  For its cure, we should employ injections composed in the  fol-
 lowing way : from one to six grains of tannin to an ounce of red wine
 from the  south  of France ; to  this may be  added from one to six
 grains of alum.
   There are some cases which resist the  means of cure above spoken
 of, and then  the  surgeon should  have recourse to the cauterization
 with the solid nitrate of  silver.   Many patients dislike the employ-
 ment of instruments ; we  therefore should not cauterize, until we find
 that other  means  have failed.   I have  seen the  instrument of M.
 Lallemand* usually employed for this purpose at the Hopital du Midi.
 It is introduced as far as the neck of the bladder ; by means of a little
 spring, the cup containing the nitrate of  silver is  caused to project,
 and the porte caustique gradually withdrawn, which slightly cauter-
 izes the sides of  the  canal.   I can hardly suppose, however, with
 Whately, that the salt only affects the diseased portions of membrane ;
 every part, sound or diseased, is equally cauterized.   This, however,
 is of no great inconvenience.  At the  time of the operation, the pa-
 tient suffers considerably in the canal, the secretion  becomes aug-
 mented, and a  scalding  is  felt in making water.  As  this usually
follows, the patient  should, after the cauterization has been performed,
be  told to expect  such consequences ;  otherwise he will become
 alarmed when he perceives the discharge tinged with blood.   In about
three days the discharge will cease, and  then the  surgeon may pre-
 scribe, with advantage, cubebs ;  or, if at the end of five days the se-
 cretion from the urethra  continues as before the cauterization, the
 surgeon will do well to repeat it, and again, on the subsidence of local
 irritation, let him employ general treatment.
1  In practice, it will be found that cases exist which do not get well
 even under the preceding  treatment, and  yet  no perceptible organic
  * An engraving of this instrument will be given when describing the subject of cau-
 terization. 
EPIDIDYMITIS.
93
change  of the  mucous membrane  exists  which can  account for it.
We  have seen great benefit derived, in these cases, from injections
of the proto-ioduret of iron, in the proportion of one grain to the ounce
of water, and augmented until the injection contains twenty-four grains
to the ounce.   The  strength should  be increased very gradually, as
the preparations of iron and iodine  are very liable to change, in con-
sequence  of decompositions easily  taking place.  If, under weak in-
jections, the statu quo remains, the surgeon should augment the pro-
portion  of the proto-ioduret;  on the contrary, should the employment
of it be followed by a sanguinolent discharge, it may be laid aside,
and  general treatment employed ; and if in a few days the discharge
cease, no further treatment is required ; if this does not happen, the
surgeon should repeat the  injections, taking care to increase their
strength.
   Another plan  of treatment which  I  have seen crowned with the
most signal  success, consists  in the employment of a dry tent com-
posed of linen.
   In speaking of balanitis,  I  have stated the great advantage to be
derived from a piece of dry lint placed between  the  glans and pre-
puce ; for it seems a law of the animal economy, that the contact of
one  inflamed surface with another  aggravates the original affection,
and  tends to keep up diseased action.   From the  observation of these
facts, M.  Ricord  was induced to try if he could not treat gonorrhoea
in the same way as balanitis ;  he was more inclined to think such a
treatment beneficial, as, in the  case of blennorrhagia of the vulva, a
cure rapidly  followed the introduction of pieces of lint between the
nymphae.   In cases, therefore,  which resisted ordinary treatment, M.
Ricord  determined  upon introducing a tent into the canal, and ob-
serving the result.  The method  is very simple, the materials con-
sisting merely of a piece of linen seven or eight inches long, a stilet,
and  a gum-elastic  catheter open at  both  extremities.   The  tent is
attached slightly  to the stilet, and placed in the gum-elastic catheter,
which the surgeon introduces, as far as he thinks necessary, by means
of the stilet; the strip of linen  is kept in its place, while the catheter
is gradually withdrawn; and, lastly, the stilet having served the purpose
of fixing the linen, may itself be withdrawn.  Thus the linen separates
the  sides of the canal, which it  effects very well until the  patient
makes  water;  it should  then be replaced.  Such treatment  is  only
applicable when  the urethra is  not  irritable, and it  can not be em-
ployed  previous to the subsidence of  the inflammatory symptoms, as
the  frequent  introduction of the catheter would aggravate the  inflam- 
94                       EPIDIDYMITIS.

mation.   I have had occasion to see this treatment employed in early
and recent cases of gonorrhcea with considerable success.  Still it
can not be recommended in the early stages, for reasons stated above ;
but in chronic gonorrhcea, where other means fail, the surgeon should
have always recourse to it.   No pain  at a late stage attends its in-
troduction ; still, as  patients have naturally a great dread of instru-
ments, we should delay its use  till  other means have been ineffectu-
ally tried.
   Latterly, long cylindrical bags,  composed  of the baudruche  of
Ducamp,  have been  recommended by M.  Crespiat, which are intro-
duced by means of a stilet, and are then filled with air or fluid.   They
act on the principle mentioned above.   In  chronic gonorrhoea, great
benefit will  often attend the introduction of a  bougie or sound, al-
though  no stricture may exist.  They are  often  useful, as they at
once check the discharge ;  or,  in other cases, their employment will
have the effect of first increasing, and then gradually diminishing, the
running.   Instruments  thus introduced may be smeared with various
ointments, such as one composed of nitrate of silver, one  grain to the
ounce of lard, or blue ointment may be preferred.   When the frequent
introduction of a bougie is attended with much pain, the surgeon may
think it proper to leave a catheter in the bladder;  and  in some  in-
stances the gleet will not  yield unless  this be done.  The diet, in
such cases, must be nutritious and strengthening,  accompanied with
cold baths in summer, and revulsive remedies, particularly blisters,
on the inner part of the thigh, or on the perinaeum.  Instead of per-
sisting with cubebs and copaiba, their use should be discontinued, and
vegetable or mineral tonics given liberally.
   In some cases, sea-bathing and change of air will alone effect what
 the surgeon  has been unable to accomplish.   One of the conditions
 of success seems  to be,  in some cases, the attempt to convert the
 chronic into an acute stage.  If all these means fail, let the surgeon
 send his patient into the country, and  allow him to amuse himself;
 but, above all things, to forget that he is laboring under a gleet. 
STRICTURES.                        95
                        SECTION  IV.

                          STRICTURES.

  One of the most frequent consequences of chronic gonorrhoea is
stricture, to the consideration of which subject we now call the read-
er's particular attention.
  Definition.—Sir B. Brodie, in  his Practical Observations on Dis-
eases of the Urinary Organs, thus defines stricture : " A mechanical
obstruction to the flow of urine through the male urethra."
  In the following pages I  shall consider the term stricture as a dim-
inution of the natural calibre of the urethra.
  Classification.—Authors  who have written on the subject of stric-
tures, differ  among themselves on  the classification of this  disease.
Sir  B. Brodie, who is so justly considered an authority, speaks in his
work of two kinds—spasmodic and permanent stricture.
  Sir A. Cooper,  in his lectures, says :  " Strictures of the  urethra
are of three  kinds—the permanent, the spasmodic, and the inflamma-
tory."
  My own observations lead me to believe that this  last classification
is the most correct, and it is the one I  shall follow in this chapter.
  Spasmodic Stricture.—The case  described by Sir B. Brodie, at
page 3 of his valuable work, will  give  a  good idea of the disease:
" A man who is otherwise  healthy, voids  his  urine one day in a  full
stream.  On the following day,  perhaps,  he is exposed to cold and
damp ; or he dines out, and forgets, amid the company of his  friends,
the quantity  of champagne, or punch,  or  other  liquor containing a
combination of alcohol, with a vegetable acid, which he drinks.   On
the next morning he finds himself unable to void his urine.   If you
send him to bed, apply warmth, and give him Dover's powder, it is
not improbable that in the course  of a few hours the urine will begin
to flow.  After the lapse of a few more  hours, you give him a draught
of infusion  of senna and  sulphate of magnesia, and when this has
acted on the bowels, he makes  water in a full stream."
  After such an able description, it would be of little use to allude
further to a simple case ; but it sometimes happens  that the spasm is
aggravated by other causes, and  the  retention increases to  a great 
96
STRICTURES.
extent before the surgeon is sent for.   I  therefore shall allude more
at length to the  affection.  It is  rarely met  with except in young
persons, or those of irritable habit; although it may become a com-
plication, as we shall  presently see,  still  it seldom affects elderly
persons.
   The causes have already been sufficiently alluded to, namely, cold,
damp, excesses in liquor ;  but  these will  only act in certain consti-
tutions.
   The frequency of the attack will also vary much, as Sir B. Brodie
observes, much probably depending upon the  patient's  constitution,
but much also on his mode of life.  One person may suffer once in
six months,  while  another may be  affected in  the same  way every
week or fortnight.  The situation of this form  of stricture, nearly all
authors are  agreed upon, is at the membranous portion of the  ure-
thra,  and is generally  attributed to a spasmodic action of Wilson's
muscles.
   The Symptoms.—I can not do  better than  state these in Sir B.
Brodie's own words.   At page 12  he says : " The  symptoms of re-
tention are formidable enough, and not the less so, as they generally
attack the patient suddenly.   He is, perhaps, sitting with his friends
after dinner, and feels  an  inclination  to make water ;  in attempting
to do so, however, he is disappointed.   A second and a third attempt
is made at different intervals,  and  all without success.   Now, how-
ever, the case assumes a more serious aspect.   There  is  an  inde-
scribable uneasiness felt in the region  of the bladder;  the  efforts to
void the urine  are no longer voluntary—the patient is forced to strain,
and the whole of the abdominal muscles are seen in convulsive ac-
tion, instinctively endeavoring to unload  the bladder of its contents.
This viscus  may be felt hard and large above the pubes.  The heart
soon begins  to sympathize with the local  irritation ;  the pulse is hard
and strong,  the face flushed, the  skin  hot, and the  tongue covered
with white fur.  Perhaps the violent efforts of  the patient may force
out a few drops of urine, and thus afford  him some relief; but the
kidneys go on secreting, and the  relief  is only temporary.  In  the
great  majority of cases the  spasm is spontaneously or artificially re-
lieved ; but  there  are,  nevertheless, numerous examples of the  con-
trary, in which the retention terminates even in death.  The bladder
itself may be ruptured  at the fundus, the  urine escaping into  the sur-
rounding cellular membrane, and into the abdomen."
   The  diagnosis of a  spasmodic stricture is derived from the possi-
bility of passing  the urine at one time  of the day and not the other; 
STRICTURES.
97
from the suddenness of the attack, not preceded by the symptoms we
shall presently see attend the other forms of stricture;  and, lastly, by
the introduction of a bougie.
  The prognosis is not unfavorable,  provided  a surgeon is called
early;  but at  a  later period it is somewhat more severe, though by
no means very serious.   The patient should, however, be  told that
these attacks,  if they become frequent, are  liable to lapse into other
forms of stricture, and the prognosis will be considered under those
divisions.
  The treatment of a simple case has already been alluded to ;  when
this fails, or  the  surgeon is called at a late period, Sir B. Brodie
recommends the following :  Believing the  cause of retention to be
local, he would reject the warm bath and bleeding, and recommends
the use of the smallest gum-catheter, which has been kept for a con-
siderable time on a curved iron wire.   It  should be introduced with-
out the wire, and as it approaches the stricture, turn the concavity of
the catheter toward the pubes, elongating the penis, at the same time
drawing it out as much as possible.  If this fails, Sir B. Brodie rec-
ommends us to try a catgut bougie, which, failing in passing, should
be pressed against the stricture, and when the patient makes an effort
to pass water,  should be suddenly withdrawn; this will often be suc-
cessful.   These  means  failing, it may be possible to introduce a sil-
ver catheter, or an elastic gum catheter mounted on a firm iron stilet,
into the bladder.
   Recourse may be then had to opium in drachm doses, in the form
of clyster, or  it may be given by the mouth every hour until the pa-
tient can make water.
  Sir B. Brodie states he can place no dependance  upon the warm
bath in comparison with opium.   Neither has general bleeding ap-
peared to him of  much benefit, though he has seen good results from
cupping  in  the perinaeum.   In the early periods, he considers the
use of purgatives beneficial.   Sir Benjamin  terminates the treatment
by citing a  case  of intermitting retention cured by sulphate of qui-
nine.
  Inflammatory Stricture.—This form of stricture  has  not been
alluded to by Sir B. Brodie.  A  description of it will, however, be
found in Sir Astley Cooper's Surgical Lectures.
  It may exist alone, or in combination with the other forms.   Not
unfrequently in acute gonorrhoea I have met with complete retention,
in consequence of inflammatory swelling of the mucous membrane;
and Sir Astley states it may follow the introduction of a bougie.  I
                               7 
98
STRICTURES.
have, however, witnessed the affection most frequently coming on in
consequence of the  use of instruments in cases of spasmodic stric-
tures, and I believe that this latter affection is very frequently com-
plicated with an inflammatory stricture.  A permanent stricture, which
is pervious sufficiently to allow the passage  of  a small  bougie, will
often, in consequence of the use of instruments, cause complete re-
tention of urine from inflammation. I have witnessed the same effects
from caustic bougies ; hence its study becomes  of great importance
to the surgeon, and deserves greater consideration, not, perhaps, as a
separate affection, but as a complication, than previous writers have
given it.
   The treatment that I have seen employed with the greatest success,
is that recommended by Sir A. Cooper, and usually adopted by M.
Ricord ; that is to say, general bleeding when the symptoms run high,
purgatives,  leeches  to the perinaeum, and the warm bath.   Much to
my surprise, however, certain modern surgeons recommend, even in
these cases, the use of the catheter, and assure us that they attempt
to pass catheters  in every case of retention of urine.  When the heads
of the profession  speak thus confidently, it is  perhaps improper that I
should recommend a  contrary  practice.   Notwithstanding, I have
seen so much mischief follow,  that I would  not recommend the use
of the instrument in inflammatory stricture, or any stricture compli-
cated with inflammation, be it spasmodic or permanent.
   Permanent Stricture may depend upon an organic alteration
of the canal of  the  urethra, or of the surrounding tissues or parts.
Let us then consider what is the nature of  these organic changes of
the canal.
   They may be twofold, depending either  upon an alteration of the
surface of the mucous membrane, or on an  alteration in the thickness
of its parietes.
   1st Variety.  Alteration of the Surface.—Various forms  of ulcers,
with their edges  more or less elevated, and  a  surface presenting a
fungous appearance,  may be the cause of stricture, as Brunner and
Mery have long since stated.
   In certain cases the calibre  of the urethra is  diminished by vege-
tations, as  Hunter, Bell, and Baillie,  have admitted.  These vegeta-
tions may occupy any part of the canal.   I have  subjoined a drawing,
which was taken from a patient in the Venereal hospital during the
last winter, representing a vegetation  seated  immediately within the
fossa navicularis.  This is a  common situation for vegetations, par-
ticularly in the female.   M. Ricord states that he found also ve'geta- 
STRICTURES.
99
 tions, not only in the membranous, but likewise on the prostatic por-
 tion of the urethra, in the same subject.
   Laennec mentions cases where he observed false membranes  at-
 tached to the mucous membrane of the urethra, thus producing stric-
 ture.  M. Ricord,  in  citing these observations,  says  he has never
 met with similar cases,  but in no way doubts the possibility of their
 occurrence.
   In addition to the lesions of surface above described, I must men-
 tion cicatrices, which may be either  the  result of ulcers of various
 kinds, and seated at various points of the  canal, or  may follow rup-
 ture of the canal, as happens in cases of chordee, or from tearing of
 the  parts with instruments, accidents, &c.  Gangrene may produce
 a loss of substance, and the part, in  cicatrizing, may not only dimin-
 ish the calibre, but  likewise shorten  the  urethra, or produce on  its
 surface bands, or bridles, which may more  or  less alter the dimen-
 sions of the canal.   Let it be remembered that cicatrices are perma-
 nent  alterations,  and  that when once formed they have no tendency
 to diminish.
   Soemmering and  other authors have spoken of a haemorrhoidal state
 of the posterior part of the canal.  This  often depends upon an im-
 peded circulation of the  part.   In  such  cases, bleeding often occurs
 under slight causes, as on the introduction of an instrument, or  even
 after voiding the urine.
   2d Variety.  Alteration in the thickness  of the Tissues or Substance
 of the Mucous Membrane.—It has been stated  that acute or chronic
 inflammation often produces a swelling of the mucous  membrane, and
 this frequently becomes a cause of stricture ; but as inflammation lin-
 gers longer, and  is most severe, in the deeper portions of the  canal,
 this variety occurs most frequently in these situations.   The swelling
 does not always present  the  same conditions ; it may be either cir-
 cumscribed or diffused—may occupy only a point,  or  the whole cir-
 cumference of the canal, and, as in all other tissues, be accompanied
 with softening or induration of the membrane.  A fungous degenera-
 tion  is  sometimes a consequence,  and not  unfrequently a callous
 thickening of the parts takes place, which bears a strong analogy to
 cartilage.
  There is, however, another alteration in the canal,  which theories
at one time or another in  vogue have prevented surgeons from paying
that attention to which it deserves.  I refer to that form of induration
which elsewhere I  have called specific, and which accompanies
 chancre in the urethra, as well as rn other  parts.  These indurations, 
100
STRICTURES.
 which  constitute the  greater portion of obstinate  strictures we are
 called upon to treat, are seated in the spongy portion, and resist usu-
 ally the local  treatment, or even become aggravated by mechanical
 means, whereas they disappear very rapidly under general treatment.
 Cancer, scrofula, &c, may give rise  to swelling of the urethra, and
 thus produce stricture.
   3d Variety.   It has  been  stated that permanent stricture  of the
 urethra may depend  upon affections  of the parts  around the canal.
 The most common among these are various inflammations of the cel-
 lular tissue, which, terminating by suppuration, occasion a loss of
 substance, and, in healing, produce cicatrices, or leave indurations
 which produce deviations of the  canal, and diminish its calibre.  In
 addition, it is  found that the prostate,, or  any one of its lobes, may
 become  enlarged ;  and  it is the universal belief, since the days of
 Sir E. Home, that stricture in the deeper portions of the canal de-
 pends upon this cause, or an abscess in the neighborhood.  It is easy
 to conceive how any substance which can act on the outside of the
 canal,  or become lodged in its cavity,  will be, to a certain extent, a
 cause of stricture.  In fine, any of the morbid states  above described
 may exist alone, or they may become  combined, and thus give rise to
 stricture.
   Causes.—Although gonorrhoea is a very frequent cause of stricture,
 still other affections may give rise to the permanent form.  M. Ricord
 cites the  case of a  young man,  twenty-five  years of age, who had
been subject to difficulty in passing water from his infancy, although
he had never had a discharge from the urethra, nor was there any
foreign body present in the bladder to  account for it.  This young
man, when he entered the hospital,  labored  under  stricture of the
urethra, and a most attentive examination failed in recognising any
alteration of form in the prostate gland.
  But if other causes may occasion stricture of the urethra, it can not
be doubted but that venereal disease, and particularly gonorrhoea, most
frequently produces it.
  Nothing is  more common, says M.  Ricord, than to meet with a
difficulty in voiding the urine,  amounting even to retention, in the
acute stage of gonorrhoea, even  at its commencement, to which the
name of inflammatory stricture has been given.   Such strictures are
the result of phlegmonous  swelling,  or of an oedematous infiltration
into the sub-mucous  cellular tissue, and they disappear  when the
acute  stage has  passed away ; but it  is not uncommon to see this 
STRICTURES.
101
state prolonged, or pass on to a chronic form, together with the in-
flammation which has given rise to it.
   Such strictures are usually of considerable extent, and are frequently
situated near the bulb,  at  its anterior part, and the nearer the orifice
of the canal according  to the duration of the complaint.  The extent
and severity of strictures  depend  upon the number and duration of
gonorrhoeas.  This  is  of  great  importance, as it proves that the use
of injections has  been  too often condemned without sufficient reason.
It has, I hope, become clear to my readers, that injections, under the
proper restrictions (which I have alluded to elsewhere), as they tend
to check inflammations, so must they prevent one of the  most pow-
erful causes of strictures;  and as astringents,  under certain circum-
stances, tend to remove the soft hypertrophy of mucous membranes,
so they may be said  to  cure, rather than give rise to stricture.   But I
must here  quit the  subject of injections.   When popular errors are
to be combated, I am always glad  to cite  the opinions  of those who
are so  deservedly respected in the profession, and on the present oc-
casion I can not help quoting a phrase of Sir B. Brodie.  That gen-
tleman, at page 9, says : " Permanent stricture frequently follows an
obstinate  gonorrhoea.  Astringent  injections have been  sometimes
considered to be causes of this disease ;  but I certainly believe that
more blame has been attached to them than they really merit.  It is
the abuse, and not the use of injections, which is to be deprecated.
I have no hesitation in saying, that  there is greater danger as to the
production of stricture  from a very long-continued gonorrhoea or gleet,
than from the prudent use of a mild astringent injection."
   The situation of stricture is various, but it is  found most frequently
at the membranous part, and at  the bulbous portion.  It has been
stated, that  when several strictures exist,  one is always found in this
situation.   There are exceptions to this rule, and M. Ricord says he
is astonished  at finding that Mr. Civiale has only met with two such
cases.
   Hunter and Soemmering state they  have never met with cases of
stricture of. the prostatic portion of the urethra.   M. Ricord, however,
has seen this part of the urethra narrowed, independently of the pros-
tate.   Mr. Crosse cites a  similar case.
   The  number of strictures may be various ; one only may be pres-
ent.   Ducamp affirms  that one, or at most two, is the usual number.
In this respect, adds M. Ricord, Ducamp is correct.   Nevertheless,
Hunter states he  has met with six strictures in the same patient.  M.
Lallemand  of Montpelier has seen seven,  and Calot eight.  About 
102
STRICTURES.
three years ago a patient was admitted at the Hopital du Midi, whose
urethra was strictured in its whole extent; there were ten fistulous
openings, the most anterior of which was seated on the side of the
fraenum ; the others were situated along the spongy portion of the
canal as far as the bulb.
  The form of stricture may likewise differ—namely, it may consist
simply in a little band, or septum, stretched across the canal: this is
called by Sir A. Cooper  the riband stricture ; a  part or side of the
canal may alone be affected.   In  cases of callous  stricture the indu-
ration may occupy the whole circumference of the canal, or a part
only,  as may be proved by the  porte empreinte  of Ducamp.  The
stricture, again, may be confined to a small part of the circumference
of the canal, or it may occupy an  inch of its extent: this, by Sir A.
Cooper, is styled the corded stricture.
  The different forms of stricture are shown in the annexed figures.
  The Symptoms of Permanent Stricture.—In consequence of inat-
tention or ignorance, a person may for a long time be subject to stric-
ture without paying any regard to it.   However, he usually perceives
that his water passes with difficulty ;  the stream  of urine, which at
first was diminished in size, becomes gradually smaller, until it comes
away drop by drop, trickling and dribbling  down,  and  staining the 
STRICTURES.                       103
trowsers of the patient; in the street an experienced eye detects at
once the individual who is laboring under a strictured urethra.   Pa-
tients suffering from stricture, when they consult a surgeon, tell him
that the urine passes in a corkscrew fashion.
  These symptoms  are not exclusively those of stricture, as I  shall
now attempt to  prove.   A sluggish  bladder will cause the urine to
dribble, as it were, and fall on the shoes of the patient;  and, on the
appearance of this symptom alone, the surgeon would be rash to come
to a conclusion that  a stricture existed.   The  same effect will be
likewise produced when the penis possesses an unusual degree of
contractility, or when it is in a state of erection.
  The  spiral  or  corkscrew  stream, as seen in the annexed figures,
may be produced  either by a stricture, or by the relative position of
the canal to the  opening of the meatus.  The canal being circular,
and the meatus linear, if the bladder does not act with its accustomed
vigor, the difference in the direction of these two portions of the canal
may give the stream of urine a spiral form.
  The cause of the urine being spirted up is sometimes owing to the
opening being high up ;  and in such cases, if the  bladder act vigor-
ously, the Stream of urine will be propelled upward instead of directly
forward.   The same effect is produced by  an enlargement of the
middle lobe  of the prostate.   Another symptom of stricture has been
drawn  from  the modification in the emission of semen.   Thus, during
the act of coition, th$  patient  feels  that an emission of semen is
taking  place, but  none  passes out by the meatus, when, afterward,
that secretion is seen oozing out by degrees.
  These modifications in passing urine, or in  ejaculation," may be ac-
companied with pain, or swelling of the penis, and the application of
the finger detects a hardness at some particular point;  often the  pa-
tient contracts the habit  of drawing out the penis, and the practitioner
might imagine he suffered under calculus, were not the  other symp-
toms of  that  affection  wanting.  Thus, in  stricture, the penis is
longer  than  usual.  Chordee is likewise often  present, and the organ
 
104
STRICTURES.
 may be drawn in erection downward, upward, or laterally ;  of course
 this chordee is to be explained by a lesser degree of elasticity of the
 corpus spongiosum, as compared with the corpora cavernosa, in con-
 sequence of the deposition of plastic lymph within its cellules.
   Another very frequent symptom of stricture is a discharge from the
 urethra,  which we call gleet, and which the French designate by the
 term suintement.   This gleet  may sometimes  be the only symptom
 present;  it may consist in a mucous or purulent discharge,  or  the
 only trace of it is to be found in a thready secretion which resembles
 vermicelli.   Slight as this sign is, it very often annoys patients, par-
 ticularly hypochondriacs, who find, by reading books, that M. Amus-
 sat considers it a symptom of  stricture,  although no other is present.
 Thus they collect their urine in a glass every morning, and examine
 it most minutely, to see if any appearances exist;  if they find a shred,
 they are miserable during the next week.
   When  it is stated that a gleet is a symptom  which often attends
 stricture,  we are perhaps wrong, as the two affections  depend upon
 one  and the same  cause, namely, chronic inflammation of the mucous
 membrane.   But although in such a case it can not be said that stric-
 ture gives rise  to a gleet, as gleet and  stricture  often  occur  simul-
 taneously, and  the gleet is thus only a continuation of the gonorrhoea,
 still  there is frequently a form of gleet which depends on and is  oc-
 casioned by stricture, as I shall now attempt to prove.
  If, as  in the above  case, a gleet may precede or arise simultane-
ously with a stricture, it is no less true that it often follows as a direct
consequence, and is one of the symptoms of it, as above  stated ; and,
moreover, it is impossible  to  cure the gleet without  removing its
 cause, namely, the stricture.*
  Daily observation shows that, when a stricture exists to some ex-
tent, the  stream of urine  is necessarily checked at the  back of the
stricture ; irritation succeeds,  speedily followed by inflammation, or,
if it previously existed, the  inflammation becomes aggravated ; the i
urine reacts  on the inflamed  membrane, which  often becomes soft-
 ened, and a secretion arises as a direct consequence of the strictured
 canal.   It is in such cases that I regard the stricture as  the cause of
 the gleet, although, as 1 observed above, a gleet may exist independ-
 * I find that Whately, in his Treatise on the Urethra, is of opinion that the gleet pro-
 ceeds from that portion of the mucous membrane in front of the stricture.  Sir B. Bro-
 die, in his valuable Lectures on Strictures, is of the same opinion.  May we not, then,
 believe that in such cases the gleet is the consequence of the gonorrhcea, and not of the
 stricture ?—a point of practical,  and not of mere theoretical importance, as will be
 shown. 
STRICTURES.
105
ently, may be produced by the same cause, and, lastly, be dependant
upon a stricture.   Hence the practical advice given by M. Ricord in
his Clinique, to pass an instrument in old-standing gleet;  otherwise,
after using injections, your patient, on consulting a brother practition-
er, may lay at your door the stricture.  If, on sounding him and find-
ing a stricture, you inform him of it, your character is saved.
   In addition to the inconvenience above stated, a gleet gives rise to
other consequences ; thus, if the canal be much diminished in cali-
bre, the discharge will, by plugging up the passage, occasion a com-
plete retention, particularly when the bladder acts feebly;  if it does
not plug up the passage, the  tenacious  secretion may adhere to the
sides of the canal, and cause the patient to make water in  a spiral
manner.
   The adherence of these shreds of mucus to the walls of the canal
might, in a case of simple gleet, by causing the patient to make water
in a spiral  stream, lead  a surgeon to  suppose that a stricture really
exists.   But, even without passing a bougie, he may always suspect
this cause, if the patient  state that the stream of urine is only altered
from time to time.   Should it, however, be permanent,  he must at-
 tribute it to inequalities of the canal; in fact, to organic change.*
   A slugglish bladder will produce  the  same effect; but this cause
 will be at once recognised, if, when that organ has nearly emptied
 itself, the stream becomes natural.
   The preceding observations may  show how guarded we should be
 in giving an opinion on the  existence  of a stricture simply from the
 signs above enumerated, as they can not be depended upon, although
 of value when  associated with others.  And have not authors been
 wrong in considering these as pathonornonic 1
   Fortunately for  the surgeon,  he  has other means of determining
 whether a stricture really exist or not.     t
    This he ascertains directly by  exploring the  canal, from before
 backward, by the aid of various instruments, composed of metal,  or
 of elastic and pliable substances, and called bougies, which may be
 either solid or hollow.   Their shape is likewise different; they may
 be either straight or curved.
    Their volume,  like their  shape, differs materially; they may be
 cylindrical, or conical, or a ventre:  by this term  I  mean that one por-
 tion of their circumference may be larger than the rest.f
   * I would ask if such cases have not sometimes been called spasmodic strictures 1
   t It may be supposed that this means of  exploration gives us at once unequivocal
 signs of stricture. Such is the case when an instrument introduced into the urethra be- 
106
STRICTURES.
   The different sizes and the different forms of bougies  are seen in
the annexed and following cuts.
                    1
                    1------__________——
   Not content with the  exploration  of the  canal from before back-
ward, some surgeons have proposed to detect strictures by means of
an exploration from behind forward.   For  this  purpose  M. Amussat
has invented an instrument which, when introduced into the urethra
by means of a  spring, causes a button  at its farther extremity to pro-
trude ; the  instrument is then gradually withdrawn, and by this means
M. Amussat  considers that he is able to detect strictures which are
not recognisable by other means.  That such is the case, there, is no
doubt;  as,  for instance, in those  diaphragmatic  or valvular strictures
above spoken of.   But, observes M.  Ricord, in one of his clinical
lectures, it  is not of such  absolute necessity to treat them; they are
permanent,  and provided  they do not  interfere  with the functions of
the canal, or by their presence occasion disease of the neighboring
parts, they should be left alone, for you do no good by removing them,
if their presence  only gives rise to some  change in  the stream of
urine; whereas, by  irritating the canal in their removal, you  only
stimulate and produce probably further mischief.  Modern practition-
ers have,  however, not been  content with simply knowing  that  a
comes firmly embraced by the stricture;  any one having once felt this sensation can
never mistake it. But, as is usually the case in medicine, if this be easy, there are other
cases in which the  diagnosis becomes very difficult. I have above stated that a spas-
modic stricture may occur, and prevent the passage of the instrument; in other cases,
it will be impossible to pass  a small bougie, whereas a large one enters without diffi-
culty.  A curved instrument sometimes  passes where a straight one will not.  A soft
instrument may likewise bend upon itself, and thus produce the sensation as if a stric-
ture existed, and the surgeon is not a little surprised, after gradual pressure to see the
extremity of his bougie reappearing at  the meatus.  It hence results, that, with the
exception of the first instance, it is often diflScult to convince oneself of a stricture and the
surgeon may be often led into error.  The preceding observations also show how ne-
cessary it is to employ various instruments before coming to a decision. 
STRICTURES.
107
stricture exists,  and seeking out every little irregularity which may
be present on the surface of the mucous membrane, but they have de-
vised means, by exploring the  canal,  to find the
depth at which it  is  seated.  But as the  organ
changes so much in length under moral impres-
sions, and  as measurements may be made  either
during traction or when the penis is hanging, no
two medical men will be  agreed on this subject,
notwithstanding  all  that has  lately been written
upon the subject.  The urethra has been farther
explored by instruments for another purpose, viz.,
to know the exact position and  direction, as well
as tightness of a stricture.   This is done by means
of bougies, at the extremity of  which  is placed a
piece of cobblers' wax, which takes the exact im-
pression of the stricture.  (See annexed cut.)  But
this  may not altogether be a true one ; frequently
true  impressions are given, but it often happens
that  the instrument  is stopped where no stricture
exists,  and  particularly at the  bulb the wax will
receive impression as of a stricture, although none
really exist.
   Diagnosis of Stricture.—The occurrence  of the
symptoms, either alone or in combination, together
with the errors which the surgeon may fall into,
have  been sufficiently spoken of here ;  it  is un-
necessary  to  revert  again  to  the symptoms by
which a stricture may be detected.
   But as there are various lesions which may give
rise to the affection, it is to facilitate the differen-
tial diagnosis of these (in order  that our prognosis
and  treatment may  not be empirical), that  I now
demand the particular attention of my readers.  '
   In respect to the differential diagnosis of vege-
tations or excrescences on  the surface  of the  mu-
cous membrane, I have stated, in speaking of their
pathology, that  they occur most frequently at the
orifice  of the urethra ; thus, in stricture  at this
point, we may suspect them as the cause, although
it must be  allowed that this alone is  of no great
use.   The introduction of a bougie detects an im-    (Portu Emprdnte.) 
108
STRICTURES.
 pediment, but nevertheless passes without great difficulty, accompa-
 nied by a peculiar sensation,  similar to that  produced by an instru-
 ment thrust through the substance of the lung.   Considerable haemor-
 rhage follows the introduction of the instrument, although the bougie
 has not made a false passage, the  bleeding being occasioned by the
 great vascularity of the vegetations.
   Vegetations may be  distinguished from a  puffy or haemorrhoidal
 state of the mucous membrane, by the absence of that  grating impres-
 sion spoken of; in both cases haemorrhage takes place.   It must still
 be allowed that the differential diagnosis between these two  morbid
 states of the mucous membrane, however important, is difficult, and
 can only be made in some cases ; of course these two states mutually
 accompany each other sometimes,  and in such  instances no positive
 conclusion can be  arrived at.
   The occurrence of strictures dependent upon cicatrices may gener-
 ally be diagnosed (independently of the general signs  common to all)
 by the bougie becoming firmly fixed in the stricture, which is with
 difficulty dilated,  and no  haemorrhage following.   Lastly, the porte
 empreinte shows that the stricture is linear, not presenting that thick-
 ened state of the  surrounding parts seen in the  following form—that
is to say, in the callous  stricture.  The  same  result is produced by
the introduction of M. Amussat's instrument.
   In  strictures caused by a callous state of the mucous membrane
 and surrounding tissues, no bleeding will follow the introduction of a
bougie, which becomes  firmly held by the stricture ;  they yield, like
the last, slowly to attempts at dilatation,  and are  usually situated deep
in  the canal, where chronic inflammation lingers the longest: thus
 we usually find them  in front of the bulb,  and the finger may often
 detect them in consequence of their extent and hardness.   The porte
 empreinte further corroborates the diagnosis.
  I can not here pass over in silence the differential  diagnosis  be-
 tween indurated stricture, the result of a simple and that of a specific
 inflammation; for I have elsewhere wished  to prove that the urethra
 is  subject, like every other part of the body, to chancre and induration
 of a specific nature.
   At an early period, however, our diagnosis  can only be a rational
 one, derived from the  history of  the case, as in both species of stric-
 ture  a discharge has been observed  from the urethra ; inoculation,
 however, will at this period decide the question.  Called upon for an
 opinion at a later period, say  two months, when all discharge  has
 ceased, our  diagnosis must be  based upon the concomitant circum- 
STRICTURES.
109
stances, namely, the occurrence of secondary symptoms, which sel-
dom fail to appear, if the induration be of a specific nature.   I have
had several occasions of observing this at the Venereal hospital, and,
as will hereafter be shown, treatment must be quite different as one
or the other view of the subject is taken—namely, whether the indu-
ration be specific or not.
   Prognosis of Stricture.—As regards the prognosis of stricture de-
pending upon  vegetations, we  can  not  expect a speedy cure, as we
are well aware how liable they are to be  reproduced even when re-
moved, and, being situated within the urethra, their removal often is
very difficult.   In respect to the softened puffy  state  of the mucous
membrane, we can usually promise the  patient a speedy and perma-
nent cure.  Perhaps, of all strictures occurring in the urethra, this is
the  most easily cured.                    ^
   Stricture depending upon cicatrix renders a cure  neither speedy
nor permanent.   The tendency all cicatrices have to contract, in con-
sequence  of  the peculiar tissue of  which they are  formed, is well
known; but we must remember that, as a cicatrix is a permanent le-
 sion, we  have to fear no augmentation of the stricture if left alone,
 provided it does not completely close the canal.   Should it narrow
 the calibre of the urethra, we must give  a very unfavorable prognosis,
 as most probably it will produce disease  of  the bladder and of the
 parts situated behind the stricture.   Lastly, we can depend little upon
 destroying the cicatrices, as we only cause  still greater ones to be
 formed.
   Unfortunately, our prognosis of  a  callous stricture is very little
 more  favorable  than the  last, unless we are called upon to treat it
 soon after its occurrence.   When  once organized,  this cartilaginous
 mass  closely resembles cicatrix ; its elements, in fact, are the same,
 and it is a rebellious form of stricture.  As  regards  specific indura-
 tion, the local disease usually disappears under proper treatment; but
 as it shows that the system is under the  influence of syphilis, the
 prognosis must be referred to that disease.
    The Treatment of Stricture necessarily follows that of the progno-
 sis, in the order of the description we have pointed out.  It, however,
 by no means follows that strictures of the  urethra should be consid-
 ered as a morbid state,  to which we are called upon to apply a treat-
 ment.   We have before stated that stricture is, in some cases, a defi-
 nite termination of an affection of the  urethra, and  bears  the same
 relation to it as do cicatrices to ulcers, or union by the first intention
 to simple wounds.   The urethra may be altered in direction, or even 
110
STRICTURES.
its calibre diminished ; and provided  no discharge follow, or any in-
convenience in the functions of the neighboring parts (as, for instance,
of the prostate, vesiculae seminales, bladder, &c.) succeed, the sur-
geon is not called upon to treat the case simply because the diameter
of the canal is slightly diminished, or  in consequence of the stream
of urine  becoming irregular ; for, under such circumstances, a treat-
ment becomes only a source of irritation, instead of a means of relief.
" I am well aware," states  M. Ricord, in a note to the French edition
of Hunter,  " that strictures  are often more  quickly cured in proportion
as they are early treated ;  but this law, general as it is, does not the
less admit  of  exceptions, particularly in that form of stricture which
may be called definitive."
  We may hence  conclude that  it  is only in cases which have a
tendency to increase, or yhich interfere with the direct functions of
the urethra, and those of the surrounding organs, that we should sub-
mit our patient to treatment.
  Many authors, and Hunter among the rest, are of opinion  that local
treatment is the only one required  in cases  of permanent  stricture;
yet the more or less inflammation present, the strength or weakness
of the patient, as  well as various complications, may require other
means than those demanded for the simple destruction of  an obstacle
in the canal.   This is probably the  case in that form of stricture which
depends upon the specific induration of chancre, and which,  usually
refractory  to a local treatment, yields to  general means employed to
cure the specific  disease.
   Hence, then, we must divide our treatment into general and local.
   The first may be simple, directed only to combat the inflammatory
state, as well as spasm and various complications which are present;
it may, moreover, be specific or special, and employed to destroy the
peculiar cause of the disease, as in indurated chancre.
   The second comprehends simple applications, as well as  dilatation,
cauterization, and scarification, or incision by the various instruments
we shall hereafter describe.   With respect to the treatment of stric-
ture by general means, I shall only refer  my readers  to what I have
previously said, in speaking of gonorrhoea and the treatment of chan-
 cre in the  urethra, and shall, therefore, pass on immediately to the
 consideration of the local treatment.
   Here  the use of various applications generally considered as tend-
 ing to the  resolution of inflammation  is often of great service, when
 applied externally, or introduced into the  urethra.  We  find that by
 these means many forms of  the induration left after inflammation 
STRICTURES.                       Ill
gradually disappear, and the cause of the stricture ceases under these
simple local means.
  In the same manner, injections into the urethra of various prepara-
tions will cure stricture which depends upon hypertrophy and soften-
ing of the mucous membrane.   These  preparations will have the
same  effect on the urethra as they have on the conjunctiva—that is,
cause a rapid cure.
  Dilatation.—It must be allowed, however, that the greatest num-
ber of strictures resist the means above spoken  of, and the surgeon is
then called upon to employ others of a more powerful nature.  Among
these I must first place dilatation.
   Dilatation, in fact, is the plan of treatment the most generally ap-
plicable, and, whether employed either alone or in  combination with
other means, most frequently succeeds.
   Dilatation has been employed, variously modified, by different sur-
geons  in different countries ; but these modifications may be summed
up  in the following manner :—
   1st. It may be sudden.   (Dilatation brusque of M.  Ricord.)  This
plan is particularly recommended and practised by M.  Mayor. It con-
sists  in passing a large-sized metallic  sound  into the urethra; and
this treatment is founded on the principle, " that the tighter the stric-
ture, the larger should be the bougie employed."
    The ingenious surgeon  of Lausanne  (says  M. Ricord, in one  of
his clinical lectures),  uses these  large  sounds on the principle that
small  ones are liable to make false passages, whereas large instru-
ments  only tend to  dilate gradually  the stricture ;  and he further
draws an analogy between the sound and the head of a child dilating
the os uteri, considering that the mechanism of dilatation will be the
same  in both.   It is  unnecessary to show how erroneous this anal-
ogy is.
    In appreciating this plan of treatment, M. Ricord has stated that,
 in principle, it is in some instances true that it  is easy to pass a large
 sound when the stricture can not be penetrated  by a small one.  Thus,
 in cases of spasmodic stricture, a  small bougie or silver catheter is
 immediately stopped,  whereas a large one  passes without difficulty j
 in old people, where the  mucous membrane of the  canal is hypertro-
 phied and softened, a small instrument often gets entangled, and can
 not be pushed forward without the danger of making a false passage,
 yet a full-sized instrument is admitted.
    When a stricture depends upon a slight band or septum stretched
 across the canal, the introduction of a large  instrument will often 
112
STRICTURES.
break through it, whereas a small one will be prevented from passing;
but in this case the violence  done to the canal may be followed by
considerable reaction, and such cases would be far better treated by
incision than thus roughly handled.
  But if these large bougies  are useful in some cases, they certainly
are not in those where callous stricture is present, for here the sur-
geon runs the risk of rupturing the urethra, if he uses force ;  and this
actually happened in M. Mayor's practice.
  I reject, then, the method as one of universal application, but nev-
theless  approve  of  it in some rare cases.  I can  not, however, quit
M.  Mayor,  without  mentioning to my  readers  a precept of that sur-
geon on the passing of instruments.  Introduce them (says he) with
gentleness, and when the  point is in contact with  the stricture, hold
the instrument close to the meatus; by this  means  you may exercise
a much greater pressure on the face of the  stricture, and the instru-
ment is less likely to take a wrong direction.   A parting objection to
M.  Mayor's plan is, that this dilatation, even when it succeeds, gives
rise to symptoms of considerable reaction, and abscess of the perinae-
um frequently occurs.
  2d.  Dilatation may be  employed  rapidly  in contradistinction to
slowly.   It consists in passing a small bougie without employing vio-
lence, and replacing it by another  of a larger size every two or three
hours, in proportion as the instrument ceases to be  firmly grasped by
the stricture.  This plan of treatment has been particularly recom-
mended by Lallemand of Montpelier, and  Professor Velpeau of La
Charite, although  practitioners generally,  and particularly Hunter,
blamed  it as prejudicial.
   It is true that, by this means, the surgeon may cause a large-sized
bougie, in a few hours, to pass through a stricture which a short time
previously resisted  a small instrument; but  there  are many cases to
which this treatment is not  applicable, particularly when there is an
irritable state of the urethra, as this successive introduction of bougies
will augment and  aggravate  it.   This is, however,  only one  of the
objections  against  the  treatment; the most powerful is the liability
of  the disease to  return, for it seems to be  a law in  the economy of
stricture, that the  relapses occur in proportion to the rapidity of the
cure of the case.   M. Ricord states that he has had under his care a
patient suffering from stricture, which three months previously had
been treated in this manner, and was supposed to be cured yet a bou-
gie of half a line in diameter passed with difficulty.
   Such are the reasons, then for the rejection of this plan, and which 
STRICTURES.
113
induce M. Ricord, in his private and public practice, to employ grad-
ual dilatation.
   3d.  Gradual Dilatation.—-This  consists  in passing  small bougies
(the size of which must depend at first upon the  tightness of the stric-
ture),  and substituting successively larger ones, allowing sufficient
time to elapse between each introduction, so that no irritation  of the
canal ensues ; should such arise, the employment  of a larger instru-
ment  must be delayed until the irritation has subsided ;  the surgeon
may then proceed with the gradual dilatation, but, on the slightest re-
turn of inflammation, discontinue its employment.  This line of treat-
ment  is slow,  but it  is very successful, and a  cure seldom turns out
fallacious.
   It follows, then, that great advantage  may be derived from dilata-
tion employed alone ; still  it is prejudicial  in cases complicated with
ulceration of the canal, as well as in those depending upon bands
crossing the urethra, where it tends only to cause irritation.  When
vegetations are present, dilatation is of no  benefit.   They will often,
likewise, prevent the passage of a bougie,  and  considerable haemor-
rhage will result if we persist in our endeavors.   Dilatation, again,
can not be relied upon in the callous stricture which is organized; in
place of giving relief,  dilatation will have the effect  of causing  a  local
inflammation, and thus aggravate the  case.  When, however, dilata-
tion is employed in  callous strictures of a recent date, the greatest
advantages may  be expected from it;  but it is often difficult, a priori,
to state whether the  callous mass  be organized or not.  As,  then,
dilatation is apt to produce reaction in callous strictures of old stand-
ing, the surgeon must be often  content when he  is  able to pass a
bougie of two and a half lines in diameter,  and not torment the canal
further.
   Another question arises  : should dilatation be employed temporarily
ox permanently ?  Each mode of treatment has its objections as well as
its advantages.   The frequent passage  of  instruments  is very liable
to  occasion  an  irritation  of the strictured  portion of  the urethra.
Leaving a bougie in  the bladder often  tends to produce an irritation
of the neighboring organs, as, for instance,  irritation of the prostate,
bladder, &c.  We should, however, prefer  the use  of temporary dila-
tation whenever  the frequent introduction of instruments is not very
difficult or painful, and when the  bougie so  introduced  ceases  to be
firmly grasped by the stricture ; when, on  successive days, it  can be
employed with facility, and when the bougie can  be easily replaced
by one of a larger calibre.
                                 8 
114
STRICTURES.
   Under opposite circumstances, we should employ constant dilata-
tion, by leaving a bougie permanently in the canal.   Various authors
have recommended that  temporary dilatation should be employed for
a longer or shorter time ;  none, however, give any definite opinion.
M. Ricord's treatment is the following : he recommends that a bougie
be introduced which is of such a size that it becomes tightly grasped
by the stricture, and he  orders the patient to keep it in that position
until it passes through the stricture easily: this usually soon happens; it
is then to be withdrawn, and the symptoms of reaction, if any occur, are
allowed to pass off.  On  the following day the same bougie is intro-
duced, and if it pass easily, the number which is  a little larger is in-
troduced, and the same directions given.  Under this treatment I have
seen a great number of strictures cured.   Of course  he does not in-
sist on the application  of this treatment to all cases of stricture.
   When a surgeon wishes to keep a bougie permanently in the blad-
der, he may allow eight days to pass without changing the instrument,
provided it does not get coated with sediment, and if no reaction takes
place.
  In a note on Hunter, M. Ricord observes :  It is not only a swelled
testicle, or a discharge from  the urethra, that  the  leaving a  bougie
permanently in the urethra may occasion, but  likewise  many other
inconveniences arise, which often oblige us to give up the treatment.
Thus,  as  an immediate  consequence, we may observe inflammation
of the neck of the bladder, which produces frequent and ardent desire
of making water, as well as tenesmus or incontinence of urine in va-
rious degrees, which will depend on  a greater or less share of irrita-
bility, or, as more commonly happens, on weakness or debility of the
muscular fibres of the bladder.  The inflammation of the bladder it-
self is not an unfrequent consequence of the employment of  instru-
ments which are left in the urethra.
  Under some circumstances, ulceration or perforation of the bladder
follows, particularly in those cases where  the instrument presses ex-
clusively on any particular point.  In addition, however, to these ac-
cidents, sympathetic phenomena occur of  a  purely nervous or some-
times febrile nature.   Under the  latter  head we  may enumerate, as
the most common,  accesses  of fever,  of a periodical or  intermittent
type, which occur  or disappear  according  as the instrument is left in
the bladder or withdrawn.
   Thus employed, dilatation may act in one  of three ways as a cura-
tive agent.  Its beneficial influence may be exerted in the same  way
as compression is supposed to act.  The introduction of a bouoie will 
STRICTURES.
115
mechanically empty the vessels of the  engorged tissue;  it will like-
wise excite or stimulate the  parts, and  cause an  absorption of the
effused secretion.  This  is what M. Ricord calls the action of com-
pression produced by dilatation.
  The  second mode in which dilatation may act, is by  occasioning
from the strictured surface a free  purulent discharge, which will di-
minish the size of the swollen parts.
  Dilatation may produce a third effect, namely, excite such a degree
of inflammation  or ulceration  as  will lead to the destruction of the
stricture.  There are surgeons who pretend that, unless bougies have
produced this  effect, the cure or amelioration  they effect will be only
temporary.  Such, however, is a very erroneous opinion, for we must
always bear in mind that  ulceration will give  rise to a cicatrized sur-
face, which has a tendency to contract; and  dilatation employed so
as to produce  ulceration, instead  of curing, will tend to aggravate the
stricture.
  M. Ricord states that the advantages of dilatation can only be ob-
tained  when it acts on the principle of compression, and  such should
be our object.
  In order that  dilatation be practicable, we have hitherto supposed
that the instrument penetrates the constricted  parts.  This necessary
condition is not  always easy, or even possible to attain ;  and in the
impossibility of passing the instrument through the stricture, we de-
rive great benefit from exercising a pressure by means of  the extrem-
ity of the bougie upon its anterior part.   M. Ricord states  that, during
the period  he had the care of the diseases  of the  urinary organs at
the Hotel Dieu, M. Dupuytren  treated many cases with great success,
by introducing every day, with great  care,  an instrument, and gently
pressing on the face of the stricture.  He was contented with making
slight progress daily, and  ultimately the contracted point admitted the
introduction of large instruments.   It  often requires six weeks to pass
a stricture ; yet, if no reaction occurs, and you are successful enough
to form a depression on the anterior part, a patient continuance of this
treatment will soon get the better of  these obstinate cases.  What-
ever be the theory that the surgeon may adopt, adds M. Ricord, it is
an incontestable fact, that, without having previously passed the stric-
ture, he may observe, under the influence of this treatment, that the
patient's evacuation of water, which  at  first was  nearly  impossible,
becomes easy and re-established  by  degrees, and  the symptoms of
retention of urine, which were imminent, cease altogether, even be-
fore the instruments have  reached the bladder. 
116                       STRICTURES.
   Other plans of treatment have been recommended.   Thus Ducamp
proposed that a bougie, open at its two extremities, and of a consid-
erable diameter, be passed till its farther progress was  stopped by the
stricture : through this first, which served simply as  a conductor, a
smaller instrument was introduced, which he considered would dilate
effectually the strictured part.
   Latterly, M.  Benique has proposed an  ingenious plan, which con-
sists in  introducing into the canal a bundle of small bougies made of
catgut,  and  independent  or unconnected  one with the other, which
the operator successively attempts to push through the stricture until
one or the other enters.  This  idea, says M. Ricord, is pretty, but it
has  been recommended  rather by a mathematician than by a practi-
cal man.
   It may be asked,  in  employing dilatation, either permanently or
temporarily, is it necessary that the bougie enter the bladder ?
   When  the stricture exists in  the  spongy part of the urethra, and
the surgeon  proposes to  employ temporary dilatation,  of course it is
quite unnecessary to pass the bougie  into the bladder; when, on the
contrary, the bougie is to remain, its  point should be introduced into
that  cavity ;  and, in order to prevent the occurrence of inflammation
or irritation, a well-curved bougie should be employed—one which
has been made  purposely—as  it  retains its  form better than instru-
ments which have a  curved  direction  given  them simply, from con-
taining a curved stilet.
   At the present  time, few authors are agreed upon the instruments
by means of which dilatation should be performed ; and, as much di-
versity of opinion exists on the  proper form, I  shall here  transcribe
the opinion of M. Ricord, published in the notes of the  French edi-
tion  of Hunter's works.
   " Conical  bougies produce the inconvenience of dilating the sound
parts more than those which are diseased, and especially of fatiguing
the meatus when they are of a large size.   On the other hand, when
they are inflexible or too  stiff, they are the  cause of false passages
more than arty others. But when the surgeon is called upon to treat
a stricture which is tight, and which can only be passed by a small
instrument, conical bougies, made of a supple material, are by far the
best, and to be preferred  to all we have previously alluded  to, and so
far favor  the introduction, that they pass those strictures  with ease
which impede or render impossible the passage of cylindrical instru-
ments of a smaller size.   Conical bougies form more easily than oth-
ers that infundibuliform impression on the face of the stricture, and 
STRICTURES.
117
they insinuate themselves gradually into the stric-
tured part, when gently directed and pushed ; be-
sides, their use is accompanied with less suffering
to the patient than that of cylindrical instruments
of a similar size.   To  conclude, if my personal
experience," continues  M. Ricord, " in  a large
hospital  had not taught me the immense impor-
tance that attaches itself to the employment of this
shaped bougie, the  opinion  of  Dupuytren would
suffice to recommend it in opposition to those sur-
geons who pretend that the employment of conical
bougies is now generally abandoned.
  " Provided bougies  are  either  cylindrical  or
conical,  when they are of a certain calibre, it is
impossible to prevent their  fatiguing the sound
parts of the  canal, as  I have  before remarked,
especially the meatus and that portion of the canal
which corresponds  to the glans.   To obviate this
inconvenience, surgeons have employed  fusiform
bougies, or, as they are called in  France, bougies
a ventre, and which Ducamp has especially rec-
ommended.   These bougies have the undisputed
advantage of only dilating the strictured portion.
The principal objection that has been  made to
them, namely, that  they pass with difficulty the
meatus,  and that  they necessarily do violence to
the points which they come in contact with, is un-
tenable ; for the utmost volume  of their  enlarged
portion  ought only to  have  a diameter  equal to
that of the cylindrical bougies which the surgeon
would employ in similar cases ; so that it will be
at  once  seen, that it is preferable only to pass
through  the meatus and the other parts of the ure-
thra, which we should spare  as  much as possible,
with this dilated part, rather  than  allow an instru-
ment of an  equal  volume throughout to remain
permanently dilating the canal.   I shall here say
nothing  of those conical bougies, to the extremity
of which a small rounded point (boule) is attached ;
they constitute  a  subtility which sound  practice  knows how to re
duce to its proper value."
(Conical
bougie.)
(Fusiform
bougie.) 
118
STRICTURES.
   Surgeons generally employ flexible bougies—some  practitioners
prefer  those  made of wax ; if, however, these bougies have  an ad-
vantage, when they are properly made, of receiving an impression of
morbid lesions of the mucous membrane, or of moulding themselves
to the natural or artificial curvatures of the canal, it still happens that,
in employing them, the operator finds that they are either too firm for
some patients, or else they do not offer sufficient, resistance,  when he
is obliged  to make several attempts before he succeeds in getting
through the stricture, as they  are liable to become soft  from the heat
of the parts.*
   " For my part," says M. Ricord, " I prefer gum-elastic bougies, al-
though, latterly,  practitioners have again introduced  metallic instru-
ments.  I  am. well aware  that their  trifling weight  adds nothing to
the ordinary dilatation, as performed with  milder and  more easily-
borne instruments ; but I would take care not to stigmatize, as some
have done, with  charlatanism,  certain persons who recommend  inflex-
ible  instruments  as  simple and  economical in hospital practice, as
patients can without danger employ them : a fact of some importance,
when the  case  requires  only occasional passing of instruments to
maintain the cure.
   " Under the  head of inflexible instruments, surgeons have classed
some bougies which are not so in reality, or,  at least, do not perma-
nently remain so, as, for instance, those made  of whalebone, which
M. Lallemand, of Montpelier, praises so much, as also those formed
of catgut,  or even those more recently introduced  ones of flexible
ivory.   These  last, made  from ivory which has  been  reduced  to a
demi-gelatinous  state by depriving it of its phosphate of lime, have
the advantage of furnishing a solid instrument which  receives any de-
sired curve, according to the case, and offers  another advantage,  that
of becoming soft and swelling, in consequence of moisture, which, al-
though  it has a tendency -to follow the direction of the canal, will be
disposed likewise to dilate it.   The  objections, however, which have
been urged against  the whalebone bougies, apply equally  to these.
Their principal  inconvenience depends upon  the  dilatation  taking
place in the strictured part,  so that the  instrument becomes fixed
there, and adheres with so much force that it is not always easy to
withdraw it, without  employing  such a  force as might possibly tear

  * I may mention that Sir B. Brodie prefers the wax bougie ; he states that this pref-
erence arises from a wax bougie retaining its bent form, whereas an elastic one has a
tendency to regain its straight direction, and hence is not well constructed for being passed
 along the curved canal of the urethra. 
STRICTURES.
119
the part, and is, therefore, not free from danger.  Nevertheless, this
objection may be, in some  measure, obviated by previously soaking
the instrument in water.   We may thus derive great benefit from this
invention, so happily introduced into France by M. Charriere.
   After having employed dilatation, and succeeded  in relieving  the
stricture, we should give directions to our patient to pass an instru-
ment every fourth day during  the  following fortnight, and then once
a  week for some time ;  should a recurrence of the  symptoms  of
stricture follow,  or  should  the  stream of urine diminish, it will  be
necessary to dilate the parts  again, and wait to see if the cure  be
permanent.                                 '
   We have hitherto spoken of dilatation as it may be very advanta-
geously employed alone, and we  have stated that there are various
cases in which it is not only incapable of producing  benefit, but tends
to aggravate the complaint; it may frequently be combined with other
plans, one of which I now propose speaking of, viz. :—
   Cauterization.—Its employment is not of modern date.  Alphonso
Ferri is one of the early surgeons who employed  it;  and Ambrose
Pare states  that he obtained  several  remarkable cures by cauteriza-
tion, previously to which he destroyed (I'usure) the  hard carnosities.
Loiseau, it  is well known, cured Henry IV. by means of cauteriza-
tion, although it was attended with accidents of such a severe nature
that he was tried for his conduct.
   Latterly, in France, it has been employed, in consequence of  the
eulogium passed on it by Ducamp, by Lallemand of Montpelier, Am-
ussat, Segalas, and others.   In England, in spite of the approbation
of Hunter,  Charles  Bell, and Whately, it  has  fallen into disrepute ;
and this is not surprising,  when a remedy like this has become  the
crotchet of certain individuals, who pretend that it is applicable to all
cases and all stages of stricture.  Unfortunately for patients, the two
opposite doctrines prevail.  One party will cite cases  of failures,  and
necessarily  disparage cauterization ;  the  other will  state that they
have never met with cases  which they were not enabled to cure : in
 the one and the other case, it is in vain to inquire  in what  forms of
 stricture this treatment was had recourse to ;  neither  the  indications
nor contra-indications are even so much as alluded to by those who
think fit to enlighten their professional brethren.
   In order  to  assist my readers in a just appreciation of the treat-
ment, I shall give such indications for its employment as will, I hope,
convince the profession  that the greatest  advantage  may be drawn
from its use. 
120
STRICTURES.
   If the surgeon thinks that it is a line of treatment which, of itself,
is applicable to all cases of stricture, without distinction, he  will find
it more frequently injurious than beneficial, for in a variety of circum-
stances he can very easily do without it; but if it is  employed with
discretion, in cases which call  for and are adapted to it, it becomes
not only a means of cure in  itself, but  is likewise a very good adju-
vant to dilatation.
   It is under these  circumstances that a spasmodic stricture yields to
a superficial cauterization, employed, not for the purpose of destroying
the tissues, but simply with the object of modifying their vitality.  In
the same  manner, strictures, accompanied with ulcerations, or depend-
ing on  granulations  seated  on ulcerating  surfaces,  or  on fungous
masses, or a softened hypertrophied state of the mucous membrane,
or simple  tumefaction of it, will be cured more rapidly and effectually
by cauterization alone, or combined  with dilatation, than by the latter
treatment  solely.
   If, however, the  caustic be employed to  destroy cicatrices, which
inevitably will be replaced by others of a still larger extent, or, if it
be used in those hard, callous  strictures in which resolution is im-
possible, far  from ameliorating  the  state of the part,  it will only ag-
gravate it, and retard or prevent a cure, which other means, more
adapted to the case, would most probably have brought about.
   Hunter only recommended cauterization in cases where  the sur-
geon is unable  to pass the obstacle ; hence, according to his views,
the caustic could only be applied on the face of the stricture.  On the
other hand, Ducamp and his school recommend  the  employment of
the caustic only in  those cases  where  the  stricture is pervious, and
thus allows the application of the substance to its parietes.   Of these
two methods, I prefer  the latter, whenever it is practicable ;  but  I
should previously dilate the stricture to  a certain extent; for, although
the effect of caustic be that of destroying spasm, and although it may
act as  an antiphlogistic, it is no less certain that its application is
sometimes followed by  inflammation  and swelling, or haemorrhage
even may result, and frequently a thick secretion will  follow and <nve
rise, like  the eschars which it  determines,  to an  obliteration of the
strictured point.  As these  accidents  are  more or less severe  we
should experience a difficulty in passing instruments.  In a note upon
this subject,  M. Ricord states, that he thinks the followino- directions
may be laid  down upon the employment of caustic :—
   1. The surgeon  may feel himself called upon to cauterize directly
from before backward (Hunter's plan),  whenever the  stricture allows 
/                        STRICTURES.                      121

urine to pass, and yet offers a resistance to the introduction of instru-
ments, however small, or however well directed.
  2. The interior of the stricture should be cauterized wherever di-
latation has been  employed without success, when but little progress
has been made, when inflammatory action comes  on, or the case gets
worse  under  our further endeavors to augment the dilatation.
  M*. Ricord is not in the habit of employing cauterization before a
bougie of three lines in diameter passes, and hence people might be
induced  to think  that when a bougie of this size passes, it is unne-
cessary to cauterize ; but, as  I  have just observed, such  is not the
case, and practice contradicts the supposition.  I have  seen cases
where a bougie of four lines in  diameter passed,  and yet suppuration
continued, and it was only checked by one or two applications of ni-
trate of silver.   It has been a favorite opinion, and one that has been
much acted upon, that caustics are endowed with a species of intelli-
gence, attacking only such parts as are the seat of the disease.  This
opinion is much exaggerated ; still, from what we observe on the pre-
puce, when we cauterize vegetations, we can easily believe that, if a
stricture depend  on these  substances, they act the part of a  sponge
sucking up freely the caustic ; but, in cases where no vegetations are
present, we do not believe that the sound parts will remain unaffected
by the caustic.
   Strictures  may be  cauterized with a variety of  substances ; thus,
Hunter employed the red precipitate, or the sulphuret of arsenic.  M.
Jobert has greatly extolled the use of calcined alum; with him it was
the philosopher's  stone, and did not produce any of the inconvenien-
ces  attributed  to  caustics.   M. Ricord states, however, that  he has
employed it,  and  he found that the powder fell  out of the little cup
and collected around the meatus ; hence he attributes the  great num-
ber of cases  said to have been  cured by this treatment to sympathy,
 and not to any direct effect of the calcined alum ; the instrument was
 modified, but the powder, in passing along the urethra, became hard,
 and failed in  its object.  The  most powerful objection to this plan,
 says M. Ricord,  is the great tumefaction it occasions.  A patient was
 placed under this line of treatment, and the stricture dilated so much
 that a bougie of three lines in diameter passed.  Two hours after we
 were called  on account of a retention of urine, and with difficulty were
 we  able to pass  a catheter ;  thus, in spite of all the praises lavished
 upon it, this  treatment is not without danger.
   Of all the preparations which M. Ricord  has tried, no one, he finds,
 possesses such decided advantages as does  the nitrate of silver. Dif- 
122
STRICTURES.
   Porte Caustiques.  ferently constructed instruments have  been used
(Lallemand's.) (Ricord's.) for this purpose, which it would be useless for me
                  to describe, as this is rather a practical treatise on
                  venereal diseases,  than  one which professes to
                  give an account of the  various treatments which
                  have been proposed.
                     M. Ricord now employs cauterization from be-
                  fore backward, in the following way :  He intro-
                  duces  a canula,  which encloses a  stilet armed at
                  its extremity with  a little  cup ; as soon as the
                  canula is in contact with the stricture, the  little
                  cup containing the powder of nitrate of silver, which
                  has been melted by submitting it to the flame of a
                  candle, is  made to project, and thus  the part is
                  cauterized.
                     I have seen this treatment put into practice sev-
                  eral times at the Venereal Hospital with the great-
                  est success.  One  case I  particularly recollect.
                  M. Ricord had treated this patient during a month
                  for a circular stricture situated in front of the bulb,
                  and had not been  able  to get the smallest bougie
                  through the stricture ; one application of the caus-
                  tic sufficed to permit a largish bougie to pass, and
                  a cure speedily took place.
                     To apply the instrument, the canula must be first
                  introduced, containing a bougie which is exactly
                  adapted to it, in order that  no mucus may get en-
                  tangled in it.  When the canula is in front of the
                   stricture, the bougie is withdrawn  and replaced by
                   a stilet, containing at its extremity the little cup of
                   nitrate of silver ; and as the stilet is hollow, a very
                   fine bougie is passed up it, and enters the stricture.
                     In  order to cauterize the parietes of a stricture,
                   I can strongly recommend the instrument of Lalle-
                   mand as the simplest, and the one which best ful-
                   fils all the indications.   It is composed of a straight
                   or curved silver canula,  containing a porte caustique
                   fixed on a metallic stilet, which is either straight
              W * or spiral, in order to permit the rotation of the in-
 strument.  The instrument  is passed beyond  the strictured surface,
 the canula is then withdrawn, and the nitrate of silver is thus left ex- 
STRICTURES.
123
posed to the parietes of the stricture, and  may be turned in any di-
rection  desired.  The portes caustiques of  M. Lallemand are of dif-
ferent sizes, according to the greater or less tightness of the stricture.
  Various have been the modifications, but they have again all merged
into the old instrument.
  Authors  have differed in their opinions as to the  time  that the
caustic should remain in contact with the stricture.  Hunter consid-
ered one minute the proper time ; but when we remember the various
sizes of the cup in which the caustic is contained, one minute may be
too long, or not long enough.  Without specifying any length of time,
M. Ricord causes  the instrument to make one or two turns, so that no
more time be occupied than in cauterizing  a balanitis, as it should be
our object to touch superficially the parts, and not to destroy the tis-
sue ;  so employed, nitrate of silver is among the best of antiphlogistic
remedies.  It  may be necessary, it is true, to reapply the caustic, but
this is  attended with no difficulty ; when  you make little progress,
you may generally suspect vegetations to be the cause.
  No absolute  rule can  be given as to the necessity of reapplying
the caustic ; if the case goes on favorably, it will be useless to have
recourse to a second application, but if  no  amendment  is observed, it
may be employed  daily.   In books, it  is stated that we should wait
the separation of the eschars ;  but they may  come away during the
night, or unobserved : again, if they are attached by any one point,
some time will elapse before they separate, and the vegetations may
have time to spread again.
  M. Ricord usually follows this plan ; he repeats the cauterization
as soon  as  the  effects arising  from the treatment have passed off.
Cauterization is usually followed by pain in making water, accompa-
nied with a slight  swelling of the membrane ;  the discharge, at first
often sanguineous, takes on a muco-purulent character.  Now, these
symptoms having passed, and the stricture not being diminished, we
reapply the lunar caustic ; if, on the contrary, a bougie  now pass with
ease, a  second application of caustic is unnecessary, and the patient
is soon  cured.   If, after having made a  certain progress, the stricture
remain  in statu quo, we should again have recourse to cauterization,
guided  by the same principles,; thus, in place of any definite rules,
the state of the patient can alone be our guide.
   Having now stated my own opinions  on  the use of caustic, I shall
give an extract from Sir B. Brodie's lectures:—
   " Notwithstanding what  I  have now stated, I very rarely use the
armed bougie in my own practice, and I never resort to it in the first 
124
STRICTURES.
instance.  My reasons for preferring the other methods of treatment
in ordinary cases are these :  1st.  Although the caustic often relieves
spasm, it also very often induces it.   It  is true that, in many instan-
ces, also, it brings on a  severe  retention of urine ;  2dly. Haemor-
rhage is a more  frequent consequence of the  use of the caustic than
of the common bougie, and it sometimes takes place to a very great,
and to an almost dangerous extent;  3dly. Where there is a disposi-
tion to rigors, the application of the caustic is almost certain to produce
them ;  and frequently the  application of the  caustic induces rigors,
where  there had been no manifest disposition to them previously;
4thly. Unless used with caution, the application of caustic may in-
duce inflammation of the parts situated behind a stricture, terminating
in the formation  of abscess.   I have known some cases of abscesses
formed under these circumstances, which, from  their peculiar situa-
tion, have proved more troublesome and  more difficult to manage than
the original disease."
   Notwithstanding  all our care, there are, it must be allowed, cases
of stricture which not only do not yield  to dilatation, but become  ag-
gravated  under the employment of the caustic.  Such are strictures
depending upon cicatrices, bridles of mucous membrane, callous in-
durations, &c.   Here, however, our  art  offers to surgeons resources
that no  theoretical  speculations can contradict.  In these forms of
strictures, which undoubtedly are often very refractory, we may  ad-
vantageously employ the knife, and this brings me to speak of incision
in the treatment  of stricture.
   Incision  or  Scarification.—Previous writers on this subject
have been too exclusive in recommending this treatment; much good,
it is true, may be derived  from it, but it is far from being applicable
to all cases, as  some  have pretended.   From my own experience,  I
can cite many instances in which M. Ricord had recourse to it with
signal success, where the  two other kinds of treatment failed.
   It is not of novel  introduction, as mention is made of it before Hun-
ter's time, although he gives  no opinion  upon it; of late it has been
revived by M. Amussat, and  still more recently the instruments have
been greatly modified  both in France and  England, particularly by
Mr. Stafford.
   The stricture may be incised in one  of two ways, either from be-
fore backward, or an  instrument  may be introduced into it, and the
parietes of the canal be slightly scarified in various points.
   The first, which may be called puncture, and which has been  pro-
posed in cases  where we are unable to pass an instrument through 
STRICTURES.                       125
the stricture, is a difficult operation, and  often ac-    (Instrument of
companied with danger, and one which the surgeon
is  not able to perform with certainty by means of
the instruments which are at present in use.   But
there is  no reason why we should despair.  Sci-
ence seems  to authorize it in some cases ;  it is
certain that  false passages are not to be so much
dreaded, and it becomes a question whether it is
not better to attempt this puncture in extreme cases,
than the  alternative of puncturing the bladder in
the hypogastric region.
   Generally, however, incision  should not be had
recourse to,  except when we can  pass the strict-
ure, and are enabled to treat it.   Perhaps  it may
be here  objected that, when we can introduce a
bougie, it is  unnecessary to use the knife ; this is
not the case, as may be collected from the forego-
ing observations.   When we have recourse to scar-
ifications, they should be very superficial; incision
of the mucous membrane is only required when we
are called upon to treat those bridles which traverse
the urethra or strictures  of considerable thickness.
Various  are the instruments which have been used,
but  their complicated nature has occasioned them
to be laid aside.  The instrument which M. Ricord
now uses is a very simple one, as seen in  the cut.
It is composed of a grooved canula, through which
passes a stilet, armed with a little blade, which is
made to  project at will.  The advantage it pos-
sesses is its simplicity, and the facility with which
it is cleaned.
   It is passed down to the stricture, and the blade
 is then  made to project, and the stricture is thus
 scarified ; the canula is then  withdrawn, and  a
 bougie passed, which is left in for an hour each day,
 and gradually augmented in size. I have frequently
 witnessed the success of this treatment, and have
 uever seen ill consequences  arise from it.
   Lately it has been seriously proposed to file down the callous  sub-
 stance of a stricture, and a still more modern invention is that of apply-
 ing the actual cautery in the following ingenious manner :  A catheter
 
126         AFFECTIONS OF THE PROSTATE GLAND.
is introduced down to  the stricture; at its extremity is a little cup;
one of its open sides contains a portion of spongy platinum ;  a stream
of hydrogen is now introduced into the canula, which ignites in the
urethra, thus forming there an actual cautery  A-priori reasoning would
lead to the  supposition that the mucus and discharge would tend to
prevent ignition ;  but supposing ignition to occur, what is to limit the
eschar which would result ?   Such are the reasons which  have pre-
vented M. Ricord from putting this treatment  in practice.
                         SECTION  V.
            AFFECTIONS OF THE PROSTATE GLAND.

  I have already incidentally alluded to the affections of the prostate.
I propose, in the present section to speak of them more at large.
  Causes.—Situated as the  prostate is (and its position may be seen
                         (e) in the annexed cut), the surgeon can not
                         be  surprised to find that gonorrhoea, as  it
                         reaches  the deeper portion of the urethra,
                         will occasion disease here, as we have seen
                         it  do  elsewhere ; and  we  may say that,
                         among the many other causes, none acts so
                         frequently as  gonorrhcea, either directly or
                         indirectly.  Violent exercise, hard  living,
                         excessive sexual indulgences, gout, rheuma-
                         tism,  cold, skin  diseases, are likewise so
                         many causes which excite or predispose to
                         the affection.
                           Symptoms.—There  are no  diseases at
                         their  commencement which are,  perhaps,
                         more  obscure than these, and the reason is
                         very evident.   Rarely or ever do  we meet
                         with  them in their uncomplicated forms;
                         the affections  are masked by other com-
                         plaints which are more painful, and  give
                         rise to or  aggravate these,  although,  at a
                         later period, diseases of  the  prostate, from
                         the inconvenience they give rise to, become
the most prominent complaints.
 
AFFECTIONS OF THE PROSTATE GLAND.        127
  In books  may be found a catalogue of symptoms  attending acute
inflammation of the prostate ; these are said to be " violent pain im-
mediately after passing water," heat'and pain  in the perinaeum, fre
quent micturition, tenesmus vesicae, intense scalding in making water.
Evacuations from the bowels cause great uneasiness, and there  often
remains a sensation as if the rectum was not completely emptied.  If
the  finger be introduced into the rectum, the gut feels hot, and some-
times the  prostate is felt as a smooth, round, and hard  body, project-
ing downward on the bowel, which the pressure made by the finger
renders exceedingly painful.
  I must admit that the cases I have met with do not exactly tally
with these descriptions, nor can I say that 1 have seen acute inflam-
mation of this gland ; I, however, do not doubt its existence, but be-
lieve it to be of rare occurrence.   The affections that I am more es-
pecially acquainted with are subacute  inflammations  and  chronic en-
largements,  and the symptoms  usually present are the following:
Patients, who  are laboring under some affection of the genito-urinary
system, complain of occasional or constant pain of a dull, aching  char-
acter in  the perinaeum, which shoots forward  toward the glans, and
causes the patient to draw forward and squeeze the penis ; this pain
occasionally extends down the thighs and toward the loins, and some-
times pain is complained of in the testicle.  These symptoms are in-
creased when the  patient gets his feet wet,  or drinks  over  night
any acid wine, or when he has committed  any venereal excesses ;
in a few days  they go off, and return  in a more severe form, and at
shorter intervals.
  On some of these occasions the urine is not voided so easily as
usual, or the call to make water is more frequent; the stream may be
forked, or stopped suddenly; when  urine passes, the pain is relieved
momentarily, but an increased  suffering is felt for a few minutes after
its  expulsion.   The bowels are often constipated, and the motions
may be flattened.  Should the  surgeon introduce a  catheter, an ob-
struction may be met with, or the pain the patient feels in the  peri-
naeum will become aggravated and last some time. Various discharges
will be mixed  with the urine, or forced from the urethra.  As the pa-
tient seldom empties the  bladder  completely,  a certain  quantity of
urine will remain in the fundus, and this becomes highly colored and
ammoniacal, adding considerably to the irritation.  The finger intro-
duced per anum detects the prostate enlarged laterally, but particularly
on the  left side ; and if a catheter be in the bladder, the prostate will
present an unusual thickness. 
128
AFFECTIONS OF THE PROSTATE GLAND.
    The symptoms I have above described rarely occur in the child or
 adult;  it is usually in individuals advanced in years that we  meet
 with them.  Many patients  are remarkable for their  ruddy complex-
 ions and corpulency, but the affection is likewise seen in the pale or
 bilious-looking  individual who  leads a  sedentary  life;  and  there is
" nothing, perhaps, which destroys  the morale of men more than these
 complaints  ; the sufferer is the  wreck of-the former individual.
    Course of the affection.—Notwithstanding the severity of the symp-
 toms we have described, the disease does not make very great progress,
 and persons live to a good old age notwithstanding.   Some surgeons
 pretend that few men attain an advanced period of life without enlarge-
 ment of the prostate ; and Sir A. Cooper  considers it a salutary pro-
 cess when the affection produces a partial retention of urine, thus pre-
 venting incontinence, which would, in old people, almost  constantly
 take place, were it not for this preventive.
   The disease, however, has a tendency to increase, notwithstanding
 all our  palliative measures ;  and complications and  affections come on
 one after another, until the patient sinks, either from exhaustion, in-
 flammation of the bladder, urinary fever, &c.
   Pathology.—I have already alluded to the condition of the parts, as
 far as we can detect them, during life, by means of the finger or cathe-
 ter ;  post-mortem examinations show that abscesses may occur in the
 substance of the organ, and open their way into the  urethra ;  and  then
 the urine, introducing itself,  will increase the mischief, forming fistu-
 lous openings, and all the consequences alluded to  in that-article.  In
 chronic cases, the middle or third lobe will be found considerably en-
 larged, and is detected as the cause of the  obstruction to the flow of
 urine, or  the passage of the  catheter, forming a valve behind the ori-
 fice.   In consequence, the  course of the  urethra  is  altered, and its
 calibre  diminished ; and if  the lateral lobes are hypertrophied, the
 canal opposite  the pubes is nearly obliterated.   I have before stated,
 in speaking of  strictures, that when any  impediment occurs to the
 stream  of urine, the canal behind it will become dilated :  this circum-
 stance  happens in prostatic affections; not only is it  dilated, but
 elongated ;  hence  the necessity of employing a longer catheter  than
 usual.
   Sir E. Home, in his valuable work on the prostate, says that the
 surface of these enlarged portions of the prostate may become excori-
 ated, and put on  the appearance of ulceration.  The mucous mem-
 brane which covers the middle lobe  may  be continued on each side
 in the  form of  a  transverse fold.  Cysts  may form  in  or about the 
            AFFECTIONS OF THE PROSTATE GLAND.        129

gland, and  become of the size of oranges, their inner surface being
lined with coagulated lymph.
  The gland will present great varieties of structure ; in some cases
we  meet with it  completely softened ; others have a scirrhous hard-
ness.
  The Prognosis is usually unfavorable, but of course much must de-
pend upon the condition of our  patient, the period at which we see
him, and the complications which arise ; every case will present va-
rieties, but too often our treatment can only be palliative.  Sir E.
Home, at page 69 of his work, says :  " If attended to in proper time,
the enlargement may in many instances be reduced, in others  pre-
vented from increasing, and, even in less favorable cases, rendered so
much slower in its progress, that the patient's life is prolonged, and
his sufferings mitigated in a very great degree."
   The Diagnosis.—Sir A. Cooper says : " The enlargement laterally
may be readily ascertained by introducing the finger into the rectum,
but the enlargement of the middle lobe can not be so  learned.  In
what way,  then 1   Why, by the  introduction of a catheter or bougie,
and the latter is the best; it will be found  to stop suddenly. You are
then to introduce  a catheter, for the purpose of drawing off the water ;
the instrument will be resisted in its  common course, and  you must
depress the handle a good deal,  with a view of tilting its  point  over
the enlarged gland :  thus the end of the instrument will be rising per-
pendicularly, as it were, behind  the pubes."
   Treatment.—I  have had occasion, in the last page,  to notice the
valuable observations made by  Sir E. Home  on  the subject of the
prostate gland. I shall, in speaking of treatment, cite him constantly;
and although "his  work was published in 1811, still modern surgeons
have varied little the  plans of  treatment that  eminent practitioner
recommended.
  In the first stage of the disease, when  no absolute obstruction ex-
ists to  the flow of the urine, great advantage may be experienced by
cupping from the  loins, or an application of leeches to the perinaeum.
These measures may be aided by a clyster containing opium, and the
internal use of Dover's powder.  The hip-bath  may be prescribed, of
a temperature agreeable to  the  feelings of the  patient.   I need not
here state, that all causes  which have given rise to, or can be sup-
posed to aggravate the complaint, must be avoided.   At this stage of
the affection, the  employment of catheters  and bougies can not be too
much reprehended.   When irritation has been alleviated, the  best
effects may be expected from  the use of hydriodate of potash, taken
                              9 
130         AFFECTIONS OF THE PROSTATF. GLAND.
in doses of from three to ten grains  three times a day.  Frictions
with iodine or hydriodate of potash, on the perinaeum, have appeared
to me to be followed by a diminution in the size of the canal.
   When the surgeon is called at a later period, the patient making
violent and unsuccessful efforts to pass water, and the bladder being
felt distended above the pubes, a warm bath, opium, and local bleed-
ing, will often effect a palliation of the suffering, and enable the pa-
tient to relieve the bladder.  When, however, this does not occur, the
practitioner  is called upon to act without delay, and  the water must
be drawn off, the same precautions being taken  as were mentioned
when speaking of  retention of urine from other causes.   I shall not,
therefore, allude to them, except  inasmuch as the  precautions to be
here taken depend upon the affection of the prostate.
   Sir E. Home, who had such immense opportunities of treating these
diseases, recommends that the instrument  should be very soft  and
smooth, to prevent its disturbing  the  urethra ;  rounded at the point,
and as large as the canal will easily admit, that it may the more read-
ily disengage  itself at the turn into the bladder.  The apertures in its
sides should  be wide, to prevent their  being clogged by mucus or
blood ;  and  the catheter should be pliant, that it may adapt itself to
the form of the parts, and give  little disturbance while retained in
the bladder.   Besides these  properties, it is desirable that  it  should
possess a permanent curvature at the point, even to a greater degree
than is usually given to the common silver catheter;  and instrument-
makers now manufacture them with a permanent and desirable curve,
and they are  far better  than those which gain  it by being kept on
stilets, and which, when warm, have a tendency to assume  a straight
direction.
   The catheter should be introduced (continues Sir E. Home) either
toward the  right or left side, with the handle nearly in a horizontal
line ; and when it reaches  the membranous part of the urethra, the
handle should be gently and  gradually brought toward the perpendicu-
lar line, the point all the time being kept in motion ; and when  it  is
nearly upright, the handle should be depressed : when the flexible
 catheter has no stilet, a good deal of dexterity is often required.  The
 great advantage of passing the instrument in a lateral direction is, that
 the point may by that means be guided into the space between the
 lateral and middle lobes of the prostate, where there is a groove along
 which it may be directed, between these two projecting parts, into the
  cavity of the bladder.   When the point is entangled in the folds  of
  the mucous membrane, instead of repeating the endeavors to pass the 
FALSE PASSAGES.
131
instrument in the same direction, there will be an advantage in partly
withdrawing the instrument, and trying to introduce it on the opposite
side, where the same thing may not occur.  If the catheter, with the
stilet, can not in this way be made to  pass, it must be tried without a
stilet;  and if it  is still prevented from going further than before, a
finger introduced into the rectum, and pressing upon the curved part
of the catheter, may  give it a right direction, so as to guide it into the
bladder.
  Sir E. Home recommends the catheter to be left in the bladder, if
any difficulty has been experienced in its introduction ; in respect to
the position of the patient, his own comfort must be principally con-
sidered ; the standing position is, however, the  best.  The catheter
may then be plugged, and kept  in position by a  common T bandage,
the longitudinal band of which is divided up the  middle into two por-
tions, one of which lies in each angle  between the  scrotum and
thigh, and furnishes  a fixed point to which the  catheter may be se-
cured by ligature.  The  time  that  the  catheter is  to remain  in the
bladder must depend upon circumstances : it may be left three or four
days, and then reintroduced and permanently kept there, or the water
may be drawn off when required.   The second introduction is less
painful and difficult.
                        SECTION  VI.

                       FALSE PASSAGES.

  The following article is a simple translation of a note by M. Ricord,
on the subject of false  passages, in the French edition of Hunter's
works.  As it is complete in itself, and as few English authors have
written on the subject,  I  prefer giving it in  the  words of the au-
thor :—
  Every point of the urethra may become the  seat of a false pas-
sage ; hence we may meet with them throughout  the whole course
of the canal.  The fixed  points, as well as the  moveable ones, pre-
sent  frequent  examples.   It is certain, however, that false passages
occur more frequently in the curved portion of the  canal, particularly in
the membranous ; although they are met with in the prostatic portion, 
132
FALSE PASSAGES.
in the substance of the prostrate itself, and at the neck of the bladder.
Although they occur at. the inferior border, still  they may be seen  at
any point of the circumference of the canal of the urethra.   They are
of various  dimensions, and  may  terminate by a cul  de sac  in  some
neighboring organ, such as the rectum ; or, after having passed through
a certain thickness of tissue, they may enter the bladder, either by its
anterior wall, or, as happens most frequently, after passing through a
portion of the canal, placed behind the stricture, or in the body of the
prostate ; or still again behind that organ, by penetrating its lateral
lobes, or the fundus of the bladder, in which  case the instrument
passes between that organ and  the rectum, or reaches it, having pre-
viously entered and passed again out of the intestine, as in an example
mentioned by Deschamps.
   There are a variety of circumstances which predispose to the for-
mation of false  passages ;  thus,  in  addition to the  situation of the
stricture, the greater or less resistance of the diseased parts, the vari-
ous directions which  the urethra has  undergone  in  consequence of
anormal or pathological states of  the prostate, the accumulation of fae-
cal matter  in the rectum, will,  in deep-seated strictures, tend to their
formation.   We must likewise consider,  as  predisposing causes,
the nature of the stricture itself, as well as the state of the  surround-
ing parts, the kind of instrument  employed to combat or pass strict-
ures, and, lastly, the greater or less care used by the practitioner.
   False passages are more  to be dreaded, in proportion as a stricture
is firm, callous, resisting, and little dilatable.  The narrower the strict-
ured passage, the more have we  to  fear the occurrence of  this acci-
dent,  particularly when  the stricture  is of considerable  length, and
when several are present;  as the most anterior one necessarily in-
terferes with the treatment  or proper direction to be given  to the in-
strument.   Should the mucous membrane be subject to chronic inflam-
mation, or should it be affected with ramollissement,  perforations are
very frequent, and it  is not necessary that this disease be  very well
marked.
   The instruments employed have a great influence on false passages.
The flexible ones produce  them  rarely, while  the use of inflexible
ones often  creates them.  The size of instruments, also, should bear
a proportion to the stricture.  Still, in those cases which depend upon
an hypertrophied state of the mucous  membrane, or where spasm is
present, it  is better to employ bougies of a large size.  As a o-eneral
rule, however, the more the diameter diminishes, the greater chance
there is of the occurrence of a false passage.  Straight and inflexible 
FALSE PASSAGES.
133
instruments  employed in  strictures, situated posteriorly to the bulb,
have been frequently the cause of these accidents.
  Allowing  that instruments are more liable to produce false passages,
in proportion as they are more pointed, as in the instance of conical
bougies, the use of which has been too much condemned, still the le-
sions they produce are  less  severe than those  which result from the
employment of instruments of a larger size, and whose volume bears
no relation to the strictured part.  In fact, in the one instance we have
only a simple perforation, or a species of  acupuncture ; whereas in
the other a rent occurs of a considerable extent, together with a tear-
ing away of the edges themselves.   Pressure on the anterior part of
the canal, as recommended by Hunter, and cauterization, as well as
the operations we have previously described,  may cause these per-
forations.
  In fine, the most frequent cause of false passages, perhaps, exists
in the hand which  directs the instrument.   A  want of anatomical
knowledge and practical  skill, too great haste, have been often the
cause of accidents that might easily have  been avoided, independent
of the existence of other predisposing causes.
  To avoid  false  passages, let the surgeon hold the bougie as short
as possible,  in order that he may more effectually be able to appreciate
the obstacles which  he has to overcome, and the direction the instru-
ment should take  ; let him draw the penis toward the instrument, in
order that tension  may be exerted on it, and thus obliterate the cul de
sac which is frequently seated in front of the stricture.   Let him fol-
low externally the direction  given to the bougie while it passes the
perinaeum ;  let him  introduce his finger into the rectum to guide the
instrument as it passes along the prostatic  portion, and  take care that
it does not deviate on either side ; let him employ less force  in pro-
portion as the instrument passes with difficulty, and only push it for-
ward when  he has assured himself that the point is  in the stricture.
   Such are the directions for introducing  the  instrument in difficult
cases, which, if attended  to, and followed  up by a judicious selection
of bougies,  will tend to the avoiding those accidents which, unfortu-
nately, are of too common occurrence, particularly when ignorance  is
joined with a desire to show off by rapidity of execution.
   The symptoms of a false passage consist of various ill effects which
the patient experiences after the passage of an instrument.   Among
these, authors have  enumerated haemorrhage.   This  symptom  is of
little  value.   There are  many patients whose  urethra bleeds very
easily without  the occurrence of a  false  passage.   In many cases 
134
FALSE PASSAGES.
 bleeding results from a ramollissement of the mucous membrane.  On
 the other hand, a false passage  may happen without  the  occurrence
 of haemorrhage, an instance of which M. Ricord mentions in his lec-
 tures, of an old man, who had  a very  severe stricture of a  callous
 form:  several  ineffectual attempts to pass an instrument were made
 by a practitioner, and the spectators were not a little surprised, in one
 of these attempts, to  observe  the  point of the  instrument protruding
 beneath the skin at the ischion.   No bleeding followed in this case,
 and yet there can exist no doubt that a false passage existed.
  Various sensations  on the  part of the patient are of an  equally
 doubtful nature; thus, some patients  exaggerate  their sufferings, de-
 claring that they feel the point of  the instrument  pricking them, par-
 ticularly at  the  fossa navicularis,  at the bulb, and at the neck of the
 bladder—circumstances which lead to the belief that alterations occur
 where none exist.   Other patients, on the contrary, suffer less than
 they expected,  and  your instrument may penetrate the walls of the
 urethra without the  patient being sensible of it.  Nevertheless, when
 a patient feels a sense of tearing or of pricking, it is an additional rea-
 son for the surgeon to be more careful than usual.   Generally speak-
ing, patients suffer  more when the bougie  passes by a false opening
than when it enters the stricture ;  the sensibility of this last is not so
great as has been pretended.  Be this as it may, it is likewise certain
that a bougie, once in a false  passage,  remains there with less pain
than when it is introduced and left in the stricture.
  With respect to the resistance felt, it is certain that in the majority
of cases the sound parts resist less than the others, and  the surgeon
may in many cases  be deceived  by the facility with which his instru-
ment passes.  That sensation  of tearing, which the patient and sur-
geon both feel, may depend upon the  rupture of one of those bridles
of mucous membrane above spoken of, or  to a sudden abrasion of
the  strictured part, as well as a division of the parts in front.    Never-
theless, when we have  once entered a strictured orifice, the instru-
ment is felt as if firmly grasped,  a  circumstance which never happens
when,a false passage has been made.
  The absolute direction of the  instrument  in relation to  the axis of
the  urethra, the possibility or not of executing rotatory  movements
with curved instruments, supposing them to be in the bladder, the fact
of urine passing  out  by the catheter, when this instrument  is em-
ployed, are symptoms upon which but little dependence can be placed.
Indeed, a  false  passage may be made when  the axis of the urethra is
 closely followed, and  the instrument  may reach the bladder  by one 
FALSE PASSAGES.
135
of those routes of which we have above spoken, without the surgeon
being cognizant of it, unless it  is by the occurrence of certain symp-
toms which, fortunately for the patient, do not always follow.   On
the other hand, without having" deviated from the ordinary passage,
the instrument, embraced tightly by the stricture, and shackled by a
bladder which  by a thickening of its walls has diminished in size,
may give the surgeon an impression that  it is taking a wrong direc-
tion, particularly  if the eye of the instrument be momentarily blocked
up by mucus or blood, thus preventing the passage of the urine.   In
addition to the  signs above given, we may add that little value can be
placed on the impressions of the porte empreinte of Ducamp, or on wax
bougies.  The same observations  apply to the toucher per anum, and
particularly the greater or less  degree of hold on the instrument.
   The  accidents  which follow as a consequence of false passages  are
not so severe as  some authors,  especially  Hunter, have stated.
   Thus, as long  as patients can empty their bladder, and there con-
sequently exists  no retention of urine ; when the false passage has
been made with an instrument of small dimensions, and does  not  ex-
ist between the bladder and the stricture, it is to be considered as a
circumstance of little importance, and one which may pass without
the patient or  the surgeon paying any attention to it;  such, in fact,
occurred in the  case above mentioned as having been seen by M.
Ricord.   It is sufficient, when we are aware of the existence of a
false passage, to  allow our patient to remain quiet some days, without
having recourse to a fresh introduction of instruments ;  the parts con-
sequently cicatrize, the stream  of urine, from  the position and direc-
tion of the false passage, tends rather to bring  together the walls than
to introduce itself into  the false passage,  except in cases where  the
false passage is  made  from  behind forward,  as may occur when a
bougie turns  upon itself, and makes a false passage in front of  the
stricture.
  In cases where the  parts are forcibly torn, or where the employ-
ment of large sounds has produced abrasions, or caustic has destroyed
the tissue, severe inflammatory accidents may arise, which may be
either of a local or sympathetic nature.   But,  as long as a false pas-
sage is not in communication  with the bladder, either through  the
means of the instrument which has produced  it, or through consecu-
tive ulceration, provided the patient can still make water, we may, by
waiting and taking proper measures to combat the accidents, ration-
ally hope to cure  our patient.  It is  only in cases of extensive lacera-
tions, accompanied with a complete retention of urine, and which call 
136             DISEASE OF COWPER'S GLANDS.

for an immediate relief of the bladder by the catheter, or in those in-
stances  where the false passage  communicates with the bladder or
the  rectum, that we have to expect the most serious consequences,
and which call upon the surgeon either to puncture the bladder, or to
combat  those  ill effects  which result from the  infiltration of urine.
There are cases in which a false  passage having been made, and the
instrument having reached the bladder, everything goes on quietly,
and shortly a  new canal, provided with  a false mucous membrane,
results.   In every case where there  exists a false passage, the  sur-
geon should recoiled  in what direction it has been made, and  assure
himself further of its existence by the porte empreinte ; the exact sit-
uation of it should be  ascertained, in cases where it has been caused
by another surgeon, in order that his instruments may have a  proper
direction given them, so that he fall not into the same error as his col-
league.
  As regards  the treatment, I  have but few words to say, as it is in-
dicated  by what has already been stated.  Thus, in slight cases, we
should withdraw the bougie, and wait till the  parts have healed; in
more severe cases every endeavor must be made to introduce a cathe-
ter, which should be left in the bladder.  If the introduction of an in-
strument be impossible, M. Ricord states that he is not certain whether
he would not  make a false passage into  the  bladder directly, rather
than perform  the operation above the pubis to relieve that organ, for
we must resort to one or other alternative.
                       SECTION  VII.

                DISEASE OF COWPER'S GLANDS.

  During the course of gonorrhoea, it not very unfrequently happens
that we find an affection of Cowper's glands come on, and this affec-
tion is more common than is generally supposed ; it may come on
imperceptibly, and the patient take no notice of  it until  there is  con-
siderable  swelling of the  parts.  This occurred in a case which  I
lately witnessed ; in other instances there is fever, and all the symp-
toms of abscess ; pain is felt in the course of the  urethra, followed by
fluctuation at one point, and  difficulty in making water.   M. Ricord 
INFILTRATIONS OF  URINE.
137
 considers that the affection commences in Cowper's glands in conse-
 quence of the extension of inflammation, and that suppuration results,
 and has a tendency to make its way outward.
   An abscess, however, may occur in the course of the  urethra, in
 consequence of an abrasion of the mucous membrane, and a limited
 infiltration of urine follow ;  the abrasion may heal, and a small abscess
 will  result, situated  close to  the urethra ; such a case it will be im-
 possible to distinguish from inflammation of Cowper's glands, if it oc-
 curs in or about  the bulb.  To the  finger this abscess will  give the
 sensation as if it were attached to the urethra by a pedicle.
   The treatment  must  consist in  attempting to prevent the formation
 of matter by  antiphlogistic means ; or, if an abscess be present, un-
 accompanied with inflammation, we may reasonably expect  to cause
 its  absorption by rubbing the part with blue ointment.   Should the
 skin become livid, not a moment should be lost; it should be opened,
 and  the matter allowed to escape ;  the part will then heal, like any
 other abscess, or  an induration will sometimes  remain, which it will
, be necessary to treat by blisters, &c.
                       SECTION  VIII.

                   INFILTRATIONS OF URINE.

  As an indirect consequence of gonorrhcea, the surgeon is not unfre-
quently consulted on account of infiltration of urine, which I shall pro-
ceed immediately to consider.
  The causes of infiltration of urine depend upon rupture of the walls
of the canal of the urethra in  some part of its course, proceeding either
from a softened state of the mucous membrane, a consequence of in-
flammation (usually of a chronic kind), from rupture or pointing of an
abscess, as  mentioned in the last paragraph, from  rupture due to vio-
lence, or to attempts in breaking a chordee.*  Most frequently, how-

  * The same effect is stated by Bell to follow from the injudicious employment of the
armed bougie, and I have myself witnessed similar consequences  result from the em-
ployment of instruments which divide the stricture.  M. Civiale,  in his " Traite Pratique
sur les Mai. des Org. Gen. Urinaires,"  states that infiltration follows the lodgment of
stones in the urethra, and cites several cases to prove this position. 
138                INFILTRATIONS OF URINE.

ever, infiltration is due to a bursting of the urethra behind a stricture,
depending equally upon a ramollissement of the canal at that point, the
action of the abdominal muscles, and an hypertrophied bladder.
   The Symptoms.—The patient suddenly feels that the urine has es-
caped, although none passes by the urethra.   A short time only elapses
previous to a swelling appearing in the perinaeum, scrotum, or penis.
The  pain in those situations is often very violent, and the patient be-
comes aware of the danger he is in; the constitution soon begins to
sympathize; his purse at first is full and rapid, but soon becomes feeble,
intermitting, and irritable, the  tongue is dry and cracked, the counte-
nance altered, and typhoid symptoms set in with remarkable violence.
   Provided no treatment is resorted to, the symptoms  become more
aggravated ; the  skin  and cellular tissue  assume a dark color, and
gangrene follows ;  large pieces  of mortified  structures become  de-
tached,  and the bones, aponeuroses, and muscles, are  exposed ; and
Desault speaks of cases  in which he has seen the whole of the skin
of the scrotum, that of the perinaeum, and the upper part of the thighs,
come away, leaving the testicles floating in the midst of this immense,
ulcer.   The patient  sinks under  this fearful complaint, breathing his
last  in the midst of  convulsions,  or, what is more common, he falls
into  a state of stupor, which rapidly increases.
   The direction which the urine follows is  usually toward the root of
the penis, thence to the perinaeum, the scrotum, and penis.  Anatomy
might induce  the surgeon  to believe that the  infiltration would differ
in the direction it takes, as rupture of the urethra occurs  in one or
other part;  but  practice  does not bear out  the theory, and the extent
and rapidity of infiltration seem rather to depend upon the size of the
rupture, upon the resistance of the  aponeuroses, and the contractions
of the bladder, than on any other circumstance ; and this, perhaps, is
less  surprising, when we consider that in almost  all these cases the
natural  texture  of the  parts  is  much modified  by  long-standing
disease.
   The Treatment.—As the presence of the  urine in the cellular tissue
causes  the mischief which is momentarily increasing, no time must
be lost; the infiltrated tissues should  be freely divided.   The num-
ber,  depth, and direction of the incisions must depend  upon the cir-
cumstances of  each particular case, and care must be taken to leave
a free passage  for the urine, otherwise a second train of symptoms
may arise.   M. Civiale, in his valuable treatise above alluded to, states
that  young practitioners  too often fall into the error of not cutting the
infiltrated parts sufficiently deep ;  for (says he) the swelling is con- 
FISTULOUS OPENINGS.
139
siderable, and, on its abatement, the young surgeon will be surprised
to find how superficial have been his supposed extensive incisions.
  Provided these incisions are  made at an early period, the very best
results may be expected ;  and all  authors who  have written  upon
this  subject are agreed that even  at  a very late period the surgeon
may hope for success from an energetic treatment, provided there be
sufficient  power in the constitution to rally and support the throwing
off of the sloughs.   Here, as in most cases of gangrene, the deformity
which ultimately results is  not commensurate with the destruction of
parts, for " nature has resources without limits," as Desault remarks.
                        SECTION  IX.

                     FISTULOUS OPENINGS.

  In  consequence of any of the causes above  mentioned, fistulous
openings may be left, which  it wrill be very difficult to cure ; and  to
their  consideration I shall  now direct the attention of my readers.
" Fistulous  openings," says  M. Ricord, " may occur in any portion
of the perinaeum or urethra.   They may be complete or incomplete ;
that is to say, they may terminate in an abscess, or on the surface of
the  skin.  Internally, they have usually only one opening ;  externally,
they may present several.   Their direction may be variable : when
they open into the bladder, the urine will escape in proportion as it is
secreted ; we shall consequently perceive  a constant dribbling from
the  fistula.   When, on the contrary, the internal opening is beyond
the  neck of  the bladder, the urine will escape only when  the patient
attempts  to make water.  There are, however, certain circumstances
which may  lead  the surgeon astray, viz.: when the internal opening
is close to the neck of the bladder,  and that organ contains but little
urine, the fluid accumulated in the lower part will be only passed du-
ring the involuntary contractions of  that organ.  Various pouches  in
the  course of the fistula, as well as  communications between the va-
gina or rectum, may likewise impede  the exit of the urine.   When
the  urinary  fistulae open into the rectum, urine will be passed only
when the patient goes to stool ; however,  the presence of the urine
will so  far  irritate the rectum  as to give rise to tenesmus, which is 
140
FISTULOUS OPENINGS.
very severe and habitual.  The more numerous the fistulae, the greater
will  be the  alteration of the tissues submitted to the  action of the
urine ;  the skin becomes thin and detached ;  ulcerations form, or else
induration or a horny degeneration ensues ;  gangrene, also, will de-
stroy the  cellular  tissue in all  eases where adhesive  inflammation
does not oppose a check to the passage of the urine.   The aponeu-
rotic layers  themselves may give way ;  the bones  in the  neighbor-
hood may become  exposed, carious, or necrosed ; and lastly, the sur-
rounding tissues may undergo a degeneration, and be converted into
a cancerous  or fungoid mass.   As long as any  obstacle to the free
passage of urine  by the urethra exists, the fistulous  openings will
evince  but a slight  tendency to close ;  from the moment, however,
that the canal becomes free, the cure of  the fistulous opening will be
speedy, and  in proportion to their short duration.  This, therefore, be-
comes  a point of importance in  regard to the prognosis, as  recent fis-
tulous  openings are not provided with those  false mucous membranes
which  are found organized  in cases of old standing.
  The temporary employment of bougies is  frequently of itself alone
sufficient  to cure fistulous openings.  In proportion as the  calibre of
the urethra is re-established, the urine  passes in a less quantity by
the fistulous opening, and a cure  speedily takes place.  But this treat-
ment is not one which succeeds so well or so often as some  others.
A great number of fistulous openings do not  yield, and it becomes,
therefore, necessary to keep a catheter  permanently in the bladder.
In addition  to these precautions, a  surgeon  should  take care  to give
the urethra its proper calibre ;  he should, in addition, provide  against
the urine passing  through  the  fistulous  opening.  This, however, is
not always easy, as urine  will pass between the walls of the canal
and the bougie, and thus reach the  fistulous  opening, or when the in-
struments are removed in  order that the patient  may make water.
The greater number of surgeons show a preference to catheters which
are left open, and which, without injuring the canal, fill it so  com-
pletely, that  the urine, finding  an  easy  and continual  passage, does
not escape through the fistulous opening.
  When, however, a certain degree of dilatation has  been obtained,
or if this be too much increased,  we shall, as Dupuytren so justly ob-
served, prevent cicatrization of the internal orifice by keeping its bor-
ders separated, and  the cure is only obtained by gradually returning
to the  employment of smaller instruments, or in altogether laying aside
their use.
   In some cases it has been recommended to attach a piece of sponge 
FISTULOUS OPENINGS.
141
to the point of the catheter, as it was supposed that such means would
more effectually tend to empty the bladder;  more recently a piece of
thread passed through the eye of the instrument has been supposed
capable of the same effect, acting by capillary attraction.  Other plans
have been recommended, but they do not present  sufficient practical
advantages to induce us to dwell upon them.  When the surgeon leaves
a catheter permanently and open  in the bladder, he should,  to a cer-
tain extent, oppose the free passage of air by means of an empty blad-
der attached to the distal extremity of the instrument.
  Catheters, however,  sometimes  irritate  the  portions of the  canal
which they touch, and occasion inflammation and suppuration ; in such
case, the persistence in the use of  instruments, far from ameliorating
the state of the disease, only tends to aggravate it, or keeps it up by
the passage of the pus through the fistulous  openings.
  In these cases the treatment must be laid altogether aside until the
unfavorable symptoms have passed away, or it should be only employed
at intervals,  so as to keep up the improvement which has been made.
  The fistulous openings must, however, be attended  to, when they
are lined with a false membrane :  it will be usually necessary to em-
ploy the knife, and incise  them like all  fistulae  in other parts of the
body, that their parietes may cicatrize.  But this treatment should not
be employed until  catheterism has failed.
  In  employing cauterization  in these cases, care should be taken to
attack the internal opening and the deeper portions, as well  as at the
external orifice of  the  fistula.   I have succeeded  by cauterizing the
urethra at the point of the stricture, or behind it, in order to reach the
internal opening, and  I have injected the fistula with a solution of ni-
trate of silver, containing forty grains of the salt to the ounce of water.
In cases where the fistulous passage  is sufficiently large, I have in-
troduced a conductor containing solid nitrate of silver ; in other in-
stances I have employed a stilet surrounded with lint dipped in nitric
acid.   I  have obtained sometimes good results from the employment
of the actual  cautery ;  this, however, is only applicable when the pas-
sages are short and direct.
  A great number of fistulous openings, which are placed in front of
the scrotum, or on various points of the spongy portion of the urethra,
resist  all  the means we have yet spoken of.  Some of these fistulae
consist in simple apertures, which it is next to impossible to feel be-
tween the skin and the canal.   On the contrary, in other cases, there
is a complete loss  of substance, forming a species of hypospadias;  to
these the name of fistula no longer belongs, as  one opening only ex- 
142
FISTULOUS OPENINGS.
ists, there being no fistulous passage.  To judge of the  difficulty of
curing these cases, the surgeon should have them under his own care ,
the difficulties arise from the slight thickness of the cellular tissue,
which is very loose in this situation, and from the interruption the
process of cicatrization undergoes  from the different size which the
penis assumes in erection, or while quiescent.
  I have tried, on three patients at the Venereal Hospital, that  form
of suture recommended by my learned friend M.  Dieffenbach, which
consists in passing a thread round  the fistula at the  spongy portion of
the urethra,  and  then drawing it together between  the  skin and the
canal.   In these three cases  the operation has failed, although per-
formed with the greatest precautions.   Two of these  patients have
been operated upon  three times, and the third has had  the ligature
applied twice. At each new trial I employed some  new modification,
without, however, gaining my end.   In one  instance the passage was
sprinkled  with the tincture of cantharides ; in another it was touched
with nitric acid  and caustic.   Once I  kept an open catheter perma-
nently in  the  bladder ; on  another occasion I allowed the catheter
only to be opened when the patient felt a desire to  make water; and
in a third  attempt I left the canal free, and the patient was cured.
  It is well known  that little success has attended the attempts of
surgeons to  remedy the various degrees  of  hypospadias;  the  results
have been similar in the attempts  to apply them to  accidental loss of
parts.  On a patient, who had lost two thirds of the inferior portion
of the spongy part of the urethra between the scrotum and gland, and
upon whom M. Breschet had previously unsuccessfully employed two
sutures, I  failed  likewise in obtaining any benefit,  although I tried one
of the plans recommended by  M. Dieffenbach, which consists in dis-
secting the skin on either side of  the abnormal opening, to a certain
extent, and bringing nearly together the  flaps by means of strips of
plaster, having previously resected the  edges.   I had recourse, also,
in the same patient to the urethro-plastie, performed at the expense
of a flap of skin taken from the scrotum; but  in  this case the opera-
tion partly failed, union not taking place to the extent of a third of the
opening, and this  in consequence  of a circumstance which it  is im-
portant  to mention, namely, that at  this  point the border of the flap
was ecchymosed at the time of union.  The other operations, I  think,
have not hitherto been sufficiently tried. 
BLENNORRHAGIA IN THE FEMALE            143
                        CHAPTER  III.

               BLENNORRHAGIA IN THE FEMALE.
                                                            I
  In reference to the cause of this disease in the female, it may here
be stated that we have seen it developed spontaneously, independent
of sexual intercourse, and as a result of certain pathological conditions
of the system ;  we have likewise traced blennorrhagia to a lymphatic
temperament, to skin diseases, to teething, &c.
  We  should  be only repeating what we have previously stated in
speaking of the causes of blennorrhagia, were we to enter more fully
into the subject.  There are, however, causes which  are peculiar to
the  female genito-urinary mucous membrane.   Thus, connexion at
too early an age, or when the male and female organs are dispropor-
tionate, will frequently occasion it.   M.  Ricord  states he has never
been able to ascertain satisfactorily that there  existed any relation
between  the  cause  and any particular portion of the mucous mem-
brane,  the seat of the  disease ; thus, the same  cause may produce
blennorrhagia of the  vulva, vagina, &c.  In fact, on this subject there
is no rule.   He states that he has been able to convince himself that
whatever may have been  the cause of the discharge, still the vulva,
urethra, vagina, or uterus, may be alone, or simultaneously affected.
Nevertheless, he is persuaded that in the female the urethra is more
generally affected alone, or  at the same time with the other organs
of generation, when  the blennorrhagia is the result of impure con-
nexion.
  Morbid Appearances.—As this branch of the subject is new to
English readers, we shall treat of it at some length, and illustrate
our observations by appropriate drawings.   In our investigations on
this subject, we have been kindly aided by M. Emery, of St. Louis  ;
and M. Danyan, the surgeon of the  Female Venereal Hospital, has,
by a particular favor, allowed us to inspect the patients intrusted to
his care ;  and M. Vidal de  Cassis has likewise  placed at our dispo-
sa1 every facility for  ? tody ing these diseases.  Thus, in a short space 
144            BLENNORRHAGIA IN THE FEMALE.
of time, an immense number of females have passed under our care,
and we have, in the intention of publishing, kept  particular  notes of
the cases.  Not contented with what we have read, we have person-
ally seen what,  we here describe ; not resting satisfied with examin-
ing the external organs of generation, we have, by means of the specu-
lum, and under  the direction of these professors, narrowly investigated
the internal organs of those females intrusted to our care.
   We  have found the mucous membrane  in  its  whole extent, or in
isolated points, of a red color, accompanied by swelling, heat, and
pain, unattended by any secretion ; thus  presenting an  erysipelatous
state, which may last a short time, and then disappear entirely, and also
we have seen other cases, which present the first stage of catarrhal
inflammation, give rise  to a morbid secretion, the  color and  consist-
ence of which  are very variable ; this  difference  seems to  have no
reference to the cause which has produced it.
   In examining the vulva, vagina, or the neck of the uterus, we have
observed the mucous membrane covered with papulae or follicles, more
or less developed, constituting a papular vaginitis, or  utero-vaginitis,
a psorelytrie, as M. Ricord terms it; sometimes  assuming the form
of small  spots, in  size  not larger than a pin's head, and isolated, or
more or less confluent.  In other  cases, these papulae look like gran-
ulations deprived of their epithelium ; lastly, they may assume a fun-
gous appearance, or the form of vegetations.  (See Plate I., fig. 1, 2.
   On  the same portions of the mucous membrane we have distinctly
seen patches more or less  numerous, and varying in extent, which
have a striking analogy with the  suppurating surface of the skin on
which  a blister has been applied.  M. Ricord has likewise witnessed
a case in which an eruption of herpes  phlyctenoides was present on
the neck of the uterus, and  the posterior part of the  vagina : lastly,
we may find ulcerations of every description seated on  the whole or
any part of the surface of the genito-urinary mucous membrane. PI. II. A.
   The discharges from  the urethra, vulva, vagina, and uterus, which
we have examined, have been very various; but the difference has
not appeared to us connected with any  one lesion or cause more than
another.   The  acute stage, whatever be the particular lesion, causes,
at its commencement, a secretion almost wholly serous, or only con-
sisting of healthy  mucus, more  abundant  than usual, but  becoming
opaque, then purulent, or of a darkish yellow color, sometimes green-
ish, and at times mixed with blood.  The chronic stage often gives rise
to a milky secretion of a thickish consistence, similar to that of cheese,
or simply to a mucous flux. 
 
JZ/
 
BLENNORRHAGIA IN THE FEMALE.
145
  The chronic discharge may put on a rusty appearance, and become
tinged with a larger or smaller quantity of blood.  These secretions,
whether in an acute or chronic stage, may have no smell; or, on the
contrary, have a very unpleasant odor, particularly when the mucous
papulae exist.  The smell, sui generis, is often so decided, that  it is
characteristic in a great number of cases : under other circumstances,
it resembles the  smell of cancer, or that of feculent matter.
  The only differences which  result from the particular seat of the
blennorrhagia are, that the secretions which come from the uterus are
always more mucous, thready, and collected  into flocculi; whereas,
those which escape from the urethra, vulva, or vagina, present a less
tenacious character than the others.
  The Symptoms of blennorrhagia in the female do not present dif-
ferences which always have a relation to the cause which  has  pro-
duced it;  these  symptoms are more especially connected with the
precise situation, or the  degree of severity of the complaint.  As the
disease is, for the most part, purely  local, be its exact seat what it
may, we do not find general symptoms present; in a few cases, how-
ever, sympathetic or constitutional symptoms accompany the affec-
tion, particularly such as depend upon the  circulation ; the  nervous
system may likewise  participate, and the  digestive  organs  may
suffer.
  We have seen women affected with  both  acute and  chronic dis-
charges, and yet complaining of no  pain, and would have been ap-  s
parently unconscious of suffering from a blennorrhagia, were it not
for the stains which they were  unaccustomed to see on their linen,
or in consequence of their husbands contracting the disease.  Never-
theless, an inconvenient  sense of heat of the vulva, accompanied  with
itching, usually announces the commencement of the disease.
  To treat,  however,  the  subject systematically, we must  describe
seriatim the affection as it occurs in the various parts of the genito-
urinary mucous membrane.   Thus the symptoms of blennorrhagia of
the vulva  consist in a swelled state  and redness of the nymphae, to-
gether with a good deal  of irritation; on separating the nymphae, the
morbid secretion at once appears, which may be confined to the vulva
alone, or may escape and become matted and harden on the hair of
the  external organs, forming  thick and offensive crusts, which com-
pletely cover the parts.   Fat women  are more especially subject to
it.  Patients laboring under this form  find a difficulty in walking ; the
desire of sexual  intercourse  is often  increased, but it is  usually at-
                               10 
146
BLENNORRHAGIA IN THE FEMALE.
tended with pain.   The  discharge renders, of course, the  diagnosis
easy.
  In blennorrhagia of the urethra, there is pain in making water, but
slighter than in the  affection of the male, and in some cases no scalding
is felt;  therefore, the absence or presence of this symptom is of no
great value as  a diagnostic sign: dysuria sometimes accompanies the
affection ; the  introduction of a  catheter is, however, seldom called
for.  The secretion does not at  once meet the eye; in order to sat-
isfy himself if really any is to be found, the surgeon should take the
following precautions :  Having  introduced  the  first finger into the
vagina, the pulp turned toward  the  symphysis pubis, let him press
somewhat firmly the urethra against the bone, at  the same time with-
drawing the finger.   In this manner, if pus be present in  the canal,
it will be squeezed out, provided the female has  not lately  made wa-
ter, and she has  a  blennorrhagia of  the urethra.  We have by this
means detected the presence of a disease that other practitioners have
not suspected.  M. Ricord estimates that the urethra is affected  in
eight cases out of every twelve females suffering from discharges of
the genital  organs.
  Blennorrhagia of the vagina is attended, in the majority of cases,
with little  pain :  the disease seems  to be very indolent, particularly
when no foreign substance comes in contact with the mucous mem-
brane ;  we have,  however, been  unable  to introduce  the  speculum in
some  cases without  causing  pain ; in others, the slightest touch be-
comes insupportable, and consequently the act  of going to stool is
very painful.  In cases of this nature, the  surgeon will not immedi-
ately perceive the discharge, as  a narrow vulva may occasion an ac-
cumulation of  the secretion in the posterior part of the vagina ;  large
quantities of feculent matter in the rectum, or a full bladder, will tend
to the same effect, and thus the discharge escapes only when the pa-
tient makes efforts to go to stool or pass urine.
   The surgeon should be aware that the traces of a discharge are to
be looked for,  not on the front part of the linen, as in the male, but
behind;  and if a woman keep herself clean by frequently washing
the parts, or retaining a sponge  in the vagina, he  will with difficulty
ascertain whether she be diseased or not.
   Blennorrhagia of the uterus may be commonly recognised by the
usual symptoms attendant on inflammation of that organ, viz., a pain-
ful feeling  of weight  in the pelvis, a distinct sense of heat communi-
cated to the  finger of the  surgeon placed on the neck of the uterus,
great pain  felt by the patient, when  the uterus  is pressed upon, from 
BLENNORRHAGIA IN THE FEMALE.
147
the vagina, as well as from the hypogastrium, a sense of dragging in
the iliac region, and derangement of the menstrual function : all these
symptoms may, however, be absent, although there is an acute blen-
norrhagia and free discharge from the uterus.
   Such an affection as this, which thus  shows itself by a discharge
from the external organs, we  can not investigate without the aid of
the speculum.  The same may  be said of the deeper lesions of the
vagina, or of the neck of the uterus ; it should not be our object alone
to ascertain the exact character  of the discharge  and the complaint
which gives rise to it, but likewise to convince ourselves of the con-
dition of the mucous membrane,  the morbid states of which we have
before described.
   Without any further  remarks  on the necessity of employing the
speculum, as we feel convinced  that time will overcome the prejudi-
ces which exist  in England against its use, more  than any argument
we can  urge in its favor, we shall at once proceed to describe the in-
strument that M. Ricord uses, and which, by personal experience, we
can recommend to our readers as being of easier application for the
surgeon, and less painful to the patient.   It consists, as may be seen
in the accompanying woodcut, of two valves united at about the mid-
(The Speculum.)
die point, allowing both extremities to be widely opened ; the narrow-
est part is thus placed  at the vulva.   To each valve a handle is at-
tached, by which means space is gained, and the light falls upon the
interior uninterruptedly,  and  pressure on  them causes a dilatation of
the two extremities, which  can be  maintained, diminished,  or in-
creased, by means of a screw.   It has the further advantage of being
adapted to the young and the old ; one instrument serves alike for all,
and the  surgeon is not obliged to have a  series, as  happens when he
employs the common speculum.  Its employment is very simple, but,
like passing a catheter, requires some practice. 
148          .  BLENNORRHAGIA IN THE FEMALE.

  The patient  should be placed on  the edge of the speculum-chair,
as seen in the  annexed woodcut, or on a bed, with a pillow under the
(Speculum- Chair. *)
head and shoulders, the thighs bent on the pelvis, and the legs on the
thighs, the feet supported on two chairs.  The surgeon should place
himself between the lower extremities of his patient, and requires no
assistant—an important thing in private  practice.   The speculum,
previously warmed and greased with a white pomatum, is thus to be
introduced :  Holding the valves of the instrument firmly together with
the right hand, the surgeon should separate  the nymphae by means of
the index and  ring fingers, while, by the aid of the middle finger of
the left hand, he depresses the lower part of the vulva.
   This should be done  gradually, but gently; at  the  same time the
extremity of the speculum should be introduced,  the  handles turned
toward the left thigh ;  the side of one of the extremities of the valve
should press upon the  middle finger ; the other valve will necessarily

  * I here introduce to the notice of the profession a chair which answers admirably
for nearly all surgical operations. Its recommendations are its simplicity, firmness, and
general application to surgical purposes.  It looks like an easy-chair in a library, and
may be raised  to a sufficient and convenient height.  It embraces the latest improve-
ments, and is particula-ly distinguished from all others by the inclination of its seat.  I
can not too strongly recommend to the profession the maker, Mr. Moon of Orange street,
who has so ably assisted me in its construction. 
I
               BLENNORRHAGIA IN THE FEMALE.           149

be applied  against the posterior  surface of the  meatus, along which
the surgeon must pass it by depressing the instrument, without tear-
ing or excoriating the mucous membrane.  As soon as the speculum
has passed the ring of the vulva, it should be directed in the axis of
the pelvis, and the operator should separate the valves ; by this means
he is enabled to see the condition of the vagina and uterus, and, finally,
the instrument will surround the neck of that organ.
   It is  unnecessary for this purpose to employ a very long instru-
ment, or push it on until the neck of the uterus is  embraced, as this
would expose the organ to laceration, and cause great suffering if the
instrument should be caught in the cul de sac of the vagina,  as often
happens.   To  avoid  this, we recommend that the situation of the
neck of the uterus  be previously ascertained by the toucher, so that
the instrument may fall at once upon it, and the neck'of the uterus
will be recognised by the smooth condition of the mucous membrane,
and by its  color, which usually differs from that of the vagina.  Use-
ful indications for finding it may often be derived from the streaks of
white-of-egg-like mucus, which flow from the uterus into the vagina.
In spite of these indications and precepts, should the surgeon find the
speculum entangled in the cul de sac of the vagina, instead of pushing
it onward, let him  gradually withdraw the  instrument, at the same
time that the valves are separated, and the neck of the uterus will at
once come into view.
   This was the method which M. Ricord followed  when he  formerly
had the care of the females, and such is the plan we have adopted
when we introduced  the speculum at the Hopital de L'Ourcine, and
we have never met with any difficulty, although we were often called
upon to employ  it in cases of various  deformities of the osseous
system, &c.
   There are, however, certain counter-indications which should pre-
vent the surgeon from introducing the instrument, at least for the mo-
ment.
   These are, first, a severe  inflammation of the vulva or vagina ; sec-
ondly, the  existence of the hymen, which the surgeon ought general-
ly to respect; thirdly, the  narrowness of the vagina in very young
girls;  fourthly, the occurrence  of  various  bands  of well-organized
membranes, which are sometimes met with  in women that have had
 children ;  fifthly, during the period of menstruation, as it is then use-
 less.  The  speculum may  be  employed, even though a  woman be
 pregnant,  provided the surgeon thinks the case requires it, and if the
 instrument be employed with care.
• 
150
BLENNORRHAGIA IN THE FEMALE.
  M. Ricord states that  the  French female in high  life  is now so
reconciled to the use of the speculum, that he often receives notes
requesting his attendance, and, in the  postscript, a demand that  he
will bring his speculum.  At the hospital, when M. Ricord took the
service, in 1830, a revolution broke out, and a strike against the spec-
ulum occurred ;  however, a few days of bread  and water quieted this
revolt of the  harem ; and now the women are so convinced of the
benefit, that they think no  more of its introduction than they do of
having a blister dressed.  They can,  however, appreciate instantly
the tact of one surgeon over another in introducing it.
  The Complications of  Blennorrhagia.—We  shall now proceed to
describe these, more especially as their consideration  will lead us in
some measure to consider the diagnosis of the various  forms we have
above detailed.   In the  affection of the vulva, and as  a consequence
of want of proper attention to cleanliness, especially in fat women,
erythema or  eczema may appear on the  thighs or external organs,
and give rise to a muco-purulent secretion, thus assuming a form of
external blennorrhagia, particularly in the groin ; such  a state often
precedes the breaking out of mucous tubercles.  The vulva may like-
wise assume an oedematous condition, by which means  a species of
phymosis of the nymphae occurs, and gangrene arises;  this may be
followed by an induration, which lasts a longer or shorter time, or an
abscess sometimes forms, which, if not opened speedily, may extend
to the perinaeum, and produce a  fistulous opening, which  it  is very
difficult to treat.  Abscesses here often result from cysts, and are lia-
ble to return, unless the  cyst be entirely cut out.  We  have,  in the
Hotel-Dieu, seen a striking example of a frequent return of the com-
plaint in consequence of  this  treatment not being followed.
  The inflammation of the urethra may extend to the bladder,  giving
rise to cystitis, retention  of urine, dysuria, depending  upon spasm or
an inflammatory state ; in some rare cases there is haematury.
  The blennorrhagia of the uterus may be complicated with the vari-
ous morbid general sensations we have previously described : to these
we  shall not now revert; but there is one which we  believe is new
to English practitioners,  at least we do not remember  having read of
it in English works.  We allude to an ovaritis, which bears an analogy
with epididymis in the male.  Thus a female suffering under uterine
blennorrhagia may be seized with shivering and a feverish state of
the system; vomiting may come on, together with pain referred to
the iliac fossa, where more or less tension may be present (in no way
resembling that superficial pain  produced by peritonitis); pressure on 
BLENNORRHAGIA IN THE FEMALE.
151
the os uteri gives no suffering ;  but if the finger be carried up the cul
de sac of the vagina, and the patient desired to turn upon the opposite
side, pain of a most acute kind will be felt.   The blennorrhagia may
cease for the moment, one ovary may be attacked only, or both simul-
taneously, as in epididymitis : revulsion will explain the partial ces-
sation of the discharge.
   Lastly, we believe that a  great number of ovarian dropsies may re-
sult from a chronic inflammation of that  organ, the  consequence of
such complications.
   A frequent complication of blennorrhagia of the uterus is the occur-
rence of ulcerations.  These may be  either  specific or simple.
   The specific ulcers may be usually  distinguished by being isolated,
although they may occupy any portion of  the  neck of the uterus ;
they may be further distinguished by giving rise to the  characteristic
pustule, when inoculation is  tried :  the granulations which  appear
upon  their  surface rapidly heal,  leaving,  however, a considerable
state of induration.  Lastly, secondary symptoms will follow  after
some time.
   Simple ulcers arise  as a consequence of inflammation ;  they are
seldom distinct: commencing at the interior of the uterus, they make
their way outward, have a great tendency to throw out granulations,
but seem little disposed to cicatrize ;  by such signs  the surgeon  will
usually be  able to  diagnose  a simple  from a specific ulcer.  During
its progressive stage, or after it has cicatrized, provided no induration
follows, it  is not easy to form an opinion ; but this is not important,
as the treatment will be the  same.  The consideration of this subject
naturally leads me to mention some points which present certain dif-
ficulties for the surgeon.  The  medical adviser is often consulted to
know if a blennorrhagia has been transmitted, or is transmissible ; or,
in other words, if the disease under which the female labors be con-
tagious, has arisen spontaneously, or be the result of a sexual inter-
course with a diseased person ?   The fact of a blennorrhagia having
been contracted by sexual intercourse is, as  we have before observed,
no proof of the syphilitic or virulent nature of the  discharge.  On the
other hand, a virulent discharge  in a female may occasion a mild af-
fection in the urethra of the man who has connexion with her, it act-
ing not in virtue of its specific influence, but as a  simple irritant.  M.
Ricord, in  consequence of  the  various investigations he has  made
relative to this subject, is convinced that a female perfectly free from
disease herself  may communicate either a chancre or gonorrhcea;
that is to say, the  virulent matter may be deposited in her vagina by 
152           BLENNORRHAGIA IN THE FEMALE.
one individual, and may be taken up  by another  in subsequent con-
nexion, without  her becoming  affected by it—she is  the reservoir
simply ; this happens not unfrequently in girls of the town.
   Admitting, as  we do, that various causes may occasion in the  fe-
male, as in the  male, a blennorrhagia which is variously designated
by the terms  whites, fleurs  blanches,  still blennorrhagia, depending
on these causes, is more uncommon than is generally supposed.   In
fact, those women who communicate the disease  present, on exami-
nation, some considerable  lesion, such as we have described above ;
hence, whenever a patient presents himself, complaining that a woman
has infected him, the surgeon, in ninety-nine cases out of a hundred,
will be right if he states that the woman with whom he has had con-
nexion is  herself diseased.  Persons having connexion with these
women do not, however, necessarily contract the disease, although it
is probable that they will do so.
   Many persons have wished  to distinguish  the whites, or fleurs
blanches, from blennorrhagia.  This, however, they have been unable
to do ;  and it is not surprising that it is difficult to distinguish things
which  are exactly similar in form, and which only differ, if we may
be allowed the expression, by an essence that we can not discover.
There  is nothing, either in the particular seat of the affection, nei-
ther in the  appearance of the discharge, nor in the alterations of the
tissues, which can distinguish leucorrhoea from simple blennorrhagia.
The only possible differential  signs,  in  some  few cases, might be
drawn  from a knowledge of the causes ; thus, in  admitting, as some
do, that the whites are those discharges which arise from the influ-
ence of individual or general causes, then, under the head of blen-
norrhagia, we should arrange all other discharges which arise as a
consequence of mechanical, chymical, or virulent  causes  which have
acted directly  on  the organs of  generation.   Such distinctions are,
however, impossible in by far the majority of  cases, in consequence
of the little degree of confidence the surgeon can place in the stories
of patients  who  deceive themselves, or wish to deceive  him.  The
most important task, then, the surgeon has to perform  is to decide
whether the blennorrhagia be virulent or not.   If  a chancre be pres-
ent, no doubt can remain in his mind that the disease is a virulent
one, and that  it  has been  contracted  from  sexual  intercourse.   In
other cases the  diagnosis  should be very guarded ; care should be
taken in the wording of certificates that a medical  man may be asked
for.  " After carefully examining Mrs.----, I do not find she is la-
boring under  any syphilitic affection, but is subject to a discharge, 
 
1° /'
•M
■"S*t>
 
BLENNORRHAGIA IN THE FEMALE.            153
which, under the influence of any exciting cause,  may become  ag-
gravated, and thus transmit the disease  to persons having connexion
with her," is a good form.
   The Prognosis of a simple blennorrhagia of the vulva is not serious,
except in a case of the occurrence of complications which abscess or
fistula might give rise to.
   In urethral blennorrhagia  the  cure  is usually rapid.  The disease
does not last so long as in the male.
   The vaginal blennorrhagia is  usually the more difficult to cure, in
proportion  as the complaint is of old standing.  When the disease
has extended itself to the posterior portion of the vagina, it is next to
impossible to cure ; like the uterine blennorrhagia, it is relieved for
the moment only, becoming aggravated  at the  time of menstruation,
and is thus interminable.  In this last form women generally are bar-
ren, for masses of thick, ropy mucus block  up the os uteri, and pre-
vent fecundation.
   Treatment.—With reference to the prevention of the disease, we
have nothing to add to what we  stated under this head when speak-
ing of blennorrhagia in the male.   In referring to the curative treat-
ment, we  shall divide it into the abortive, and the treatment of the
acute and chronic stage.
   Here, as elsewhere, the abortive treatment should be employed ; but
women seldom  apply in time ; the medical man is never consulted
during the first few days : this may be attributed to their modesty, or
to a cause  which (were I not afraid of  maligning  the sex)  I should
attribute to that  unaccountable, but no less  true statement—want of
cleanliness with respect to the genital organs.
   In  the treatment of  the acute stage of blennorrhagia of the vulva,
great benefit may be derived from warm lotions, containing opium or
belladonna.   If  excoriations similar to those found  in balanitis are
present, the surgeon will find great benefit from cauterizing the sur-
face, and keeping dry lint between the diseased parts.  If no excori-
ations are present, dry lint alone will usually suffice.
   When the acute stage has passed, astringent injections may be had
recourse to with advantage.
   Blennorrhagia. of the urethra, as  it resembles that in the  male, re-
quires a similar treatment.
   Blennorrhagia in the vagina.—In addition to the ordinary antiphlo-
gistic remedies,  it is particularly important to use frequent injections,
in order to remove all  matter which may stagnate and produce a great
source of irritation.  These injections are best employed when the 
154            BLENNORRHAGIA IN THE FEMALE.
patient is in a warm bath.   In cases where pain  is felt, injections
should not be persisted in.  Further benefit may, however, be derived
from injections—namely, as astringents.   To  this effect, the patient
should be placed on a bed, the hips raised, and then the  injection
should be pushed gently, and allowed to remain.  The tube of the
syringe should be of an elastic  substance.  When the case is com-
plicated with a granular state of the  mucous membrane, a ball of lint,
moistened with  various substances,  may be employed,  attached by
means of a thread which passes out of the vulva, to enable the patient
to withdraw it at will.  However, the greatest advantage  is usually
to be derived from slightly touching the parts over with the nitrate of
silver.   An augmented  secretion usually follows this treatment, but
soon ceases, and a  cure  takes  place.  Injections of nitrate of silver
may be employed, but not with the same advantage as the solid sub-
stance.  When  it is impracticable to introduce the  speculum, benefit
may still be derived from the application of the  solid stick of nitrate
of silver.   In other cases we may derive great benefit from plugging
the vagina with dry lint, which should be changed  twice a day.
   Blennorrhagia of the uterus.—In the acute stage of the disease, in-
jections into the uterus  are dangerous ; leeches,  likewise, should
never be employed, or placed on the neck of that organ, as has been
recommended: when placed  on the groin, or opposite the spine, they
have as good an effect, and  they do not here cause inflammation,  or
produce virulent sores on the  os uteri.  In the chronic state, injections
of nitrate of silver  may be used (two grains to the  ounce), and the
quantity has been augmented to ten grains.  This substance has suc-
ceeded better than  any other.
   Since my return  to England, my late master (M. Vidal de Cassis)
has called the particular attention of the profession to the subject of
injections into the  uterus ;  and as  I witnessed many of the  cases
treated in this manner, I may be allowed  to subjoin  my own opinion
upon the subject, and make a few practical observations which I hope
will be found interesting.  It is certain that, if fluids be injected into
the uterus in abundance, and with considerable force, on  the 'dead
subject, some portion of the liquid may pass into the peritonaeum ; this
result, however, is  by no  means certain.   When injections are em-
ployed on the female during life, some practitioners believe that these
same consequences  ensue.   Such is not, however, my own opinion.
I have injected the  uterus many times, when at the  Female Venereal
Hospital, with the  happiest  results, and have  no reason to believe
that fluid  ever got into the peritonaeum ; immediately  after the opera- 
BLENNORRHAGIA IN THE FEMALE.
155
 tion, the patient has occasionally complained of colic and pain in the
 loins ; these symptoms usually disappear in a few hours by warm fo-
 mentations, therefore I have had no cause to reject on this account a
 treatment which  has the advantage of curing a very obstinate affec-
 tion.   There are, however, some precautions necessary to be taken.
 A long tube is to be introduced  into the os uteri, and a syringe con-
 taining a very small quantity of the solution may be firmly attached
 to it, and  the fluid  should be pushed on with but little violence ; for
 it must be  borne in mind that the cavity of the unimpregnated uterus
 is very small, and that large quantities of fluid forcibly impelled might
 possibly pass into the fallopian tubes, and thus escape into the cavity
 of the  peritonaeum—consequences not very probable, but which might
 give rise to very  unpleasant circumstances.
   Treatment of the complications.—Retention of urine rarely occurs in
 the female ;  it may, however, demand the use of the catheter.
   In inflammation of the neck of the bladder, or in cystitis, the usual
 antiphlogistic means should be used, and great benefit is derived from
 cold clysters containing laudanum.  When the complaint has resisted
 this treatment, the  mucous membrane may be rubbed over slightly
 with nitrate of silver, by  means  of the instrument of Lallemand.  In
 the male we have seen this treatment followed by success.
   Vegetations  should be destroyed by excision when possible, but
 they are very liable to return.
   Stricture, from the  nature of the female genital organs, is very rare ;
 perhaps it does not occur once in ten thousand cases.
   When abscesses form in the nymphae, they should at once be opened
 by large and free  incisions, which ought to comprise the whole length
 and depth of the tissues,  and cysts should be removed.
   Cases of fistula, which  arise previous to the surgeon having been
 consulted, or which occur in consequence of bad management, must
 be treated on general principles.  Thus, the first object to be attained
 is to keep  the sides of the fistula in contact, and this may often be
 attained (provided  the fistula  be recent) by means  of position and
pressure.   At a later period, when the fistulous opening is lined with
an organized false membrane, the solid nitrate of silver may be used
in order to destroy the false membrane and produce an eschar ; when
this fails, pressure should be used on  the sides of the fistula.  The
nitrate of silver may  be often  replaced with advantage  by the nitric
acid, particularly  when the sides are indurated, or by means of the
uretome the callous structure may be incised.  Unfortunately, cases 
156
BLENNORRHAGIC OPHTHALMIA.
present themselves which resist all treatment, and it only remains for
the surgeon to recommend cleanliness.
   In  the oedematous state of the vulva, which we have previously
spoken of, instantaneous relief will be procured by dividing the part
which may be supposed to form the stricture.
   Bubo must be treated as in the male.
   Chancres require the same treatment here as when they occur in
other  parts.  We refer our readers to that subject.
   The treatment of the various nervous and other complications
which occur in  uterine blennorrhagia must be conducted on general
principles ; but the cure of the local disease will often cause them to
disappear.
   Ovaritis  must be treated by our most powerful antiphlogistic reme-
dies, otherwise abscesses will  form and open either into the vagina,
peritonaeum, or rectum.
                        CHAPTER IV.

     FORMS OF BLENNORRHAGIA COMMON TO BOTH SEXES.
»
  Having now described the forms of blennorrhagia which  are pe-
culiar to either sex, we come, according to  the plan we have above
laid  down, to speak of those forms which are common to the male
and female.   In the first rank stands blennorrhagic ophthalmia.
                        SECTION  I.

                BLENNORRHAGIC OPHTHALMIA.

  Blennorrhagic ophthalmia, or what in England is usually term-
ed gonorrhoeal ophthalmia, is not unfrequently seen ; yet it is a rare
affection? in proportion  to the vast number of cases of blennorrhagia
which we have witnessed.  Its exact situation is  pretty regular : 
BLENNORRHAGIC OPHTHALMIA.
157
thus it usually occupies  the palpebral  surface of the conjunctiva, or
the ocular  surface may alone be diseased ; however, we most  fre-
quently find them both affected at the same time.  The follicles at
the commencement may be the seat of the complaint, or the substance
of the  conjunctiva, or the. sub-mucous cellular tissue.   Usually  one
eye is affected only at a time ; but,  in new-born children, both  are
not unfrequently seen in a morbid condition.
   Causes.—On this  subject there is  much  difference of opinion,  and
at the present day  two doctrines divide the  medical world; one class
of practitioners insisting that the disease  is a consequence of sympa-
thy ; another class asserting that it results from the blennorrhagic pus
coming in direct contact with the conjunctiva.  The supporters of  this
last opinion reject  altogether the doctrine of sympathy ; on the con-
trary, the advocates of the first doctrine admit that blennorrhagic oph-
thalmia may be produced by direct contact.
   We  shall now consider these opposite opinions, and first of sym-
pathy.
   The authors who take this view of the subject consider that  the
affection  depends  upon a  sudden suppression  of a blennorrhagia,
which, not  knowing what to do with itself, passes* by sympathy to
the eye.
   Such persons have assumed  two things  as  proved which we  can
not allow :  First, that the discharge  is suddenly driven into the sys-
tem ;  secondly, that  there  exists  a sympathy between the eye  and
the urethra,  vagina, &c.   Observation proves,  constantly, that  the
blennorrhagia of the genital organs continues,  and is not checked at
the time  the ophthalmia breaks out;  therefore there is no metastasis.
There  are  no  proofs, either, of sympathy between the  eye and  the
urethra ;  we have  stated  that it is a  rare affection in comparison to
the number of cases of blennorrhagia; if it were  a sympathetic  affec-
tion, we should expect it to occur much more frequently.
   Another reason which makes us believe that it  is not a sympathetic.
affection  is, that in women it is a much rarer affection than in  men;
now, sympathy is  usually supposed to act more powerfully in  the
former class, or at  least equally so.
   One eye only is  affected at a time  in by far the majority of cases :
how can  sympathy explain this ?  why does one eye sympathize more
than the other with the genital organs 1
   These, then, form the reasons which oblige us to reject the doctrine
that blennorrhagic  ophthalmia is a consequence of metastasis or sym-
pathy. 
158
BLENNORRHAGIC OPHTHALMIA.
  We advocate  the  second opinion, viz., that  direct contact of the
blennorrhagic  discharge is the cause of the  ophthalmia, for the fol-
lowing reasons : Observation  clearly points out that matter directly
applied to the conjunctiva will and can produce the ophthalmia; we
are well aware that it  is not  always possible to trace the disease to
direct  contact, but are we consequently to  reject the doctrine, and
conclude that none has taken place, simply because we have not
traced it 1  Certain circumstances, such as the temperature or humid-
ity of the air, influence considerably the disease, rendering infection
more probable, and aggravating the complaint.
  Age likewise  has its predisposing  effect: thus, children born of
parents laboring under a blennorrhagic discharge are very liable to be-
come  infected, in consequence of direct introduction of the matter, and
both eyes are usually equally affected.   The period of infancy passed,
all ages are equally liable.
  Sex, as we  have above  stated, has  a marked influence in predis-
posing individuals.   The  male is, in a tenfold degree, more liable
than the female ; the reason is simple.   In making water,  the man is
obliged to handle the penis ; curiosity also makes him wish to exam-
ine the state of the discharge frequently ;  thus his hands become
soiled  with the purulent secretion, which may easily come in contact
with the eye.
  In woman, however, the contrary happens ; her fingers are rarely
soiled, for she is lamentably neglectful of the ordinary duties of clean-
liness.  When one eye  is affected, the probability of the other be-
coming so likewise will depend  upon  whether the patient  lies on the
same  side or  not, thus favoring the discharge to come in contact with
the sound  organ.  It will be rendered still  less probable when the
bridge of the  nose is high, for  the same  reasons.
  Symptoms.—At the commencement, the symptoms are similar to
those  found in common ophthalmia; the patient feels as if a foreign
body intervened between the body and the lid.    Should the surgeon
be called upon to examine the  eye at this period, he will find that the
lower eyelid is first attacked ;  it is redder than usual, and presents a
flocculent,  red appearance ; the disease does not remain, however,
long confined to  this spot, but  spreads over the whole surface of the
conjunctiva ;  there is considerable lacrymation, followed speedily by
a muco-purulent discharge, which soon assumes a purulent  charac-
ter ; the  follicles participate in  the disease; the mucous membrane
assumes a granular appearance, and a sanguineous discharge, or even
pure blood, appears on  the surface. 
BLENNORRHAGIC OPHTHALMIA.
159
   The  secretions now form crusts around the lids, and are often
so acrid that they excoriate  the  cheek and parts which they come
in contact with;  it, however, does  not produce  any effect on being
inoculated.
   Granulations are  so common  in  this affection, that it has been
called  granular ophthalmia;  this proves that the inflammation  has
gained  the body of the mucous  membrane.  The symptoms do  not,
however, stop here ; oedema of the lids takes place to such an extent
that the patient loses all power of opening them, and they remain per-
manently closed,  causing the secretions to be shut up,  as in case of
abscess.  The upper  lid, allowing  of a greater distension  than  the
lower,  covers it, and trichiasis often results; oedema of the  cellular
tissue of the conjunctiva occurs, and chemosis follows ; thus  the cor-
nea is  surrounded with a mass of oedematous infiltration.   Should
phlegmonous inflammation occur,  an induration  will follow in conse-
quence of lymph being  thrown out.
   The other parts of the eye  become successively attacked ;  intoler-
ance of light follows ;  the cornea becomes clouded, ulcerates,  and
hypopium succeeds.  The ulceration may result from  the mere me-
chanical effect of the pus, which by its acrid qualities macerates or
softens the cornea; or  it may ulcerate, from the circulation being in-
terrupted ;  hence, destruction of  the parts follows from insufficient
nutrition.
   These unfavorable symptoms follow one another so rapidly, that in
twenty-four hours the  eye may be lost.  When the disease has ex-4
isted five days, and  the use of the  organ is preserved, the  surgeon
may hope to save  it.  When the acute stage has passed, the affection
may terminate either by resolution, which  gradually occurs, leaving
a considerable hardness, or cicatrices of the cornea may result, or the
iris may become adherent, or be covered with false membranes.
   Delitescence is a very rare termination.
   Diagnosis.—In this  point of view it  is impossible, by any of the
signs taken singly, to satisfy  one's  self  of  the existence of  an oph-
thalmia which  is the  direct  effect  of gonorrhcea  or blennorrhagia.
We have  before  observed that  the granular  state  of  the  mucous
membrane  does not prove  the  specific  nature  of the complaint,
but shows  only that the body of the membrane is  the seat of the
disease.
   The intensity of this form has been considered as a  characteristic
symptom, but the  practitioner will  find he can not depend solely on it,
as other forms of ophthalmia have this sign in common. 
160
BLENNORRHAGIC OPHTHALMIA.
   The coincidence of blennorrhagia is not conclusive, for any individ-
ual may become affected with ophthalmia  independently  of gonor-
rhoea ; the latter complaint does not prevent him from being affected
with  a simple  conjunctivitis; when  it  occurs,  however, it  is  a
sign of importance,  but not an unequivocal symptom of a specific
disease.
   However, the coexistence of blennorrhagia of some of the mucous
membranes, great intensity of the  complaint, together with a granular
appearance of the mucous membranes, will usually be sufficient evi-
dence  that  the disease is blennorrhagic ophthalmia.   In moist,
damp weather, the surgeon should be on the  alert to treat actively
inflammation of the eyes in persons laboring under blennorrhagic
affections.
   There is still another question which we should  not  leave unno-
ticed.  How can we diagnose a  virulent from a mild blennorrhagic
ophthalmia 1  We  positively affirm that no case has ever been shown
us which we could call virulent;  we have inoculated, but no pustule
has been produced, and we are not aware of authors having cited ca-
ses of it;  we therefore believe that there is no virulent form, strictly
so called.
   Prognosis.—There is no form of  ophthalmia,  the prognosis of
which is more unfavorable than  the one we are describing;  conse-
quently, when the surgeon has  a case to treat, he should  never
take the whole responsibility upon himself; the patient only ob-
serves the  slight redness, and if in twenty-four hours  the organ is
lost, his treatment will be blamed ; a second opinion should, there-
fore, be called in.
   " To give an idea of the unfavorable nature of the prognosis," says
M. Ricord, " when I was Dupuytren's interne, that distinguished  pro-
fessor never had a case that was perfectly cured, or a  patient that re-
covered his sight completely when once attacked with this complaint,
and yet it was not from the fear of taking blood, for  six or eight bleed-
ings were ordered in as many days."
   Treatment.—To use the words of Lisfranc, in one of  his clinical
lectures, " you should tumble upon  this complaint, the arm bent, and
the mind firmly convinced that it  is better for your patient to run the
risk of losing all his  force than his eye, for one can be recovered, the
other is irremediable."   But it is  at the  commencement  that we  may
hope to be of the greatest service  ; on the first appearance of redness,
let leeches be applied  to the temples, and  the mastoid  process, and
let the patient be briskly purged.  Should general inflammatory symp- 
BLENNORRHAGIC OPHTHALMIA.
161
toms be present, general bleeding  may be called for.   Without wait-
ing, however, to allow the disease to gain ground and  correct his
diagnosis, the surgeon should at once employ the nitrate of silver in
substance, not with the intention of its acting like a caustic, but sim-
ply to  change the  character of inflammation ; for, as we have  fre-
quently had occasion to observe, this substance  is endowed with anti-
phlogistic properties.  To apply  it properly, the  eyelids  should be
everted, and then the solid stick of nitrate of silver  should be rapidly
passed over the  surface, so as to whiten it slightly; immediately in-
ject cold water under  the eyelids, and by this means the nitrate of
silver will not touch the cornea.
   This treatment should be  accompanied by that  above  mentioned,
together with poppy-head fomentations, and great  relief may be de-
rived from belladonna placed in the nostril of the affected  side.
   At a later period the  surgeon will  do well to prescribe a seton in
the neck; by such means nature seems as if taken by surprise, and
frequently the eye is at once  relieved.
   The patient's he»d should be raised and turned to the affected  side,
to prevent the secretion coming in contact with the  sound  organ.
   When chemosis is present, the  surgeon should not hesitate to cau-
terize it, or, in case of that treatment not succeeding, he may readily,
by means of scissors, cut off the swollen and oedematous cellular tis-
sue.  This  will  tend materially to unload the vessels of the part.
   When the chemosis  is indurated, cauterization may  be  tried;
when, however,  the  circulation of the cornea is interfered with, the
surgeon will do well to scarify it (the  chemosis), as recommended by
Scarpa.
   Supposing that the first cauterization does not succeed, it is by no
means a reason for discontinuing it; in its reapplication, the surgeon
should bear in mind the following rules :  Cauterization is  usually
succeeded by a sanguinolent  secretion ; this  lasts  some few hours ;
if, at the end of  that time, it  does  not return to its  purulent state, if
the eye becomes redder than  before, the surgeon may with advantage
reapply the  caustic.   M. Ricord has  reapplied it four  or  five times
under these circumstances.   When, however, the secretion becomes
purulent, and then serous, and  the other symptoms of inflammation
abate,  no further application of the caustic is required; it is  now
worse than  useless, and will tend only to  excite  the  inflammation
afresh.
   This  constitutes the  treatment  which we  have seen  employed
with the greatest success ; we shall not, however, quit the su'ojec
                              11 
162             BLENNORRHAGIA IN THE ANUS.
without saying a few  words on  some  other remedies which have
been used.
  M. Ricord is opposed to the use of mercury, as it often causes sal-
ivation ; for, although the ptyalism might act as a counter-irritant, it
is too near the seat of the affection, and causes  only another disease,
instead  of curing one.   Our opinion,  from what  we have seen of
mercury in other affections of the eye, &c, differs greatly from that
of our learned master, and in spite of his objections, we should feel
called upon to use it in certain cases, and  under certain restrictions.
As  regards the propriety of reproducing the original blennorrhagia,
we  have nothing further to add to what we stated  in our general ob-
servations on  blennorrhagia,  except to  repeat that, though recom-
mended by Baron Boyer, it is very dangerous, and does not produce
the  results he anticipates.
                         SECTION II.

                BLENNORRHAGIA IN THE ANUS.

  It may be asked,  Is  there  such a disease as this 1  We answer,
Yes.   Nevertheless, it is very rare ; but in large hospitals, set apart
for diseases of the genital organs, it is occasionally met with.  We
have seen some cases—one lately, which was clearly proved, as a
police officer was witness of the unnatural crime, and the boy entered
the hospital suffering greatly from blennorrhagia  of the rectum, and
presented the following symptoms.  How far it  may be common, it
is not here for us to decide,  but as a consequence of direct infection
we believe it an unfrequent  disease ;  the error of thinking it so de-
pends  upon  the following  circumstance.   A  secondary symptom,
which we call  mucous  tubercle, and which very often follows an in-
durated chancre, is very common in the hospital: we have  given a
very good plate of it.  (See  Plate V., fig. 4, and PI. 7.)
   Hence M. Ricord  interrogates the patient on this score, and exam-
ines the anus  frequently.   Now, as the mucous tubercle gives rise
frequently to a discharge, a  superficial observer might suppose that
the disease  has been contracted by direct contact, particularly when
the tubercles are  ulcerated.  After a  careful examination of these 
BLENNORRHAGIA IN THE ANUS.             163
cases, and  after inoculation of the secretion, &c, we have satisfied
ourselves that we have only had to treat a secondary symptom.
  The symptoms of blennorrhagia of the anus are but slightly alluded
to by authors, and yet they are of great importance, more especially
in medico-legal inquiries, as we have more than once stated.
  Symptoms.—Pain and difficulty in going to stool usually accompa-
ny the disease ; however, such symptoms exist  equally  in haemor-
rhoids and other affections of the rectum ; a discharge from the gut
takes place, resembling that from the urethra.   The lesions of the
intestines  may be similar to those we described in speaking of the
vagina, and the pain is very often intense, in consequence of the faecal
maUer passing over the excoriated and inflamed gut, thus forming a
severe complication ; chancres may occur, which, if accompanied, as
they sometimes are, by a spasmodic action of the intestine, render
defecation very difficult, or even impossible.
   The disease may assume  either a  chronic  or  acute* character.
 When acute, the  circumstances and complications  render it very se-
 vere ; when it takes on the chronic  form, the position  and difficulty
 of  local treatment render the cure very tedious.  Buboes seldom fol-
 low, but abscess at the margin of the anus is not unfrequent; it does
 not, however,  necessarily form a communication with  the intestine,
 though fissures of the rectum may frequently result.
   The affection is usually seated just within the sphincter, and does
 not extend beyond the second curvature of the rectum.
    The cause  is, as we have stated above, the effect of direct contact
  of  the blennorrhagic secretion ;  it can not be produced by swallow-
  ing the  secretion, as some authors have pretended.  The other gen-
  eral causes of blennorrhagia might give rise to  the disease, but sel-
  dom do so.
    Diagnosis.—This is by no means easy, for we occasionally see
  blennorrhoid discharges from the rectum, and to distinguish such from
  blennorrhagia is usually impossible.   Notwithstanding,  the medical
  man is  sometimes called upon to give evidence ;  it is therefore of the
  greatest importance that he fully understand this  subject, as the life
  and reputation of several individuals may depend upon his opinion ;
  and for these reasons we purpose examining some of the signs which
  have been given in books.
     M. Cullerier, one of the surgeons of the Venereal hospital, states,
  in an article  he  has written  on  this subject, that  an opinion may be
  formed from  the funnel-shaped  appearance of the rectum.  The case
  which we lately saw proved completely that this  funnel-shaped ap- 
164
BLENNORRHAGIA IN THE ANUS.
pearance of the anus does  not necessarily follow the commission of
an unnatural crime ; no such appearance was there present.
  Those who have dissected phthisical patients  must be likewise
aware  that this appearance will be often found, as it depends upon
the absorption of the fat;  an inflammatory affection  may  cause a
swelling of the parts around the anus, and give the opening a funnel-
shaped appearance ; hence, then, we infer that the crime may have
been committed without this pretended  sign being present; and if it
does exist, there is no reason to suppose that the crime has been per-
petrated.  Our readers will, therefore, appreciate the value of such a
symptom.
  The color of the discharge has been cited as assisting the diagno-
sis ;  but taken alone this is of no use, for it gives the surgeon no in-
formation as to the cause.
  In simple blennorrhagia of the rectum inoculation affords no assist-
ance ;  if, however, chancre be present, inoculation will then  satisfac-
torily prove that the complaint has been caught in  an unnatural man-
ner.   The  occurrence of buboes will not assist the diagnosis, as some
have supposed ; observation  clearly shows that they are often pro-
duced by simple irritation.
  The  antecedents of the  patient  seldom  aid the diagnosis, as he
rarely  acknowledges that he has been guilty of such a crime.
  In fine, when no chancre exists, there is  no one unequivocal sign
that  the complaint, which the surgeon  is called to pronounce upon,
depends on a disease contracted in unnatural connexion ;  there is,
however, a circumstance on which M. Ricord lays great stress ;  we
refer to a rent or tearing of the margin opposite the coccyx  and peri-
naeum,  which he  has  never found  in  persons unaccustomed  to  the
crime.   He further states, when this  condition has been observed,
that the patients, on being pressed, have avowed  and confessed  the
manner in which the disease had been contracted.
   Prognosis.—This must be  always unfavorable, as, during the acute
stage, the passage of the faeces irritates the membrane, and may give
rise to abscesses.  In the chronic stage, if the disease have reached
the deep parts of the rectum, we can have no hopes of speedily curing
it, as it is difficult to apply  local treatment.
   Treatment.—The first indication we have to fulfil is to empty the
rectum, and to prevent constipation as much as possible ;  this is best
done by lavements.   When, however, fissures of the rectum exist, the
introduction of the  clyster-pipe is difficult, and should not be contin-
 ued ;  laxatives only should be used.   Cubebs  and copaiba are  not 
VEGETATIONS.
165
only useless, but highly prejudicial, as they tend to irritate the rec-
tum, and have no effect in checking the discharge.
  The direct means consist in keeping  the parts perfectly clean, in
employing injections of nitrate of silver of the usual strength, and, in
some cases, advantage may be derived from the use of the tent.
                        SECTION  III.
      BLENNORRHAGIA OF THE MOUTH, NOSE, AND EARS.

  M. Ricord, in his immense practice, has  never seen any disease
or discharge which could be classed under this head ;  he is therefore
disposed to treat such descriptions as fabulous, and to attribute them
to simple catarrhal affections.
  In the umbilicus, and in the fold of the groin, discharges may appear
as the consequence of dirt, or the development of mucous tubercles ;
the  treatment  must, of course, be founded on general  principles and
consideration of the cause.
                        SECTIOjf  IV.
                         VEGETATIONS.

  Under the general term of non-virulent affections  I place vegeta-
tions, which, though not necessarily, are frequently a consequence of
sexual intercourse, and must  therefore be considered.   Vegetations
are generally designated by the terms, warts, cauliflower excrescences,
cockscombs, fyc.   (PI. VI.)
  Pathology.—In  color vegetations differ  considerably ; sometimes
they are of a very vivid red  or  scarlet;  this happens  particularly
when they are seated on the glans  penis at the entrance of the ure-
thra in the male or female, on the inner margin of a narrow prepuce,
and, generally speaking, when they are not constantly exposed to the
air.  When seated  on the skin they are much paler, and  by exposure
become even quite  black.
  Their consistence and sensibility differ considerably : they may be
quite horny, very little if at all sensible, and quite dry ; or they may 
166
VEGETATIONS.
be moist, secreting a dirty and offensive fluid, flaccid, and sensible to
the ordinary stimuli.
   Sometimes they are attached  to the skin by a sort of pedicle ; at
others, they have a broad base,  and  are flattened.  In  number and
size the  same variety occurs ; we meet often with one or two, very
small and pointed ; in other instances, the male or female organ3 may
be completely covered with them.  They are more frequently situated
on  the mucous membrane than on the skin, although they are met
with on the thighs ;  still, however, they are found on  those parts of
the skin which are more closely allied to mucous membrane.   Their
growth depends apparently on the little pressure and the moisture
which surround them ; for, if pressure be made, and if artificial means
be employed to keep the parts dry, their growth is retarded.
   Their structure is  very peculiar : a cluster of vegetations is  com-
posed of a number of granular bodies  connected by a common base ;
the size of  the  granules differs  greatly,  usually that of  a small pin's
head ;  these granulations are more or less conical ; when not com-
pressed,  they  are  covered by epidermis or epithelium, which  often
becomes  horny in exposed situations ;  if a section be made of this
cluster, it seems to consist of an hypertrophied dermis, which is much
thicker here than elsewhere.  Some  authors  believe vegetations to
consist of the papillae of the skin, which from some cause are hyper-
trophied, and lift  up the epidermis covering them.  Others believe
them to depend upon an hypertrophy of the crypts, which form the
exhalents on the skin, having assumed a conical appearance.  What-
ever views my readers  may  have upon  the subject, let them be as-
sured that  their origin is deeper than is imagined; hence arises the
difficulty of removing them, and the necessity of taking  certain pre-
cautions  if we  wish to cure them radically.   They  are plentifully
supplied with blood-vessels,  bleeding freely when  cut; their sensi-
bility differs greatly ; in some cases vegetations are nearly destitute
of sensation ; when  they have been much irritated, they become ex-
ceedingly sensitive, and  the secretion they give rise to seems to in-
crease that sensibility.
   The causes appear to arise from irritation ;  some persons believe
them to be  the  consequence of venereal disease, and pretend to speak
of syphilitic vegetations as distinguished from others.   Observation
leads me to the following conclusions :  Any secretion which will oc-
casion irritation of a surface for a prolonged period may produce vege-
tations.  We have often seen them in boys and adults affected with
natural  phymosis, or who pay no attention to cleanliness ; in such 
VEGETATIONS.                      167
cases, it is the secretion of the glandulae odoriferae which produce the
disease, for connexion has never been indulged in.   Sir A. Cooper
in his valuable Lectures On Surgery,  states  two causes which prove
that the secretion of warts is contagious, and he does not think  that
the blood of these bodies can become the infectious agent.   I  have
met with similar cases, but  I am not prepared to say that the matter
they  secrete is of  any peculiar property, acting otherwise than as
a simple irritant, which,  as I have said, is alone sufficient to produce
warts.
   In  females  they  depend upon gonorrhoea or  irritating discharges ;
the  secretion of  chancres often  produces them,  not,  I  believe,
in virtue of any specific  action, but from its irritating qualities, and
modern authors no  longer consider them a secondary symptom.   It
is of  no great importance in medical jurisprudence that these points
should  be  properly appreciated.   I may here  mention an instance.
A late interne at St. Louis'  hospital was  shown a child with these
vegetations completely encircling the genital  organs, which he in-
stantly pronounced  to be syphilitic ; and the mother immediately sus-
pected  an  old man who was  in the habit of playing with the child,
who lived in the same house with her ; and the answers of the child
appeared to corroborate these suspicions, or they were (as often hap-
pens) tortured into an acknowledgment.   The authorities were ap-
prized,  but  did not think it necessary to take any measures.  I ex-
amined the  child,  and found that the vegetations  existed in great
numbers, of a dark and horny consistence ;  there was a considerable
quantity of  serous discharge from the vagina.   The child was puny,
lymphatic ; and I could  detect no marks of violence on  its  person.
This  circumstance induced me to tell the interne  that he had come
rather hastily to a conclusion on the nature of the vegetations.  Their
pale,  horny, dark character showed that they had existed a long time,
notwithstanding any  statement  of the  mother, who seemed at all
risks  to tax the old man  with rape.
   The discharge from the vagina, as I assured him, was often pres-
ent in scrofulous children ;  it  existed in this instance, and its serous
character showed that it  did not depend upon recent infection.  Now
these appearances did not tally with the  commission  of rape, or the
idea  of infection  contracted a few days before.  I believed the man
innocent;  and I mention the case here, as the  circumstances which
attend it are peculiar, and I  believe it be an instructive one.
   Complications.—Vegetations may exist alone, or be complicated
with a variety of other affections : in the  female we  often find  dis- 
168                     VEGETATIONS.
charges  which  produce,  keep up,  and aggravate  the complaint.
Excoriation of the surrounding tissues is often likewise a complica-
tion.  Ulcerations, both of a simple  and specific nature, frequently
attend the complaint, and render it more difficult of cure.  But by far
the most frequent in the London hospitals is condylomata, and hence
these two affections are often confounded together, and attributed to
the same cause.  In  the female, the situation of vegetations often
gives rise  to a  complication, particularly when  they are of a very
vascular  kind and occupy the meatus, causing that affection which
has been described by Sir C. M.  Clarke and Sir B. Brodie.  In the
male, vegetations  co-exist with  balanitis, chancres,  paraphymosis,
phymosis, complications which are often severer than the original af-
fection, and which it is necessary to remedy previous  to treating the
vegetations.
  The diagnosis of vegetations is  generally easy ; there is, however,
one affection with which they may be confounded ;  I allude to con-
dylomata.  The  practised eye  will, in  such cases, however, rarely
be  deceived.  The former  affection is  pedunculated, the  granules
small, covered with epidermis ;  their color is florid.    The history of
the case, and the existence of some irritation, help the  diagnosis.
  In the latter affection the bases of the condylomata are large, the
granular  patch is flat, apparently destitute of epidermis, and covered
with  a whitish  or yellow  secretion, rarely occurring without other
traces  of secondary  symptoms, probably the patchy  excoriation of
the tonsils, or a  papular eruption on the body.
  When vegetations  and condylomata occur  together, the local
characters I have above mentioned aid the diagnosis.
  The prognosis is  favorable, although  the  patient  should  be made
aware that, when destroyed, vegetations are very liable  to recur.  If
not removed, however, they may create great local  irritation,  and
produce very intractable sores, although  possessing  nothing specific.
In some  few cases I  have witnessed,  when  vegetations are very ex-
tensive, no sooner does the surgeon get  rid of one crop than  another
appears ;  the disease is hydra-headed; but  under the treatment
whichT shall immediately recommend, this rarely occurs.
   Treatment.—When these bodies are few  in number, it is only ne-
cessary to  remove the cause which keeps up the irritation, and they
will disappear of  themselves.   Ablution with  tepid  water, or  an
astringent wash, will  often suffice, provided dry lint be used to pre-
vent the vegetations  coming in  contact with one  another.  They
shrivel  up and  soon  fall away, and are not reproduced.   In such 
bjyZ^)A, rSf-
22, J
j
 
 
HERPES PRAEPUTIALIS.
169
cases as these, any dry powder may be employed, and, as far as my
experience goes, the  simpler  it is the better; and I should recom-
mend hair-powder in preference to those stimulating ones in use,
which, however, are not without their danger.  I have often had oc-
casion to witness vegetations.surrounded with a hard crust composed
of some powder mixed with the secretion, and producing an augmen-
tation of suffering ; hence I do not recommend  them.  When the
patient will  submit to the use of instruments, nothing succeeds  so
well  as excision of the vegetations with a pair of curved scissors,
taking care  to  cut them as close  as  possible to their roots.   The
incised  parts bleed  freely ; but this should  not deter the surgeon
from  cutting off as  many as possible, placing  dry lint  upon  them
when the bleeding has ceased;  the coaguja  and lint should be re-
moved by the use of the warm bath, and the  greatest attention paid
to cleanliness, at the same time that means should be taken to check
any discharge which  may run over the affected part.  If powders
be used, the  part  should  be  carefully washed and  dried previous to
any more 'powder being  applied.   When these means fail, caustics
may be employed, but the surgeon will find  them very inefficacious
compared to the other means.   Nitrate of silver produces but little
effect;  its action is superficial, and it forms a hard cake on the vege-
tation, which is irritating  and  does not fall off for some  days, when
the vegetations are often as large as before.  The caustic potash is
a very unmanageable preparation ;  it extends further than is wished,
and the black and decomposed  substance is very irritating.   How-
ever, as an adjunct to excision, the employment of the  solid nitrate
of silver  is  beneficial; but the surgeon should not employ it to the
bleeding  surfaces : when the excised parts have ceased to pour out
blood, and the part is washed, let the stick of nitrate  of silver be
 applied to the centre, and the  vegetations will not reappear.   Gener-
 al means are of no benefit, unless they tend to check any discharge
 which keeps up the irritation.
                        SECTION  V.

                    HERPES PRAEPUTIALIS.

  Among non-virulent affections is a complaint which  pathologists
have agreed  to call herpes praeputialis.  Willan and Bateman have 
170
HERPES PRAEPUTIALIS.
classed it among vesicular diseases.   It commences by a cluster of
small vesicles, seated on a patch of inflamed skin :  the vesicles may
become ruptured, and the secretion of the part may cause ulceration,
and little sores are thus produced.  The reader who  is not familiar
with this  disease, will gain  a very good idea of its characters by
examining Plate  III.,  fig.  3: the affection  is  there  seen  in  all
its stages.  I think I can  not do better  than extract the following
case from my note-book, together with the observations which I made
upon it, as they comprehend  whatever is known upon the disease.
  August 15, 1839.—My friend Dr. Fisher, of the Place Vendome,
directed A. G-----to call upon me, and ask my opinion upon  a sore
on the  penis, this morning.   On the prepuce and glans there  are
several ulcerations presenting the following appearance : one is a
small distinct ulcer, covered with a whitish secretion, the base is red,
and gradually lost in the surrounding  tissue ;  close to it is a distinct
vesicle  filled  with a limpid fluid;  there are various others,  which
more or less resemble the two spoken of.
  On the  right buttock there  is a patch of vesicles  of the size  of a
five-shilling piece, the base of each being as large as a  pin's head;
some are  filled with a serous, others with a yellowish fluid.
  Close to the anus is  another  patch, which is completely covered
with a yellowish crust, such as is seen on the face of children.
  The History the patient gives of himself is the following:  he left
England  in  consequence of bad health and indigestion, and  is now
returning  from Geneva.  On Thursday last, the 8th instant,  having
been  three days in a diligence, he felt a singular pricking near the
anus, and at that period the  sore on the penis first appeared, but ha?
made no  progress since.  Being interrogated on the subject of ex-
posure to contagion, he  states that he has not had connexion more
than twice, the last one dated two years back.   As to the probability
of having  contracted it  on a water-closet, he states that he did sit
down  on  one which was very dirty, a short  time since.   He adds,
that had  he  reason to  attribute the affection to contagion,  he would
willingly  avow it, having no motive for concealing the truth.
  On  again  questioning him, he states that he is very subject to in-
digestion  and to eruptions ; lately he  has been particularly inattentive
to diet, eating at a table d'hote, &c.
  Such is the history of the case given by a very intelligent young
man, who can have no reason for concealing anything, as he  is very
anxious to pursue his journey.  He naturally asked  me for an opin-
ion  on the sore, and this  leads me to consider the diagnosis.  The 
HERPES PRAEPUTIALIS.
171
 circumstance of an ulceration onlhe penis, presenting the characters
 above noticed, in a young man of twenty, is very strong prima facie
 evidence that a chancre  exists ; but we are aware that the presence
 of a sore on the penis does not prove  that  it  is a chancre, for other
 sores may appear on the  penis, and chancres may appear on arty part
 of the body.
   As to the characters of chancres, we have stated them to be those
 attending  other ulcerations,  and that other sores  may put  on the
 character  of chancre.  In young men, suspicion is excited because
 they are more exposed ; but any age is  necessarily liable.   Thus,
 then, as far as we have yet seen,  the present case has as many cir-
 cumstances for supposing it to be  one of chancre as not.
   Now if it be not a chancre, what is it?   The prepuce is liable to
 other vesicular diseases.   Thus, in addition to chancre, eczema and
 herpes praeputialis are not unfrequently seen on that part.  Can the
 present complaint be any of these 1  It presents a vesicle  of a con-
 siderable size, seated on  an elevated patch: these, we  see at once,
 are not the characters of  eczema, for by referring to this latter affec-
 tion it will be  found that eczema presents a very small vesicle, in
 great quantities, thickly and irregularly sprinkled over an  inflamed
 and reddened skin.   Herpes praeputialis, like herpes labialis, usually
 appears in distinct patches of about some ten or twelve large vesicles
 on a red base, which, at  the  end of a few days, fade away and dry
 up of themselves, or, if the  irritation continue,  form little  ulcers.
 They  generally depend,  not  upon local irritation, but upon disorder
 of the digestive organs;  on the contrary, eczema usually accompa-
 nies, and is produced by,  local irritation.
   So far, then, it will  at once be perceived  that we  are  in doubt
 whether this case be due  to a specific  cause or  not.  If it be  a sim-
 ple affection of the  skin, it can be only herpes praeputialis, and we
 exclude eczema, and come to  the  conclusion that it is either a chan-
 cre or herpes.
   As to the probability of its  being a chancre, we should  add, that
 our patient has not been exposed to contagion, and unless we allow
 that a chancre arise  spontaneously, the present  case does not depend
 upon a specific contagion.
   Is it probable that the present case is an herpetic affection 1  We
 find on studying herpes, on the lips and  prepuce, that it is usually
preceded  by general disturbance   of the digestive  organs; that it
occurs in persons possessing a delicate skin, and such as are subject 
172                        ECZEMA.
to skin diseases ;  that it never exists except in patches, and that these
patches may be numerous.
   Now these circumstances  are  all present in the case before us:
the vesicles are not only present on the penis, but likewise on the
buttocks, where there  has never been an abrasion of surface ;  hence
inoculation could  not have acted here,  although it may on the sound
surface of the mucous membrane.
   For these reasons, then, we have diagnosed  the case to be one of
herpes praeputialis, which from  the moisture of the part has ulcerated.
   The prognosis is favorable, inasmuch as the course of an herpetic
affection, when properly treated, is excessively simple ; we therefore
gave our patient every reason to suppose that  he would be perfectly
well in a few days.
   The treatment we recommended, was particular attention to diet,
advising him to live upon milk and vegetables, with meat and wine
in moderation, avoiding  all heating dishes.  We prescribed aperients
and bitters, and a local application of lint dipped in aromatic wine.
   August 18. This patient left  Paris quite well.
                        SECTION VI.
                            ECZEMA.

  The  surgeon is  occasionally consulted on  account of a severe
affection of the genital organs  which pathologists  call  eczema.
This  disease  is generally spoken of only  in treatises  on skin
diseases; however, as it occasionally is a consequence  of sexual
intercourse, I have  thought proper  to  allude  to it, and accompany
the description  with a plate which the reader will find in Plate IV.,
fig. 3.
   Causes.—Eczema can generally be  traced  to the  application of
some irritating substance to the skin.  In cases which we are  about
to treat of, the  blennorrhagic discharge is the  usual exciting cause,
together with inattention to cleanliness : hence we very frequently
witness cases of the affection in prostitutes.   In men, however, who
work in a business where much powder or dust is  disengaged, this
affection of  the genital organs is not uncommon, and of course quite
independent of any  venereal  complaint.  The surgeon  should  not
forget that mere friction of  the trousers  will  produce it; by itself it 
EXCORIATIONS.
173
 is  no sign of venereal  disease.  I have found it more frequently in
 persons who have red or auburn hair than in other individuals.
    Symptoms.—Eczema  is characterized  at its commencement by a
 feeling of itching, heat,  and redness ; the parts become swollen, and
 these symptoms are followed by an eruption of small vesicles scat-
 tered over the surface :  when scratched, a serous fluid exudes, form-
 ing little scales on the skin, and increases the irritation.  The disease
 may  assume the chronic  form;  in this state  the drawing was taken:
 the skin is red and swollen; the surface covered with the secretion
 above  mentioned, which is hardened by exposure, and crevices are
' seen running  between the little lamellae : from these issues, at first,
 a clear, and in the  more advanced stages a sero-purulent secretion,
 giving  rise to larger and  firmer  scales, and the disease is then called
 eczema impetiginodes.
   The diagnosis is easy, and does not require further allusion.
   The prognosis, in  simple cases, is favorable, but in the severer
 forms no prospect  of an early or speedy cure  can be given, as this
 affection is one of the most obstinate.
    Treatment.—Great  attention  to cleanliness is frequently sufficient
 to  cure the patient, at  the same  time  that all exciting  causes are
 carefully avoided.  In the more advanced stages, local bleeding will
 be called for, and some emollient  application, such  as bran-water,
 goulard-water,  poultices, particularly  those  made  of potato-starch ;
 linseed-meal, by its rancidity, often exaggerates the complaint.
   When these means fail, it may be found advantageous to stimulate
 the part by rubbing the organ with nitrate of silver, when all irrita-
 tion has ceased, and employing dry lint to prevent  friction.
                       SECTION  VII.

                        EXCORIATIONS.

  Definition.—By the term excoriation, I here mean abrasion of
the  epidermis or epithelium, the result of  sexual intercourse.
  We meet, in practice, with some few individuals who can not in-
dulge in sexual intercourse without being  subject to excoriations ;
such persons  are  not observed  to  have a particularly fine  or  clear
skin: we have met with the affection in patients who on other parts
of the body have a thicker cuticle than usual, and yet are very sub- 
174
EXCORIATIONS.
ject  to  abrasions  in  connexion.  Excoriations, however, are more
frequently met with in persons who naturally have a long  and nar-
row  prepuce, and pay little attention to cleanliness.
  The number and position of excoriations differ greatly, but it is in
the neighborhood of the  fraenum that they are most frequently seen,
and they often occur upon the patches  of the glandulm odoriferce at the
base of the glans penis.  They may  rapidly heal,  or, if neglected,
ulcerations may  follow, and be kept up by the secretions of the part;
these sores, as  far as physical  characters go, we are unable to dis-
tinguish from chancres, to which thev bear a strong resemblance in
situation, size, &c.
  The treatment is the simplest possible : washing the penis several
times in the day with a little goulard-water, and when dried placing
a small strip of lint between the glans  and prepuce, will rapidly
cause these excoriations to heal.  When this  object is gained, the
surgeon, to prevent a repetition  of the annoyance, may recommend
some astringent wash, and  engage  his  patient to  partially uncover
the glands ; by such means, together with strict attention to cleanli-
ness, or washing the  part daily with a little spirit, the abrasions of
the skin will not reoccur, and the patient will be relieved from much
annoyance  and danger in promiscuous  intercourse. 
PART  II.
SYPHILIS.
                         CHAPTER I.

                      PRIMARY SYMPTOMS.

   In the introduction it  has been stated that venereal diseases may
be naturally distinguished into two orders :  to the first of these I have
already sufficiently directed the attention of my readers.  There, how-
ever, remains the second division, no less important, if considered in
relation to the primary symptoms it gives rise to, or to those general
or constitutional results which modern surgeons believe to be a direct
consequence of the primary.
   This second order, the description of which will form the subject of
this part, has been  styled—
   Syphilis.—Syphilis is a virulent affection, the essential character
of which is its dependence upon a special cause, or  a distinct virus.
   The term syphilis is derived, according to Fallopius and Swediaur,
from <">", with, and (ptita, love ;  or, according  to  Bosqnillon, from
<r«p\os, deformed or disgraceful; other authors state  that it is derived
from w, hog, and <P^eiv, to love.
   Modern  authors  have  subdivided  syphilis, as above  defined, into
separate stages, and this  arrangement I shall follow, believing it  the
most natural; and  I, moreover, consider it a plan  fraught  with  the
advantage of placing the symptoms which successively arise in a clear
methodical manner before my readers.
   The first stage includes primary symptoms, or the  immediate effects
of the specific cause, occurring on the spot where the special virus or
virulent matter has  been  deposited.   Example, chancre.
   The second stage embraces secondary symptoms, which follow as a
consequence of absorption of the virus ; these may be hereditary, but 
176
CHANCRE.
are not capable of transmission by inoculation.  Example, various
affections of the skin and mucous membranes.
  The third stage comprehends tertiary symptoms, which are not ca-
pable of being transmitted by inoculation, and are not hereditary, but
manifest themselves by certain pathological alterations of the submu-
cous and subcutaneous tissues, as well as morbid appearances  in the
fibrous and osseous structures.
  We shall, in the present chapter, describe the first  stage, or primary
symptoms, commencing with chancre.
                         SECTION  I.
                           CHANCRE.

  Definition.—Chancre (says  M.  Ricord), or syphilitic ulcer, is a
specific ulceration depending upon a special and identical cause, al-
ways similar in its nature, under whatever form it presents itself, and
derived from an ulcer similar to itself, which it  reproduces  during a
certain period  of its existence, and which, constituting a local disease
at its commencement, gives rise, under  circumstances we can often
appreciate, to symptoms of general poisoning, known by the term sec-
ondary symptoms.
  Anatomical  characters of chancre at its commencement.—The best
means  of studying these characters is to observe them in cases of ar-
tificial chancre produced by inoculation, as we can here examine them
at our leisure.    They are well delineated in Plate IV.
  If the pus be  taken  from a chancre during its  ulcerating period,
and introduced, by means  of a lancet, under the  epidermis of the in-
ner part of the thigh, or any other part of the body, the following re-
sults will be obtained.
  During twenty-four hours succeeding the operation  the inoculated
point becomes red, fig.  1, a; in the course of the  second and third
days the surrounding parts are slightly swollen,  and  assume a papu-
lar appearance, or already traces of a vesicle are  seen on the summit,
fig- 1> °, c > on l^e thi^ or fourth day a fluid, which is more or less
transparent, is observed beneath the epidermis, and a distinct vesicle
becomes apparent, where the papula previously existed, and  a dark
dot is seen in  the centre, owing  to the coagulation of the blood which
had escaped through the puncture of the  lancet, fig. 1, c, d;  from the 
 
*■
?%* A
,f
#
a
2
 
CHANCRE.
177
fourth to the fifth day the vesicle  assumes a pustular character, and
a distinct depression is  seen in the centre, so that it represents very
distinctly at this  period the small-pox pustule, fig. 1, d. e.  The red
areola,  which  has been hitherto gradually augmenting in intensity,
now as  gradually fades away, and the  cellular tissue, which was
slightly oedematous, becomes infiltrated with plastic lymph.   On the
sixth or  seventh day the pustule is observed  to be wrinkled, in con-
sequence of the contents  becoming thicker, and  ultimately a crust
takes the place  of the pustule, fig. l,f,g.   If not interfered with,
this crust assumes a conical appearance, increasing always at its base ;
it ultimately falls of, leaving an ulcer  seated  on a slightly indurated
base, in depth equal to  the thickness of the skin :  the  bottom of the
ulcer is covered with a whitish pulpy  substance or false membrane,
which  adheres  so firmly, that  it is with difficulty wiped or washed
off.  The ulcer is generally circular, and appears  as if made  with a
punch,  fig. 1, h.
   The  margin, if viewed  by means of a microscope, will be found
dentated and covered with a secretion similar to that seen at the bot-
tom  of the  ulcer.  The border is slightly oedematous, or indurated,
and the areola around it of a browner tint than at the previous stages ;
this oedematous condition  of the  border  occasions a slight eversion
of the  edges, and hence the ulcer may assume a somewhat infundi-
buliform appearance.*
   The surgeon, however, must not expect that  the course of every
chancre he  meets with in  practice will be  similar to this artificial
sore.   Observation teaches us that primary sores  may commence in
either of the following  ways.  The matter from an already infected
individual may introduce itself into the follicles which exist in such
numbers on  the glans penis, and  as  the opening  closes, little  ab-
scesses or pustules form, which then go through the stages mention-
ed in  the  preceding paragraph;  and a  good idea of this form of
chancre may be obtained from PI.  IV., fig. 2.
   More  frequently, however, the  matter  comes in contact with an
abraded surface, together with mucus or some secretion which forms
a sort of crust, and then the  chancre is in the same condition as seen
in PI.  IV., fig. \,g;  provided no mucus  be present, the abraded sur-
face does not become dry, but presents the appearance seen in Plate

  * Provided the patient keeps his bed, is in a good state of health, and commits no
excesses of any kind, the course of a chancre produced in the artificial manner above-
described will pass through these regular phases, but under opposite circumstances the
artificial sore may take on any of the varieties hereafter to be mentioned.
                                12 
178
CHANCRE.
IV.jfig.l.g-.  Chancres may commence in any  of these  ways, or  the
matter may be introduced under the epidermis or epithelium, by leech-
bites, punctured wounds, &c. ; they will then  follow the course of
follicular or artificial  chancres.   Lastly, the absorbents may carry
the matter along a lymphatic vessel, cause the ulceration of  it, or of
a lymphatic gland, and thus the chancre appears as a little abscess
in the course of  the vessel, presenting, when the  scale  falls off, the
appearance seen in Plate V., fig.  2.
   If the pus of a chancre, such as we have described it, be  examin-
ed by the microscope, it will be  often found to contain animalcules,
particularly the  vibrio lineola of Muller.   The  experiments of M.
Donne have likewise proved that  it may present either alkaline or
acid properties, circumstances depending upon its situation, &c.
   It varies in consistence, but is  usually of a thin, serous, and san-
guineous character ;  however, the peculiar pathognomonic character
of the pus  is the action which it has on the animal  economy when
inoculated ; for I may here state that no other secretion with which
we are  acquainted, or  which I have  seen employed, will  produce
similar effects.
   This pus will  produce  no such  specific effects on  animals, not-
withstanding all the attempts which M. Ricord and others have made
to inoculate them; hence, as far as  experiments  can prove it, its
effects seem to be confined to the human species.
   Progress of Artificial Chancre.—If the sore be kept clean, it shows
very little tendency to increase, and  may remain a considerable time
in statu quo, provided no excesses are committed ; the disease has a
very mild character, quite at variance  with  those symptoms usually
attributed to it.   Weeks may pass,  and the chancre  not be larger
than a split pea, although  the  areola  may become  somewhat  more
livid.
   The anatomical characters of the ulcerative period are not, however,
always so  simple as we have above described them; in consequence
of circumstances to be mentioned hereafter, the chancre may assume
various appearances,  which are considered by M. Ricord sufficiently
distinct and characteristic to deserve particular attention.
   I shall consider these varieties under the following heads.
   1st Variety,  or  Phagedenic Chancre.—Every chancre  may be
strictly said to be phagedenic, that  is to say, it destroys the tissues
which are in contact with it, but  in  simple, uncomplicated' cases, its
progress soon becomes checked and limited by the infiltration of
lymph which sometimes surrounds it, and which Hunter considered 
CHANCRE.
179
as one of the features of a genuine chancre.   When there is an ab-
sence of this induration, which, when occurring in a slight degree, I
shall call healthy, we may observe the 2d variety of chancre, which
I shall call Diphtheritic Phagedenic Chancre, an example of which is
given in  Plate V., figure 1.*   Its form may be various ; it has a ten-
dency to extend rather in breadth than in depth, in consequence of
the skin  or mucous membrane offering but little resistance to it.   The
surrounding parts are but slightly swollen, or if any swelling be pres-
ent, it has rather  an oedematous or phlegmonous character than the
specific  induration ;  in size  such ulcerations cover a large surface,
and secrete a thin, darkish colored, acrid  pus.
   3d  Variety:  Indurated Chancre.—I  have  not  thought it  neces-
sary to give a drawing of the indurated chancre, a form which Hun-
ter described ; it is rarely met with either in London or Paris.   The
cases which I believe Hunter meant, were chancres as seen in Plate
IV.,  figure 1,  A,'  provided they had an  indurated base  and sides,
or what  I should now describe as  a simple chancre on  an in-
durated base.  This sore and the following is the one  spoken of by
Mr. Carmichael  as giving rise to the scaly venereal disease.
   4th Variety : Indurated  Phagedenic Chancre.—The simple super-
ficial sore will occasionally become indurated to a  considerable ex-
tent, and plastic  lymph be deposited in the cellular tissue around and
beneath it in large quantities.  In these cases the centre  of the in-
duration  is observed to assume a dark appearance, and what M. Ri-
cord calls  an  interstitial  gangrene results, which gains  by degrees
the whole surface ; commencing at the centre, it reaches the circum-
ference,  and then becomes limited;  it seems as if this gangrene re-
sulted in consequence of insufficient nutrition from  compression  ex-
ercised by the induration  upon the vessels.   A good idea  may be
formed of this  chancre from Plate  V., fig. 2.   I  have  lately seen
under Mr. Lawrence's care  at St.  Bartholomew's  hospital  several
cases of this description.   The cicatrix  of a previous sore became
cartilaginous and quite transparent;  in a few days  red streaks were
observed running  through  it; these became  darker until the whole
indurated mass lost its transparency, and assumed the  peculiar char-
acter seen in Plate  V., fig. 2.
   5th Variety :  Gangrenous  Chancre.—In  addition to the form of
phagedenic chancre  last mentioned, the result of excessive  indura-
ration, there is likewise another, the consequence of excessive inflam-

  * This is the form of chancre which Mr. Carmichael considers as giving rise to the
phagedenic venereal disease, and has by him been named acute phagedena. 
180
CHANCRE.
mation, which I shall call gangrenous  chancre.   Violent inflamma-
tion may attack any simple chancre as it does other parts of the body,
and gangrene of the chancre  follows, succeeded  by a  grayish or
blackish slough, which, on falling off, leaves the  surrounding tissues
in an  infiltrated state, but no induration  remains.   The secretion ap-
pears of a very  acrid, irritating character, and consists rather  of
liquid tissues destroyed by the gangrene, than of pus or any secre-
tion from the blood.   (See Plate  V., fig. 3.*)
   Period of Reparation.—Under whichever of the forms  above de-
scribed  chancre may have first appeared, the  reparative process is
ushered in by the appearance of healthy granulations  on the  surface
of the sore, the  margin, which was slightly elevated, becomes on a
level with the ulcerating surface.  The cicatrix extends from the cir-
cumference  toward  the centre ;  finally, the indurated base becomes
absorbed, and a perfect  cicatrization, level with the surrounding skin,
occurs.   When the chancre has existed on the skin or mucous mem-
brane, a slight  cicatrix only will remain  ; but on  parts  where the
cellular tissue is not in  abundance and lax, as on the glans penis, or
neck of the uterus, a depression will often result.   A stain  long re-
mains on the spot where the chancre has existed ;  at first of a livid
hue, it gradually grows  paler, until the  cicatrized point ultimately be-
comes whiter than the surrounding skin.
   The reparative stage, like the ulcerative, has  its varieties.   Thus,
instead  of healing  rapidly, and from the  circumference toward the
centre, various  points on  the surface  begin to  cicatrize, or on  one
side only of  the chancre.   In other cases  the sore cicatrizes, but no
sooner does  this happen than it begins again  to ulcerate, or as the
cicatrix commences  on one side the  ulcer enlarges on the other;
thus we have a chancre lasting an  indefinite length of time.  The
granulations may likewise be slightly or very much raised above the
level of the surface ;  in the latter case  forming the ulcus elevatum of
some  writers.  Such a sore, however, has usually lost  its specific
properties, and the secretion it furnishes is no longer inoculable.  In
some  cases the ulceration in cicatrizing becomes indurated;  instead
of forming a healthy cicatrix, we observe a callous thickening, which,
on the slightest cause, breaks out again into an ulcer of a very un-
healthy character, as occurred in Plate  V., fig.  3.   Lastly, a chancre
will become changed into  what I shall hereafter describe  as a mucous
tubercle.  In this  case, instead of being gradually  covered  by a

  * Different varieties of chancre, and their different positions are shown in Plate IX. 
CHANCRE.
181
healthy cicatrix, there will be observed upon it an hypertrophy of the
tissue, of a softish texture-like  mucus, but lobulated, as represented
in Plate VI.*
   Cause of Chancre.—" Cause," observes M. Andral, in his valuable
Lectures  on General Pathology, " is  a term which, in  the natural
sciences, may be employed in two senses.
   " 1st. It refers to, or represents, a force or  power susceptible in
itself of impressing  a change on  matter;  as matter is inert, every
change which it undergoes  must be the result of a force which phi-
losophers have agreed to call cause.
   " 2d. The word cause is  employed  in  speaking of a fact which
has preceded another fact, and which is  associated with it;  and we
apply the term to the phenomenon, upon the manifestation  of which
another phenomenon depends."
   Barthez calls  this  an  experimental fact, and it is in this sense that
I intend using the word cause in the following pages.
   The cause of chancre I have, in the preceding section, traced to the
secretion of another chancre, for we found that, when introduced under
the epidermis, it constantly produced a peculiar series of phenomena.
   Let us now, then,  see how far observation can enable the surgeon
to study or explain the circumstances which constitute, form part of,
dispose to, prevent, &c, the  action of  this cause.
   In tracing chancre to the secretion of another chancre, the quantity
of which,  although very minute, will  constantly produce its  effects,
M. Ricord was necessarily led to push his investigations further; but
neither  the microscope,  physics, nor chymistry,  have enabled him to
isolate the cause :  all his endeavors have hitherto  failed in  separa-
ting it from the  other component parts of  the secretion of the sore,
and whether it exists as an  entity, or in combination with the globules,
or the fluid part of the pus, or whether  these serve only as a vehicle
for it, we  are unable to say,  nor  do we venture  even an hypothesis
upon the subject, so  few are  our data for forming an opinion.
   We are  equally ignorant of the exact parts of the sore which se-
crete it.   We find it  on  the surface of  the ulcer; washing or wiping
it away only removes it for the moment—it becomes secreted afresh
directly afterward ; but,  as  in the case  of  other secretions, we are in-
  * These varieties in what I call the reparative process have formed the basis of a
division of chancres described by Mr. Evans, and more lately laid stress upon by Mr.
Skey.  This  reparative stage of chancre is, I believe, the  one which, according to
Mr. Carmichael, gives rise to the papular eruption, and hence forms the papular variety:
that gentleman not taking  his divisions from the primary sores, but from the eruptions
which he believes to follow them.  I shall have again occasion to allude to this opinion. 
182
CHANCRE.
capable of discovering the molecular action, but it would seem to be
a vital one, and does not  resemble that peculiar action of leven—a
term applied to it by ancient authors.
  This secretion, removed from the surface of the chancre, and kepi
in close  bottles during seven days, will produce at the end of that
period all its  effects, proving that the vitality of the part is not ne-
cessary for the preservation of its peculiar effects.  Once secreted,
it becomes independent of its source, resembling the virus  of cow-
pock, small-pox, &c.
  Various chymical agents have the property of neutralizing or destroy-
ing it; thus, if the alkalis or acids be mixed with it,  and inoculation
afterward attempted, no effects will follow;  these same substances
will likewise  destroy the  property which inoculation  has invested
the  sore with, of producing an analogous secretion, provided they be
employed at an early stage.
  Simple substances, or ointments, will have no influence either in
destroying or aiding the effects of the secretion.
  We shall then, in accordance with the usual custom of authors,
call this peculiar secretion, which is the cause of chancre, a virus—
not  that we  have been able to show its separate existence, but. simply
because the word secretion is too vague.  We shall combine it with
the  word syphilitic, as this term distinguishes it from all other morbid
agents, and  treat of the cause under the  denomination  of syphilitic
virus.
  Origin of Syphilitic Virus.—We have just traced  syphilitic virus
to the  secretion of a particular sore which secretes it, generated by
the  virus of a  similar ulcer produced in the same way ;  at least we
can affirm, that at the present day there exists no well-authenticated
observation  in the annals of science, which proves the  spontaneous
origin  of syphilis.
  Undoubtedly (observes M. Ricord), we  daily meet with  cases
which it is difficult to  explain ;  but when we  consider the  many
sources of error liable to occur, and that our patients have an inter-
est  to  deceive  us ;  when we reflect that the disease is  contracted
under illicit circumstances, we should remain convinced that the one
exceptional  case in a thousand ought to be attributed to the same cause
as the nine hundred  and ninety-nine, the origin of  which  is regular
and constant;  and as long as it can not be shown that  other agents,
as well as the secretion of a chancre, will produce  syphilis (as  we
understand  the term), we  shall  not  be convinced that it can arise
from the operation of any other agent. 
CHANCRE.                       183
   Allowing that in the present day chancre can not be traced to a
 spontaneous origin, still, say some authors, it is no less certain that
 this affection must have commenced somewhere and on some one.  We
 fully agree in this, and we frankly state, that in the present state of
 science it is impossible to determine where, v/hen,  or  under what
 circumstances, it first appeared ; in this respect, however, the origin
 of the virus is  concealed from us, as is that of many other material
 objects ; but although the origin of a thousand facts be concealed,
 the existence of these facts is incontrovertible.
   If we may be permitted (says M. Ricord) to proceed  by analogy,
 we shall see in the history of the vaccine matter several curious and
 important inductions.  The transmission from the cow to the human
 species has not always been so  well known, yet it must have always
 occurred.  Suppose, then,  that at the present time we were ignorant
 of its origin, it would be no less incontestable that the vaccine matter
 is not of spontaneous origin in the human race, and that it becomes
 developed as a consequence of inoculation, or by means of the spe-
 cific matter taken  from an affected person, and applied to a healthy
 individual. •  Is it not possible that  an analogous source, in the first
 instance foreign to the human species, may have furnished  the  first
 germ of syphilis, which, when  once  engrafted, has propagated and
 maintained  itself, as the vaccine matter, which, like it, was at first
 foreign to the  human species ?   It  is certain that true chancre has
 never  been  seen  on any  animal with which  we are  acquainted,
 despite the researches which surgeons of the present and past ages
 have made ; and it is no less certain that, notwithstanding my experi-
 ments at the venereal hospitals,  1 have been unable to inoculate any
 animal with chancre, so as to produce  its effects ; but who  can say
that we shall  not discover to-morrow what we were unable to find
yesterday, or what we are in search of to-day ?
   Leaving, then, this interesting but speculative  field  of  inquiry, we
turn to the consideration of those accessory circumstances and con-
ditions which are necessary for the  production of the  special effects
of the virus.   These we propose describing under three  heads.
   1st.  Necessary conditions  of  the chancre from which the virus is
taken.                   /
  2d. The means and conditions of the agents of transmission.
  3d. The necessary conditions of the  parts about to be contami-
nated.
  Necessary conditions of the chancre from which  the virus is taken.—
In  the  first  place,  it must itself have been derived from  another 
184
CHANCRE.
 chancre, which must be at the period we have called specific or pro-
 gressive, for we have  already remarked that it  is  during  this first
 period of the existence of the  chancre that the peculiar virus is se-
 creted.   Provided the chancre  be thus derived, and  presents the
 ulcerating  stage, notwithstanding  the length of  time it has existed,
 be the physical characters well marked, the shape  circular or oval,
 the situation on the  genital organs, arms, mouth, &c, still  the virus
 will produce its effects if the other conditions be present.
  We have just stated  a general  law, namely, that certain condi-
 tions of the sore, from which the virus is taken, are  indispensable to
 the production of chancre.  Yet to this law there are apparent ex-
 ceptions ;—a  man has  connexion  with a prostitute, and  chancres
 appear on the penis ; the  external and internal genital organs of  the
 girl are examined, and no chancre is found.  Here is the virus act-
 ing, and yet, say some people, it does not come  from an  ulceration
 Such cases in practice are not uncommon, but they in no  respect in-
 validate our position, for there is every probability that the virus has
 been  recently deposited  from an ulcer of a third individual on the
 vagina, which being  covered with mucus prevents its local action on
 that membrane, and  thus  the vagina  merely serves  as a vehicle for
 the virus, as any one of the means we are about to speak of.
  The means and conditions of the agents of transmission.—The fact
 that the virus is capable of being separated during a space  of seven
 days, from  the ulcer which has produced it, without losing  its con-
tagious  properties, has  been already mentioned; at the end of that
period, if still in a liquid state, or, if dried, provided  it be only moist-
 ened, the virus may be transmitted in  a variety of  ways, of which
we may enumerate some of the most frequent.
  Lancets or other cutting instruments may accidentally become soil-
ed with the virus, and thus the surgeon  may unconsciously inoculate
 an incised  wound.   We have been witness  of a case of this kind:
venesection was ordered and performed in the usual way ;  a few days
after, the patient drew the attention of M. Ricord to the point in the
arm, which assumed  all the characters of chancre, and was  very dif-
ficult  to cure, as induration followed.  Such a case shows the neces-
 sity of great caution in the employment of instruments which may
have been soiled with the  virus.
  The Penis may serve as an agent of  transmission of  the  virus, as
 in cases like the following : A young  man  had connexion with a
 prostitute ;  in the course of the same day he had connexion with a
 female who previously had been free from disease ; in a short time 
CHANCRE.
185
chancres appeared  on the second female, although the young man
never presented any symptoms whatever  of syphilis.  Here, then,
the penis was  a simple agent of transmission, as the lancet was in
the last case.
   The vagina  may become a  means of transmission of the virus ;
this frequently happens in prostitutes.  An individual suffering under
chancres has connexion with a girl; a quantity of virus is left in the
vagina, but produces  no action, as the mucous membrane is covered
with a secretion.   Should  a  second individual have connexion with
this female under these  circumstances, the virus may affect him, and
no local disease be  discovered  on  her genital organs, even after the
most  minute examination.  Such  cases are not unfrequent.  Here
the penis has performed the part of a sponge, and completely cleaned
the vagina, which was simply a passive agent of transmission.
   Various  secretions have been often  accused of causing or trans-
mitting  the  virus.    The semen is spoken of  as among the most
frequent.  That this  may occur  is  undoubted;  when a  urethral
chancre exists, the semen may, in passing over it, carry along the
virus which is  placed on the surface ; in a similar manner  the milk
may become a vehicle for it, provided a chancre exists on the nipple.
The saliva  may become charged  with the virus, if a primary sore
exists on the mouth, of which we shall hereafter give instances.
   At  the  present  day  we are little  disposed to give  credence to
stories of chancre  transmitted by means  of the  breath; and in the
nineteenth century a minister of the crown is not likely to be  accused
of communicating  the affection to his royal master by means  of
whispers.   We now-a-days attribute  a chancre rather to the company
a man keeps than to the air he breathes.
   Various articles have the character of transmitting chancre ; thus,
Mr. Colles believes that in Ireland  the inmates of a cottage have
become infected by the use of the sole spoon that a  peasant family
possesses.
   M.  Cullerier mentions that at the venereal hospital  chancres may
be transmitted from one individual to another  by means of  tobacco-
pipes, drinking-glasses, &c.   The  employment of chamber-pots, and
sitting on water-closets, have  been successively invoked to explain
various difficult cases.  Believing  that such means of  transmission
are possible, we maintain that they are not probable, and the  medical
man should be very cautious  how he admits them : patients will  be
always disposed to conceal the true source  of disease, if illicit prac-
tices have been indulged in ;  and in affections of the mouth it is very 
186                        CHANCRE.
difficult to distinguish primary syphilitic sores from various aphthous
ulcerations which are epidemic, and run through whole families, in
consequence  of similarity of  diet,  clothing, low,  unhealthy situ-
ations, &c.
  Sheets have been believed capable of  transmitting the virus;
patients affected with  simple eruptions on  the  skin have  slept in
sheets on which the secretion of chancres has fallen, and the simple
sores have  been converted into characteristic chancres.   I witnessed
a case where this was  possible, in a patient of M. Puche, who pre-
sented chancres on  the penis ; he stated that he was taken up in
consequence of the riots of May,  and put in a prison  where prosti-
tutes had been previously kept; about two months afterward chancres
appeared on  the penis.  Now here we might suppose that this was
the  source of the affection ; but when we state  that the prisons of
Paris are the scenes of unnatural crimes, we should  rather conclude
this to be the source  of the sores, and not the sheets.
  Hildanus has given rather an odd story of a young lady affected
with chancres, who could in no way account for their origin ;  she at
length remembered  having disguised herself in  man's  apparel, some
short time previously, and danced the whole  night at a public masked
ball; it was then found that  a young man,  who was at the  time suf-
fering under chancre,  had worn the trousers previously, and  conse-
quently it was believed that  the  said pair  of pantaloons had trans-
mitted the  disease.  In  such cases, when  the  medical man  has to
decide  about  a young woman, a masked ball, and  a  pair  of soiled
inexpressibles, with  a youth in the distance, we may  excuse him if
he  is  lenient to  the fair  sex.   Various articles  used in dressing
wounds  may accidentally become the  means  of  transmitting the
virus,  particularly sponges, lint,  &c.   During  the  last winter,  M.
Ricord removed a portion of  diseased bone from the orbit in a patient
laboring under tertiary symptoms ;  the  wound  took  on a peculiar
appearance some few days afterward, and inoculation of the secretion
at once showed that  this wound had, through the intermedium of lint,
or the water, or sponge (it was  impossible to  say  which), become
inoculated  with virus from another source, for the patient himself
presented no  primary affection ; in this  case the  instruments could
not have been the source, as  they were new, and  had not been pre-
viously used.
   This case should  put  the  surgeon on his guard; and in venereal
hospitals the greatest attention should be paid  to cleanliness ;  this, 
CHANCRE.
187
 however, is not always possible, in consequence of the habitual care-
 lessness of the attendants.                 .
   The  necessary conditions of the parts about to be contaminated.—
 For the production of  artificial chancre on the skin, we  have already
 stated that it is necessary to introduce the virus beneath the epidermis,
 and we may add that an abrasion of that  structure  is always neces-
 sary for the  action of  the virus.  In  practice, we find  that  chancre
 follows  abrasions,  excoriations,  fissures,   incisions,  leech-bites,
 wounds, scratches, &c.; hence  results that variety in shape which
 the sore may assume ;  around the  rectum we observe  those ragged
 fissures which have no analogy with  the  circular chancre described
 by Hunter.  We  have  lately seen a chancre on the thumb of an
 individual, having the  shape of an ordinary small incised wound ; he
 stated, that in following his occupation as a tanner, he cut his hand ;
 he slept soon afterward with  a prostitute ; the cut surface  became
 inflamed, and he was unable to cure it with the usual remedy, namely,
 bathing the hand  in the tan-pits.  He  left the hospital cured of the
 chancre by the usual treatment.
   The  previous considerations will at once explain why the animal
 economy is more  liable to chancre at one  period of life than another;
 thus the delicate  skin of the infant, as well  as its greater vitality,
 render infection (ceteris paribus) more probable than at any other
 period of  life; on the  contrary, the dry and shrivelled condition of
 the  tegumentary covering at the  decline of life,  causes  chancres to
 be comparatively  rare.   We find, moreover, that absorption  is slug-
 gish, and the chances  of exposure to  the virus  are  less than at the
 age of puberty, when  the passions of youth and a forgetfulness of
 consequences lead to such frequent exposure.
   We may mention the influence of sex as a  predisposing cause.
 The female exposes herself less  than the male, consequently is less
 frequently the subject of syphilis  ; but when, as in the case of pros-
 titutes, she exposes herself to contagion, we nevertheless do  not find
 chancre so frequent; this depends  upon the structure of the female
 genital organs, which are not so liable to abrasions as the male.   In
 Paris, the frequency of the fleurs blanches may be mentioned as a
 cause of this species of exemption, as it  shields the parts from the
 action of the virus.
   For the  production  of  chancre on mucous membranes,  the same
principle holds good;  there must be  a lesion of continuity of the
 epithelium, otherwise  the  virus will  have no effect.  There is au
apparent exception to this law, but closer observation shows that it is 
188
CHANCRE.
 not a  real one.   The virus  may  insinuate itself into a mucous or
 sebaceous follicle,  and having destroyed  its  lining by a species of
 irritation, comes in contact with the  cellular tissue, and  then  a pus-
 tule or abscess is formed.   When  situated in a little mucous follicle,
 the virus may remain inactive some  days in consequence of the cyst,
 as the virus is in the same  condition as when  enclosed in bottles;
 the cyst being destroyed, the virus acts directly.   This was probably
 the case in  the instance of  Mr. H.,*  and explains some cases  of
 supposed incubation.
  * On  the 24th of September, A. H., a young surgeon, twenty-five years of age, had
 connexion for the last time with a woman of the town. He observed at the time that
 she suffered under a discharge.  Immediately after connexion he washed himself care-
 fully with cold water. Suspicious of the consequences, he paid great attention to clean-
 liness, and took care to wash and examine the penis daily.
  On the 6th of October—that is, twelve days after connexion—while in a warm bath,
 he observed two small but suspicions spots on the glans penis.  In the course of the
 same day he asked the opinion of a young  medical friend, but on examining the glans
 no trace of them was apparent; he took a long walk, and in the  evening a small swel-
 ling appeared in the right groin.
  On the morning of the 7th he  observed these spots again very apparent, and employed
 some sulphate of zinc as a local application.
  On the 8th they assumed a vesicular character.
  ■October 9th.  Mr. H.  consulted  me  to-day; on  the  glans  penis  there are two
 ulcerated points, which  present all  the character of follicular chancres delineated in
 plate IV., fig. 2, with this difference, that they have been ruptured. In accordance with
 my views  of syphilis, I felt called  upon to cauterize them with a pointed pencil of
 nitrate of silver, and ordered the part to be constantly washed with lint soaked in aro-
 matic wine.
  On the. 10th, a superficial sore appeared  near the fraenum, which was cauterized, as
 well as the sores on the  glans penis ; the glands in the groin remain stationary.
  October 11th. During the course of the last night, a superficial sore appeared on the
lining of the prepuce, which I cauterized  this morning, thus making four sores at
 present  existing.  Nitrate of silver was applied freely to the  other three, and the aro-
matic wine and lint ordered.  There is no inflammation present; of course the nitrate
of silver has somewhat increased the ulcerating surfaces.
  October  12th.  The caustic was again applied.
  13th.  The sores are going on so well that Mr. H. would not submit to  a further appli-
cation of the caustic, and took a very long walk.   To continue the aromatic wine.
  15th.  The  two sores on the  glans penis  are completely healed.  The ulceration on
the prepuce is becoming somewhat indurated, but is  nearly healed.   The sore on the
franum  discharges considerably.
  17th.  All the sores are now completely healed;  induration of that one  on the prepuce
 and some redness alone remaining to show where the disease has existed.  As I thought
 a continuance of the aromatic wine and lint could serve only as an irritant, I desired
the patient to leave them off.
  18th.   The induration and hardness of the prepuce remain,  accompanied with some
redness.  I therefore requested M. Ricord to look at it.  He, however, would not give
 an opinion, as he was uncertain if the induration depended upon a specific disease, or
 npon irritation, the consequence of cauterization: he, however, leaned to the latter
 opinion, from the antecedent history of the case",  &c.; he recommended that the aro-
 matic wine be continued, and to watch the result. 
CHANCRE.
189
   In our  investigations we have not met with a single case which
would  seem to  contradict the  general law we  have  attempted to
establish,  namely, that  abrasion of the epithelium or  epidermis is
necessary for the  action of the  virus ;  some  authors differ in this
opinion, considering that  simple contact  of  the  skin  and virus is
alone sufficient for the  development  of a chancre.  In these  last
cases, the virus might  probably  act as  an irritant or escharotic, and
destroy the surface ; the virus would  then  come in contact with  the
cellular tissue, and such cases, far from  contradicting, prove the prop-
osition  we have above  laid  down.  There are other cases which,
interpreted in  a different  manner, might lead to the supposition that
syphilis may be introduced into the system without any abrasion of
surface.   Chancre  may heal in  a few days,  as we have elsewhere
stated; the  virus  may introduce  itself into a  follicle or point of the
skin, and the follicle may become  closed,  or  the point  by which it
was introduced perfectly heal in a short time j  in none of these cases
abrasion of surface will be apparent, yet chancre will become devel-
oped,  giving  rise  to the  opinion  that  lesion of continuity  is  not
necessary.
   We think we may  with advantage here inquire, if there are any per-

  23d.  The indurated point  has been slightly ulcerating the last few days, and now
presents  an excoriated surface; on the  glans  there is likewise an excoriated point,
which is distinct from the situation of the former chancres.  M. Ricord saw Mr. H, and
at once declared the sores to be specific.   They were of a secondary nature, he believed,
and would not inoculate or reproduce the disease.  Ordered to wash with the aromatic
wine, apply an ointment of calomel and opium, friction with a drachm of blue  oint-
ment, and bathe on alternate days.  A mild diet was ordered.
  24th.  During the last twenty-four hours, the point which had completely healed at
the fraenum has again broken out; the  surface is excoriated; there is a point of the
same nature on the prepuce. M. Ricord's bandage and an emplastrum vigo on the
bubo. Continue the treatment.
  2'5th. The indurated sore on the prepuce has not increased in size, and is nearly dry,
being covered with a yellowish crust; that at the fraenum is in the same state as yester-
day. The fresh ulceration on the prepuce bleeds on uncovering the glans, which was
very painful yesterday; the pain was much alleviated by soaking the penis in water;
the aromatic wine causes great pain.  Continue the treatment, and observe a horizontal
position, was my prescription to-day.
  P. S. The bandage remains well on, and is not tiresome.  The frictions have occa-
sioned an eczematous eruption on each thigh where the ointment has been applied.
  November 4th. The sore  on the prepuce has now completely cicatrized; the treat-
ment has been  carefully followed; but Mr. H. is a determined smoker; in  other
respects he has committed no excess.
  7th. The induration of the sore still remains, though it is much diminished in extent;
there is a slight mercurial foetor of the breath, and a somewhat red state of the gums.
M. Ricord saw the patient to-day,  and  desired  friction every third day, taking  care
against cold.
  This patient left soon after for England. 
190
CHANCRE.
sons non-susceptible of chancre ?  If we choose to depend  upon the
word of some authors, as well as some men of the world, there exist
certain privileged beings who are not susceptible of syphilis.
  It is  a fact,  founded on experience, that  some few persons pass
through life without contracting  chancre, although they have exposed
themselves to contagion.   Such persons do not present the accessory
conditions we have just spoken of;  thus the virus did not  remain
long enough on the epidermis  to  destroy it  and act on the cellular
tissue below.   If it be the case of a female, the vagina was proba-
bly coated with thick mucus,  which  prevented the  contact of the
virus, or it was  inflamed ;  and experience shows that an inflamed and
secreting surface will take  on  with  difficulty the specific action of
chancre ; the same  occurs  on  a blistered surface, the secretion ap-
pears to wash  .the virus away.  If, then, any part covered  with a
perfectly healthy and compact  epidermis  be exposed  to contagion,
we are not surprised at seeing no effects result;  this fact also proves
the correctness of our opinion.   But we can  not agree with those
who believe that there are individuals who resist the action of chan-
cre ; we are certain that we  can  produce a genuine chancre on any
individual who. will submit to inoculation : the privileged few will then
find that they  have previously escaped  contagion from one  of the
circumstances above mentioned.
   When  the virus  is taken from a sore under conditions before de-
scribed,'and transmitted by means of any of the  agents mentioned,
and lastly, brought in contact with the tissues in certain conditions,
the effects will be regular and constant, and the point of the skin with
which the virus comes in  contact will be the seat of the chancre ;
its  development will, moreover, as seen in Plate IV., fig. 1, a, b, c,
begin  immediately, so that no incubation can be  said to occur.  In
practice, however, cases happen which apparently contradict  these
statements, and which are believed by some  persons to prove the ex-
istence of incubation.  Patients sometimes  state  that a chancre has
only existed a  week, and  yet they have not exposed themselves to
contagion for a month previously.   Here the patient makes a wrong
statement, although without any intention of deceiving the surgeon ; for
on closer examination it will be often found that he has, from inadvert-
ence or other cause, never examined the affected  part since the time of
exposure to contagion and the period that pain or some other symptom
first called his attention to the chancre, which he observed a week
 ago ; in such a case, it would be correct to  say  that he observed the
 chancre a week ago, but not that it has only existed for that period. 
CHANCRE.
191
How often have we not been called to treat bubo, or even secondary
symptoms, when  interrogating the patient  he affirms he  has  never
had  primary sores; yet, on uncovering the  glans, we have shown
him  sores which he had never observed, and was not cognizant of,
inasmuch as they had given rise to no inconvenience 1
   There  are, however, other cases which are brought  forward to
prove, and which at first sight seem to indicate, incubation; the case
of Mr. H. is a good instance.   Persons expose themselves to conta-
gion ; they wash carefully the parts exposed ;  they examine day by
day to see if chancres are produced ; when several days have elapsed,
they observe certain suspicious-looking pimples ;  here, however, we
may naturally suppose that the virus has entered,  during coition, the
mucous or sebaceous  follicles, and lies inert, until, by the irritation
it  produces,  destruction of the lining membrane  takes place ;  it is
then  placed under  conditions most  favorable for its development.
That this is not mere  supposition,  the case of Mr. H. proves ;  most
probably this always occurs in urethral chancre, as experience shows
that  a secretion from the canal rarely occurs before the fifteenth day,
and this fact has been dwelt upon by M. Puche, who wishes to form
a diagnosis by this means between gonorrhoea, the  consequence of
simple inflammation,  and urethral  chancre.   We shall again  have
occasion to mention and discuss these points.   Such cases as we
have  described, if they do not explain our views,  at least must  tend
to shake confidence in the supposed theory of incubation.
   Is  there more than one cause of chancre ?   We have, in the prece-
ding sections, spoken of one  cause  alone, and we have studied the
conditions  necessary for the  action of that cause ; we have spoken
of it as constant in its effects when placed  under  the necessary con-
ditions for its development;  thus  far we have seen no  reason for
supposing that there exists  a second or third virus.  Authors  have
not always been of this opinion, and persons  have counted as  many
as five viruses; they have founded this  opinion upon the number of
primitive sores, or secondary eruptions ; however,  few men of the
present day admit more than one,  which may, according to circum-
stances we are  about  to mention, give rise to any of the variety of
primary sores we have  spoken of under the head of the anatomical
characters of chancre.
   To the consideration of the causes of the varieties we beg now to
call the attention of our readers.
   Causes of the Varieties of Chancre.—On examining fig. 4,  a, b,
plate IV., the reader will observe what surgeons are otherwise  well 
192
CHANCRE
aware of, namely, that chancres on the same individual usually present
similar  physical characters :  thus, an  indurated  and a phagedenic
sore are not met with on the same  patient: but if several  chancres
exist, they are usually simple, indurated, phagedenic, &c.  Inocula-
tion of a great many sores  proves, likewise, that chancre will  gener-
ally assume the same characters on the same individual—we  say
usually, for when the situation of a sore  causes it to put on a peculiar
aspect, of course the inoculated point on the thigh, not influenced by
similar  causes, will not exactly  resemble the sore whence  it was
derived.   The  knowledge  of this  fact, viz., that  all sores have  a
tendency to take on the same characters in the same persons, is of
use, inasmuch as it should  deter  practitioners  from employing inocu-
lation in gangrenous or  phagedenic sores ; an evil which  we have
dwelt upon elsewhere,* and the non-observance  of which we con-
sider liable to bring inoculation into disrepute.f
  Scruples which can  not be too much  admired, have prevented
M.  Ricord from inoculating one  person with the secretion  of a sore
from another; we have  been thus unable, by direct experiment, to
show  that an indurated sore will not  produce its  fellow, or that  a
phagedenic  sore will not cause a phagedenic ulcer on another con-
stitution ; but although we have been unable to  solve this question by
direct experiment,  observation has satisfactorily shown that  the char-
acters of sores do  not depend upon the source from which  the virus
is derived.   Need we cite  the celebrated case, detailed by  Dr. Fer-
gusson,  of several English officers who  were attacked eaoh  by a
variety of  sore, contracted by connexion  with the same female,  a
Portuguese opera-dancer ?   We are acquainted with three  students
who had connexion with the same grisette during one evening ;  one
was affected with a phagedenic sore;  the other  was a long  time
recovering from an indurated chancre ; the third had a simple exco-
riation, which was slighter than that which we witnessed on the  genital
organs of the female, whom  we examined a few days after the  debauch.
  If the source of the varieties does  not  exist in the nature of the
chancre from which it was  derived, as the preceding cases and thou-
sands of others clearly  prove, we must look for them  elsewhere.
Our belief is,  that no one cause  can be assigned for the varieties;
chancre, like other diseases, may be modified by a variety of circum-

  * See Lancet, vol. 1,  1839-MO, pages 354, 533, &c.
  t Since the above was written,  I have had occasion to witness the deplorable effects
which injudicious inoculation may produce.  Phagedena of the thigh has succeeded to
a most fearful extent in one case,  and the life of the patient was despaired  of. 
 
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CHANCRE.
193
stances;  thus, climate, constitution, age, plethora, debility,  bad air,
insufficient clothing, &c, are so many causes which will tend to pro-
duce the  varieties of chancre.
  An attentive examination of the varieties of chancre has enabled
us to enumerate  some of the  causes which appear to give rise to
them ;  thus, bad food, insufficient clothing, intemperate habits, expo-
sure to cold, local stimulating  applications, are a few  of the causes
which make a simple chancre take on the diptheritic character.
  Young plethoric persons, who use  great  exertion, or who are
addicted  to the abuse of spirituous liquors, at the same  time that they
expose themselves to vicissitudes of  the  weather,  or who  change
suddenly their diet or climate—such, we say, run a great risk of the
chancre assuming that variety which we have called gangrenous pha*
gedenic.
  Scrofulous individuals, or old men who have led a dissipated life,
or men subject to the diseases of  hot climates, persons with skin dis-
eases, and constitutional  complaints, whose health has been ruined
by several courses of mercury, as well as those whose chancres have
been treated injudiciously, will be found to present the serpiginous
variety of chancre.
  Lastly, we arrive at the indurated variety.   Here the cause  is  by
no means clear, yet it is the one which we are most interested in dis-
covering.  The indurated chancre may appear in a variety of con-
stitutions.  The one delineated in plate  V., fig. 2, occurred on the
penis of  a young man of a clear, transparent complexion, of short
stature, but who could not be  said to present very evident marks of
scrofula.   In the case of Mr.  H., detailed at page 188, the constitu-
tion was  good, though somewhat lymphatic,  and  he was subject to
hypochondriasis.
  Sex seems to have some  influence; it is most common in males,
yet we have seen various cases in women.
  Situation  apparently interferes  but little,  as chancre may, in any
situation, take  on this character,  although  an ulcer  situated  on the
prepuce is most frequently indurated.
  We have been unable to connect induration with  any peculiar  mode
of local  treatment;  we have  seen persons affected with the  most
obstinate forms of indurated chancre, who had not been treated either
locally or generally ;  on the other hand, the most simple and judicious
local management of a  sore,  immediately after its  commencement,
has not  always prevented  the  occurrence of this character, which
deserves  so much attention from the practitioner, as  it  betokens a
                               13 
194
CHANCRE.
peculiar liability to secondary symptoms ;  the  relation between the
two we can only observe, and not account  for ;  it is one of those
primitive facts  (as M.  Andral calls  them),  the solution  of  which
science, as it at present exists, does not permit us to a tempt, and of
which a more or less probable hypothesis  can  only remove the diffi-
culty one step farther back.
   The  Diagnosis of Chancre.—In describing artificial chancre, con-
sidered in  reference to its  chymical,  physical,  and  microscopical
characters, as well as the local effects produced on the  economy
when the secretion is introduced into the system,  we have given the
diagnosis of chancre.  But it may not  be  uninteresting to consider
practically the subject, and allude to such cases  as present difficulties.
A case  is presented to our observation at its  origin; that is to say,
we are  consulted for a  pustule, a small abscess,  or an  excoriation,
such as seen in plate IV., figs.  1 and 2.  How  is a correct diagnosis
to be  formed  in this  case ?   A  rational  diagnosis  may  often be
founded on  the appearance,  situation,  history, and  course of  this
stage of chancre, but only a rational one.  The value  to be attached
to each circumstance we shall consider in detail.
   1st.  The Appearance.—It  is a fact which no one who has  seen
much of venereal disease can  contest, that a primary sore presents
characters which are very striking, and there  are many surgeons who
rely principally upon them in forming an opinion on the nature of a
sore.   M. Velpeau has assured me that he lays great  stress upon it.
This opinion will  be corroborated  on referring to plate  IV., figs. 1
and 3,  with its accompanying description.  But  though a primary
syphilitic sore has generally a peculiar physiognomy, still it is incon-
testable that other sores, not of a specific nature, may assume all the
aspect of real chancres.   If,  for instance, a piece  of corrosive  subli-
mate be placed between the  glans  and the prepuce, a sore, in every
physical character  resembling chancre, -will  follow; hence we con-
clude, that the appearance of the chancre is only of relative value in
the diagnosis.
   In further illustration of the difficulty which  attends the diagnosis,
when a surgeon judges  of the nature  of  a sore from its  appearance,
I may mention that many of the most  eminent men in our profession,
both in England and France, differ in opinion upon the diagnosis of
the disease represented in plate IV., fig. 2.  Several of those to whom
I  have submitted it, say, " Your diagnostic  sign  of inoculation  was
unnecessary ;  we  should have judged  it syphilitic from its appear-
ance."   I  have met with many  who have stated the contrary, and 
CHANCRE.
195
ridiculed the* notion of chancres existing on the leg.   " These sores
are chronic ones, such as you may see in my hospital any day," said
a learned surgeon, lately, when I showed him the original drawings.
  If, however, a primitive sore usually assumes the characters above-
mentioned, it is no less certain that in some few instances it presents
no peculiar features, yet it is no  less a chancre.   Thus, then, the
mere  presence  or absence of  certain  appearances can not  alone
enable us to decide upon its nature.
  2.  The Situation.—As  inoculation  has proved that chancres may
occur on any part of the skin or mucous membrane, the mere situ-
ation  of  a sore  will in no way assist  our diagnosis, unless as urging
us to  examine  more  carefully those parts  which are most likely to
conceal them from our view, such  as the deep portions of the vagina,
uterus, urethra, rectum, mouth, &c.
  3.  The History of the  Sore.—If there is any one circumstance
which has led, or leads surgeons frequently to form a false diagnosis,
it is the history.  Thus, supposing that a patient avows that he  has
exposed  himself to infection, and  a sore follows, the simple fact of
exposure only gives presumptive evidence that a sore is syphilitic,
inasmuch as this sore may have been produced by simple irritation,
or by abrasion.   It is not sufficient to know that connexion has pre-
ceded, but it is likewise  necessary that a reasonable  time only has
elapsed  between the act  of  coition  and the real, not the reputed
appearance of the sore.  We  are  well  aware that the  space of time
before a chancre  appears may be considerable, as occurred in the
case of Mr. H----.   (See  note,  page 188.)  Here,  probably, the
pus introduced  itself into a sebaceous follicle, and only came into
action when it had destroyed the epithelium, and thus  acted directly
on  the cellular tissue.  But  allowing the possibility of  this fact,
which is rendered probable by the experiments of M.  Ricord, we
must  not give  credence  to all such statements, or  suppose that
chancre  has  appeared six weeks after  connexion;  for we find,  on
interrogating the patient, that through  inattention  or some  other
cause, he has not examined whether,  during  the interval which  has
elapsed between the  last coition  and the  period at which he first
observed the chancre, a sore existed or not; and  it will often  be
found  that a chancre, of a supposed week's duration,  has in fact
existed a  month.  What surgeon is not well aware that patients
complain of buboes or other symptoms, and  deny ever  having had
primary sores ?—yet, on uncovering the glans, he shows  the patient
a chancre, of the existence of which  the latter was ignorant. 
196
CHANCRE.
   The history, then,  like the  situation, aspect, §c, is, alone, insuffi-
cient to found a diagnosis on ; but if it is deceitful when the patient
is  desirous of telling the truth, how often may the surgeon be misled
when the patient, has reason for concealing  his antecedents.  In the
female it is next to impossible ever to attain the truth.   The irritation
of the menses, or some other  cause, is alleged to explain the ulcer-
ations about the genital organs.  We have mentioned elsewhere* the
case of a female who suffered under  ulcerations around the rectum,
yet at first strenuously denied that they could possibly be syphilitic;
although, at last, she was obliged to admit the fact.   We might cite
numerous cases to prove that an absplute reliance can not be placed
on the history of patients.
   4. Various Complications.—It is certain that buboes occurring with
sores are prima facie evidence  of  their being  syphilitic.   But we
should recollect that any simple irritation  in scrofulous habits will
give rise to them, and perhaps such buboes  are more difficult to treat
than any others.   Similar observations  may  be made on other com-
plications.  In fine, we may state,  that  these circumstances, when
present, can only furnish a rational diagnosis.
   5. The Course.—It is very true that chancre  frequently has little
tendency to  heal,  but on the contrary, gradually progresses; these
are, however, characters not peculiar to chancres.   There are various
sores, which, in scrofulous and  scorbutic  constitutions, spread and
heal very slowly.   On  the  other hand,  some true  syphilitic  sores
heal in  twenty-four  hours ; but it is  no less certain,  that although
such exist, they are of rare occurrence.
   When these characters are  absent, it by no means follows that the
sores are not syphilitic, and  it is from the  ensemble, and the greater
or less probability,  that our  diagnosis  (a rational  one) must be
formed.
   The Absolute Diagnosis.—In obscure cases, and when it is abso-
lutely necessary to decide upon the nature of  a sore, more especially
in medico-legal inquiries,  evidence  such as we  have mentioned
would be  insufficient.   There remains, then,  inoculation, which,
although one of  its  greatest advocates, I  would not  unnecessarily
employ ;  it  will,  however, at once  decide  upon  the  nature  of  a
sore.  Here, neither ignorance  nor  deception  on the  part of the
patient, nor  want of experience or  observation and deduction on
the  surgeon's part, will interfere  with  the conclusion.   The  accu-
racy of  the  test,  the  certainty  of  arriving at  the truth, and  the
                     * Lancet, Nov., 1839, page 354.
                                 4 
CHANCRE.
197
 reputation of the surgeon, will  counterbalance all objections  to  the
 operation.*
    Diagnosis of  the  Reparative  Stage  of  Chancre.—The surgeon is
 not only called upon to give an opinion  during the ulcerative  stage,
 but he may  be consulted  at  a later period, when the  sore is healing,
 or when induration  alone remains ;  or  lastly, when  all  traces have

   "The following cases, taken from a paper  I read before the Parisian  Medical
 Society, show the utility of inoculation:—
   "In the bed of No. 10, in the second ward of the venereal hospital, lies a patient,
 thirty-two years of age, a shoemaker by trade, of fair complexion.  He states that from
 the age of thirteen till his  eighteenth year, he was liable to ulcers on various parts of
 his body, the cicatrices of which are still visible; from the last-mentioned period he has
 enjoyed good health.  About fifteen months since  a bubo appeared, which suppurated
 and healed in about six weeks.
   " About five weeks ago  the  patient observed a chancre on the prepuce, four days
 after connexion;  soon afterward several chancres  appeared around the corona glandis,
 and he consulted M. Ricord as  an  out-patient.  During the time he was following the
 treatment prescribed, a vesicular eruption made its appearance on the inner part of the
 left leg, which  he distinctly remembers having scratched, and from that moment, the
 sores began, and increased  in size.
   " Present state—Chancres still exist on the penis, which discharge freely; on the
 inner part of the left leg there  are twelve ulcerations of different sizes, but assuming
 all the characters of  primitive syphilitic sores.  Inoculation with the pus of these sores
 was made, and the characteristic pustule was produced.  See plate IV., fig. 3 a.
   " This, then, instead of being a case of secondary syphilis, which was inoculable, is
 simply  an eczema which was  inoculated by the  nails of the patient,  soiled with the
 secretion of the primitive sore on the penis.
   " On the 27th of February, 1838, a man presented himself at the out-patient room,
 complaining of chancre at  the root of the  penis, and accidentally, as it were, showed
 M. Ricord a sore on the frenum of the tongue.  The characters of it were sufficient at
 once  to arouse some suspicion as  to its nature, and this patient was immediately
 admitted.  Inoculation of the secretion on the  sore in the mouth was made, and a
 characteristic pustule followed.   All doubt was now removed,  and the avowal of the
 man additionally proved that this was a primitive syphilitic ulceration.
   " A boy,  fifteen years of age, of puny stature, lymphatic temperament, and  not,
 apparently,  arrived at the age of  puberty, so slightly were the organs of generation
 developed,  entered the seventh ward,  suffering under an ulceration of a suspicious
 character, in the left  groin.  He gave the following account of himself:—
/  "Had never had connexion with any females,  or frequented their  society; about
 three weeks previously the  sore appeared  on the groin, but it could not be ascertained
 if it commenced as a bubo or a sore.
   "As  this sore  presented all the  character of chancre, except  as  to  its history,
 inoculation  of the secretion was performed,  and a well-marked characteristic pustule
 followed.  On  these data the boy was interrogated more  closely, and M. Ricord then
 found that he  was in the habit of sleeping  with a fellow-workman who presented
 chancres on the penis, which had existed some weeks.  Both parties denied any unnatural
 practices; and whether the virus dropping on the sheets inoculated the scratch previously
 existing, or  whether  a scrofulous bubo preceded, which was caught by contact of the
 contagious  principle, it is not here my object to inquire ; but I cite this  case, to prove
 that without inoculation the case  would  have remained very obscure."—Lancet, 1.
 c. pp. 354, 533. 
198
CHANCRE.
passed away.  In the  first and  last cases it can be of little conse-
quence to ascertain  the  nature  of  the  affection ;  if it should  be,
particular caution must be used, and a rational diagnosis is still more
difficult than in the first stage.   Called upon to  give an opinion when
induration alone remains, the surgeon whose eye and touch are accus-
tomed to  syphilitic induration, will  rarely fail to decide upon the
specific and peculiar cartilaginous feel, particularly when seated in
loose cellular tissue, as  on the prepuce ; in other situations it will be
very difficult to decide upon it, particularly when placed in the deeper
portions of the canal, &c.   But we shall  return again  to this  subject.
In these last instances  we must wait patiently for the results, for, if
the induration be specific, secoridary symptoms will inevitably appear
in a short time, and thus clear up any doubt.
   Prognosis of Chancre.—In  the definition of  chancre,  we  have
stated that  at its  commencement it is a local disease, and that it
gives rise, under circumstances we can  often appreciate, to symptoms
of general infection.   We  shall,  then, in the following pages, con-
sider the prognosis under two heads :—
   I. The prognosis of chancre as a local disease.
   II. The prognosis  considered in reference to the probability of
general and constitutional infection or secondary symptoms occurring.
   I. Prognosis of Chancre  as a local disease.—In describing simple
or artificial chancre, we have mentioned  that in a good  constitution
it has a regular and constant course ; beginning as a pustule, abscess,
or excoriation,  it becomes  an ulcer;  granulations  are produced;
cicatrization  follows,  and it heals perfectly, without  treatment, in a
space of time which varies between three and five weeks;  therefore
we may unhesitatingly state that  the prognosis of simple chancre is
favorable.
   In a practical treatise, however,  it is not  sufficient to state  this;
the surgeon should consider the  prognosis  under a variety of points
of view, for in practice he is daily called upon to decide on the prog-
nosis of this or that form of chancre.  It is to facilitate this  often
difficult task that we propose devoting  the following  pages, founded
on the strict  observation of  a number of cases.
   What probability is there  of a chancre, which is simple at its com-
mencement, assuming one of the varieties which  we have  described?—■
On this subject the surgeon can  only be  guided by a knowledge of
those circumstances which seem to dispose to their production, viz. :
If the patient has been exposed to bad or insufficient nourishment, has
resided in an unhealthy situation,  or  has  led a dissipated life, it is 
CHANCRE.
199
probable that the chancre will assume a diptheritic phagedenic char-
acter.  If the digestive organs be disordered,  or  provided irritating
substances are, or have been, applied locally, particularly in  scrofu-
lous subjects,  a serpiginous sore will possibly result.
  Should the  chancre occur in young plethoric persons addicted to
excesses of any kind, particularly to the use of spiritous liquors, at
the  same time  that  they employ much the part affected, we may
anticipate the  occurrence of the gangrenous phagedenic sore.
  Lastly, as  to  the  probability of  a  sore  assuming an  indurated
appearance, we must  acknowledge our ignorance, for, although we
have witnessed  it in persons of lax  fibre, or in others of clear com-
plexion, still we  can give no indications, as hitherto we have been
unable to associate it with any one temperament or constitution.
  What will be the probable duration of the chancre ?—Simple chancre,
when left alohe, usually heals in a space of time varying from three
to five weeks; when  properly treated, perfect  cicatrization may be
obtained in from eight to ten days ;  there are, however, circum-
stances which have  great influence  in retarding the  cure—among
others we  may mention the  situation;  thus  a chancre situated on
the  fraenum, or  margin of  the prepuce, when a natural  phymosis
exists, will  be prevented from healing by the rupture of the cicatrix
when erection occurs.  Chancres in  the urethra, bathed as they con-
stantly are by the urine, or when  situated  at the margin of the anus,
or within it, will be so irritated by the distension of the gut, during
the   passing of  faeces, that  cicatrization will  be  often   unusually
retarded.   Other instances might be  given to show that the situation
of simple chancre must influence  the prognosis.
  The size of simple chancre must necessarily  modify our  prognosis,
as to its  duration ; for a large surface generally requires a longer
time to cicatrize than a small  one ; yet large  ulcerations sometimes
heal as quickly as small.
  The  number  of chancres might  be  supposed  to influence  the
prognosis, yet practice  teaches the  contrary.   Patients  presenting
several chancres are  as  speedily cured as those who have but  one
sore :  cicatrization going on with equal rapidity in all.
  The  duration of a  diptheritic  chancre can  never  be foretold, yet
we  may be guided, in some respects, by the state of the constitution,
for, in proportion as it improves, we observe the sore to  present a
more favorable aspect.
  When we are called upon to give an opinion on the probable dura-
tion of a Serpiginous Sore, we can not be too guarded ; it is true that, 
200
CHANCRE.
by rest and  proper treatment, many such sores will speedily assume
a healthy appearance; but  others resist, and require years to cure,
and, when on the point of cicatrizing, again resume all their former
virulence.
  In respect to the gangrenous phagedenic chancre, we may be  more
confident,  as, by judicious treatment, the gangrene may be confined
to the  parts  it  has already attacked, and  a speedy  cicatrization be
expected.
  Lastly,  the  indurated sore will, if  left to nature,  remain in statu
quo, or, if it cicatrizes,  a cartilaginous nodule will remain, unless
general and local treatment be employed,  and even then it will dis-
appear very gradually.
   What probability is there of any of the affections termed complications
occurring ?  Did we enter  on this subject, we should  only  repeat
what we  stated  when  treating  of the  complications ; we  therefore
refer  our  readers to that section.  In  diptheritic chancre, we should
remember that haemorrhage is often to be dreaded, as well as fistulae,
their  situation  depending upon the tissues  and parts  affected.  In
gangrenous  chancre a large and  rapid loss of parts is always to be
apprehended;  but although deformity results, it is not so great as the
state  of the sor"e would lead the surgeon at  first to suppose.
  In  respect to  complications, the serpiginous and indurated  sores
present nothing  remarkable.
   What renders the occurrence of successive accidents* probable ?
—" Successive  accidents," says M.  Ricord, in  his  Treatise on
Inoculation, " are  a consequence of the  extension  of the  disease
(de proche en proche), or  a simple extension  of the primitive local
symptom, as, for instance, the  production of new chancres, simple or
virulent abscesses, virulent or simple  adenitis, &c.
   Is  a bubo likely to follow?  This is a  question  which the patient
suffering from a chancre  often asks.    Without entering, however, at
length, into a discussion of all the causes which occasion the develop-

  * By successive accidents, we mean such affections as are only a gradual continuation
of the same disease, for instance, the production of new chancres, the development of
sympathetic buboes or abscesses, from extension of inflammation ; and the occurrence
of symptomatic buboes produced by the transport of the syphilitic virus.
  Whenever, then, the secretion of a chancre is retained in contact with the tissues
which secrete it, or comes in contact with such portions of the body as are  susceptible
of inoculation, we have reason to dread the formation of successive chancres; hence,
chancres of the anus, of the prepuce where a natural phymosis exists, or of the four-
chette in the female, often produce successive accidents.  Besides, whenever a solution
of continuity in the neighborhood of a chancre exists,, subsequent 6ores are probable,
from contact with the virulent secretion. 
CHANCRE.
201
ment of buboes, we shall here mention such as refer particularly to
chancre.  The mere existence of a simple chancre does not neces-
sarily  cause bubo ; in  the female, for instance, bubo  is  rare.   We
have  never seen  artificial chancres on the thigh, of the male  or
female, followed by them.  But if chancres  on particular parts  are
seldom followed by buboes, there are likewise other situations which
exercise the greatest influence on their formation : it  will be found
that in every one hundred men suffering under  bubo, at least eighty
have presented chancres around  the  fraenum or inferior part of  the
glans  or prepuce.   When bubo  occurs in the  female, the chancre
will be found most probably at or around the meatus.   This fact, of the
situation of the chancre and  occurrence of bubo, may be reasonably
explained by the connexion which exists between the  part primarily
affected and the gland, by means of a lymphatic vessel which carries
the virus directly to it.  And it also proves that the theory of exclu-
sive venous absorption is  not tenable : but it  seems in accordance
with the doctrine of imbibition.
   In answer to  our patient, we must  be  guided principally by  the
situation, not the size or the variety of the  chancre; but we shall re-
turn to this  subject under the head of bubo.
   The  fact of the tendency which buboes have to follow chancres
situated on the fraenum, further shows the  surgeon  how cautious he
should be in attributing  buboes to this or that treatment; in  all  such
calculations, we should take  into  consideration the position of  the
sore.
   We may here add, that bubo rarely follows any of the varieties of
chancres, unless they be situated in one of these particular spots.*
   Does the  treatment alter the prognosis ?   In the preceding pages
this question has been already answered :  but to resume.  A simple
uncomplicated  chancre  will  heal  without treatment  in about from
three to five weeks, when properly treated  in eight or  ten days—the
varieties, by judicious management, in longer or shorter periods,  de-
pending upon the causes which give rise to them.
   Is the chancre or sore contagious ?  To this the medical man should
answer peremptorily, yes or  no.  By allowing connexion, let  the
practitioner remember he is an accomplice, be  it through ignorance
of the consequences, or  out of deference to his  patient.   Let him re-
member that a sore which is  about to heal, or which has just cicatri-
zed, is very liable, under the slightest  irritation, to  inflame, ulcerate,
and present any or all the varieties above described: thus, the patient
                    * See Ricord's edition of Hunter. 
202                         CHANCRE.
may by ignorance or imprudence lose the organ.   On the other hand,
who will state that a sore which is not perfectly cicatrized is incapa-
ble of transmitting the infection 1   It should not be forgotten  that it is
impossible to say how little virus is sufficient to infect an individual;
the edge of a sore which is still unhealed may contain the quantum,
and such a permission of the  surgeon may lead to the greatest afflic-
tions in more than one family, and the innocent child may suffer  for
its parents' credulity, or from  the  surgeon's  ignorance  of  the laws
which regulate the secretion of the virus*
   II. Prognosis considered in reference to the probability of general
and constitutional infection, or secondary  symptoms.
   It  is not our intention here to trespass upon the interesting subject
of secondary symptoms, as we shall hereafter treat  of them  at great
length;  but there are some considerations which so directly relate to
chancre and its prognosis, that we shall  here consider them.
   If it be  an  undoubted  fact that secondary symptoms are a direct
consequence of chancre, it is  no less certain that  they do not in every
case ensue.  The following facts, drawn from observation, may per-
haps assist the practitioner in giving an opinion on the greater or less
probability of their occurrence.
   1. Stage of the Sore.—When  the  chancre has proceeded  beyond
the vesicular  form seen on the third day, we can never guaranty an
absolute  indemnity  from secondary syphilis  ; the symptoms may  ap-
pear during the ulcerative or  reparative  stages, provided these  are
retarded by any circumstance.
   2. Duration of the  Chancre.—As  secondary symptoms  are  the
consequence  of chancre,  it  might be reasonably supposed that  the
longer it lasts, the more subject is the individual to their occurrence.

  * The importance of the great discretion which it is necessary for the surgeon  to
show, has been lately impressed upon me by the following case : An old  fellow-pupil
of mine at St. Bartholomew's hospital, now established in a distant part of  the country,
treated a young man for  some venereal affection and secondary symptoms ; when he
was nearly well, this patient asked the sanction of my friend to a marriage which he
was about to contract.  The penis was free from disease, as my friend believed, no sore
being apparent, though a few blotches remained on the trunk.  On such authority the
marriage was solemnized, and in a few months the disease broke out again in  both
parties, and presented the well-marked coppery blotches.  On interrogating my friend,
he assured me of the correctness of  the statements of both parties, and their honorable
 conduct; but in the conversation he accidentally alluded to a stricture of  a very  obsti-
 nate nature which his patient had previous to marriage. The views of M. Ricord  on
 the existence of chancres in the urethra were unknown to him, and he agreed with me
 in the possibility of such an occurrence, and no longer admitted that secondary symptoms
 were transmissible, which opinion this isolated case had induced him to believe, con-
 trary to his views. 
CHANCRE.
203
This, absolutely speaking, is true, and is a reason for locally destroy-
ing the virus, which is a constant secreting focus ; but the practitioner
will be wrong to suppose that secondary symptoms only follow chancres
which have existed a long time.   Experience proves that they follow
a chancre which has  healed without treatment, in a few days;  and
we have witnessed cases of chancres which have  existed eighteen
months  and two years, without producing these consequences.
   3. The Number and Size.—The preceding observations apply equally
to these circumstances ; it is not on such data as these that we can
alone found our appreciation of the prognosis.
   4.  Situation of Chancres.—Chancres on any part of the body, viz.,
on the mouth,  finger, penis, or anus,  &c, will be followed in an equal
proportion by secondary symptoms.
   If, however, secondary importance can only be placed on the stage,
duration, size,  number, and situation of primary sores in forming an
opinion on the probable occurrence of general infection, the same does
not hold good in reference to the varieties.  Daily experience teaches
us that the serpiginous and gangrenous sore is rarely followed by con-
stitutional  symptoms ; the  phagedenic diptheritic occasionally gives
rise to them ;  the  indurated almost  always.  It is well known  that
Hunter was so imbued with this opinion, that he denied a sore to be
syphilitic, unless it presented an indurated base.  M. Ricord lays so
much stress upon it, that when a patient enters  his wards, presenting
an indurated chancre  of six weeks' duration, and when no secondary
symptoms  have  yet  appeared,  he  puts him  on  a " traitement ex-
pectant," and few days pass before the occurrence of the well-known
characteristic symptoms of general infection.  M. Ricord  never al-
lows  a patient  to leave his hospital when  the slightest  induration
even of the cicatrix exists ; should  he, in spite of admonition, quit,
he is told that secondary symptoms will result, and the prediction is
found to be too true.
   Let us now inquire how far the complications can assist  our prog-
nosis in reference to  the occurrence of  secondary symptoms.   We
may  erase  from the  list,  gonorrhoea, paraphymosis, and  phymosis,
as they can have little direct influence in disposing to constitutional
syphilis.
   The  circumstance  of the existence of bubo  demands a separate
consideration.    A-priori reasoning  would lead to  the supposition,
that when  a bubo co-exists, there would be  a greater probability of
constitutional  syphilis following, than when chancre alone appears.
Experience on a large scale, however, contradicts  such an opinion; 
204
CHANCRE.
bubo, as we shall  hereafter find,  is but an internal chancre, and by
no means proves that the virus has entered the system;  and we do
not find  that  absorption takes place more rapidly from this chancre
in the gland than from an open chancre.  This circumstance, more-
over, seems to prove that the venous system plays an important  part
in occasioning the general infection.
  Lastly, we  shall speak of the local treatment of chancre, in as far
as it may  lead to the  probability of the  occurrence of secondary
symptoms.
  In the first  place, let us again repeat that secondary symptoms
will follow  when no treatment  is employed;  they may (though in a
far less proportion) succeed the most judicious local treatment.   On
the other hand, secondary symptoms may  not occur, although  the
chancre be allowed to proceed without treatment.
  Secondary  symptoms  do not necessarily follow, although the local
treatment of the chancre has been injudicious.
  In respect to general treatment, the same  observations hold good.
Secondary  symptoms do not necessarily follow when general treat-
ment has been neglected.  The best and longest-continued plan of
general treatment will not, in all cases, insure your  patient against
their occurrence.
  These facts at once show the absurdity of some persons' reasoning,
who attribute  to  the effect of treatment what in fact  is  only the
natural course of the  disease ; it is from want of acquaintance  with
the natural history of the complaint, that unjust blame or injudicious
encomiums are heaped upon so many therapeutic agents.
  Preventive  Treatment.—The legislature of France, finding venereal
affections very common  and very severe, in  1498 and the following
years, proposed  means  of  checking them, by confining those  that
were diseased in a species of  prison or hospital  in the  faubourg
St. Germain and  at Bicetre, flogging them very severely before and
after incarceration.   We find, however that these coercive measures
were soon relaxed, and the law became a dead letter, inasmuch as its  v
execution was, generally speaking, impossible ; secondly, the  per-
sons affected  with the disease were  too highly connected, and the
disease, notwithstanding the punishment, had increased,  and become
aggravated to such an  extent,  owing to  the concealment of the
primary  symptoms,  and the  impossibility  of receiving so many
patients, that  it was ultimately given up;  and who that calmly  con-
siders the subject can be surprised, or would propose such a punish-
meat, or cause  the infraction of the  liberty of the subject at the 
CHANCRE.
205
 present day ?  Our modern legislators  have, I think, fallen into the
 opposite error.   They imagine that the odium tacitly attached to the
 disease  by society, will  suffice to  deter  persons  from  exposing
 themselves to contagion, and that government ought not to interfere
 or take any steps to check it, as it would be encouraging vice, appa-
 rently forgetting  that neither religion, nor the laws, nor a knowledge
 of the consequences, will deter men from  exposing themselves to
 syphilis.   Is the medical man to remain a silent spectator of the
 ravages of the disease, as some sensible but short-sighted individuals
 are inclined to wish him to do, because any success which  attends
 the  precautions  he recommends will tend to act as a premium upon
 dissipation ?  Were  it proved that  this apathy of the surgeon  was
 attended with a  moral effect on the  community, the question might
 bear a different complexion ; but daily experience and the history of
 the past prove the contrary.
   Let no one accuse the medical practitioner of immorality, if, in the
 discharge of the  duties of his profession, he  can suggest any preven-
 tive means against a disease which  is frightful in  itself and  in its
 consequences ; for the surgeon  well  knows  that immunity from dis-
 ease  does  not any more lead a libertine to continue his dissipated
 habits, than do successive  syphilitic  diseases check those  propen-
 sities.  On the other hand, a first fault may, by the non-observauce
 of those precautions,  render  a  whole family miserable, and  entail
 disease which it may be impossible to cure.
   Guided by these principles, which we trust will not be misinter-
 preted, we   shall  now consider if there be any means of prevention
 of chancre.
  Is it possible to prevent the occurrence of chancre ?   If  chancres do
 not arise spontaneously, and we trust we have convinced our readers
 that at least at the present day they do not, then we think we  are
 justified  in stating that we can protect an individual from them ;  but
 if it be possible, what means  can we recommend for this purpose 1
 In other words, what is the prophylactic treatment of chancre ?
  Syphilis   at the present  day  is widely diffused ;  although  it no
longer presents the dreadful appearance that it did in the last  centu-
ries, still it exists, and is liable again to break out with redoubled
violence, if the  circumstances which favor  its  development  occur.
It becomes, then,  the legislature to put a check to it as far as it lies
in its power ;  and we are of those who think it possible that it might
be effectually destroyed, although we feel convinced that this will not 
206                        CHANCRE.

occur, as the disease  must be better and more generally understood
before such a universal extinction can take place.
   The  French, more than any nation,  are  advancing  in  the  way
which is most likely to eradicate it.   Who has not read the work of
Parent Duchatelet 1*  Who is not aware that this  distinguished  phy-
sician and philanthropist has, during a long life, done more perhaps
than any other  individual to check syphilis ?   He has given us the
natural history of prostitutes ;  he  has pointed out the means of legis-
lating for these unhappy creatures,  who  form, in fact, the focus of
chancre ;  and until  means  be taken in other countries to  subject this
class to some sort of  control, it will  be in vain for us to hope  for a
diminution of the evil;  not that we pretend to say that even in
France  all  has been done which  might or should  be  attempted,
although we do not  mean here  to  criticise French treatment.   Did
other countries follow in their steps, Europe would  have cause to
rejoice.  As general  prophylactic means, the institution  of hospitals
and  dispensaries for the gratuitous treatment of these complaints, is
of the highest importance ;  and M. Ricord thinks it would not be  use-
less  to  make the following preservative, means  known wherever  a
man exposes himself  to contagion ; he has likewise suggested that  a
capable person be attached to each brothel, so that both males and
females who expose themselves might be examined.   This measure,
by no means impracticable, would tend greatly to diminish the fre-
quency of the disease.  These are a few of the general prophylactic
means which would  tend  to the  object  a community has  in view.
We  shall not stop here to examine the feasibility or legality of them,
as these subjects have so fully been discussed by Parent  Duchatelet,
but proceed to speak of the
  Direct Prophylactic Treatment of Individuals.—The surgeon  may
be consulted under two circumstances :  1st, by a female or prostitute
who runs the risk of  communicating the  disease.   In this  case an
examination  of the  external  organs  is  not alone  sufficient; the
employment of  the speculum is of the greatest aid  in discovering the
existence of internal  disease.
  The practitioner should likewise recommend frequent ablution, as,
without producing the disease, the  virus may be contained  in the
vagina,  but not  act in  consequence of a layer of mucus; hence the
recommendation  of  the  use  of   injections  after connexion.  " If
women," says M. Ricord, " were only more attentive  to  cleanliness,
  * See his book, " Prostitution in Paris," translated from the French—Otis, Broaders,
& Co., publishers, Boston. 
CHANCRE.
207
and took more care of themselves, venereal complaints would be less
common."
  If consulted in the case of a person who is afraid of transmitting
the disease, or when connexion is dangerous  on account of a sup-
posed infection, the chlorine washes, soaps, and the other means of
more  effectually cleansing,  disinfecting,  or  chymically acting upon
the morbid secretions, ought to be employed; the more the parts are
rendered clean, the less we have to dread infection.
  The  preceding observations relate particularly to those women of
the town who are constantly exposing themselves to the virus.
  2d. The  surgeon may  be consulted by a person  who wishes to
know what precautions he should take if  he exposes himself to con-
tagion.   From  the previous  description of the accessory conditions
of the tissues which are  necessary to the action of the virus, the
reader may  at once infer the necessary general prophylactic means •
however, there are several points which deserve a separate  consider-
ation.   Thus, frequent washing the parts liable to be exposed to the
virus, with astringent substances, will, as it were, tan the parts, and
be a powerful means of  prevention of the disease.  But if  this plan
be  advisable, the  use of alkaline or chlorine washes  immediately
previous to  connexion is very prejudicial, as removing any mucus or
smegma which might serve as a defence against actual contact of the
virus ;  a person  should carefully examine  and  guard against  any
abrasion, and, if any such exist, connexion should not  take  place.
The observance of the  few preceding recommendations would pre-
vent, we are sure, a multitude of diseases.
   " There is," says M.  Ricord, " a means, which the final cause of
all sexual intercourse rejects, which morality has always blamed, but
which necessity and certain circumstances may occasionally tolerate
—:I mean the condom."
  The  condom, which  permits only mediate sexual  intercourse, is
frequently, as Astruc has so well remarked, only an illusive guarantee ;
it is sometimes torn ;  in other cases, the substance of which it is made
is  pervious; or,  again,  in consequence  of  having been previously
used  and not properly  washed, it  may be  contaminated;  lastly,
though it be made of  good materials, and remain perfect, it only pro-
tects those parts which it directly covers ; the  root of the penis, the
angle of the scrotum, as well as the groin, remain exposed.  In con-
clusion, the condom, even under the  most  favorable  circumstances,
can only guarantee an individual from contracting a gonorrhoea.
   Coition should not be prolonged, and ejaculation should take place, 
208                        CHANCRE.
as this will frequently prevent the  occurrence of urethral  chancre,
the sperm acting as a cleanser of the canal.   Some persons believe
that infection is more likely to  occur after ejaculation ;  this we see
no reason at all for believing.
  After coition, the greatest  care  should be  taken in washing the
exposed parts ; for this purpose, alkaline and weak chlorine solutions
are preferable, as they have the property of cleansing and decompo-
sing any contagious matter, without producing local irritation.   Any
abrasion or lesion of continuity should  be immediately cauterized;
and  it is useless to hesitate or attempt a diagnosis between the con-
sequences of friction and that of the virus :  it is better to cauterize
unnecessarily than to expose the patient  to the chances of infection.
  Curative Treatment.—In spite of these precautionary measures,
or in consequence of no attention being paid to them, a chancre may
become developed in a follicle, an  ulceration or abrasion of the sur-
face may appear, or an abscess or pustule follow.
  1. When a pustule is formed,  or when a  mucous or sebaceous
follicle is observed through the skin, filled with  pus, as may be well
seen in Plate IV., fig. 2, it should be opened, and a stick of nitrate
of silver, cut to a fine point, introduced  and passed around the little
ulcerated base and sides ; we prefer this to the plan of excision with
scissors, which may be  employed  when the pustule is seated on the
prepuce ; but as patients do not like a surgeon to employ instruments,
and as we have  more reliance on  the nitrate of silver than on ex-
cision, we recommend its general  adoption.
  2. In cases  of abrasions  or  ulcerations, the  stick of nitrate  of
silver should be passed slightly over the surface, our object being to
destroy only the surface.   From ignorance of the reasons of employ-
ing the caustic, we have seen the local irritation increased, and con-
siderable escars form from the profuse employment of this substance,
a plan that can not be too much condemned.
  In the first instances,  it is very often  unnecessary to reapply the
caustic ; usually, however, the parts should be cauterized as often as
the eschars fall  off,  and  the ulcerated  surface  does  not put on a
healthy, granulating appearance ;  when this commences, the granula-
ting portions of the sore should be  left to themselves ;  but whenever
the surgeon suspects that the sore, or any part of it, secretes the
virus, he should continue the application  of the nitrate of silver.
  It is, however,  not only necessary to destroy the virus which
is secreted, as  well  as the parts  which give  origin to it, but the
practitioner  should  endeavor to  check  as  much as  possible  its 
CHANCRE.
209
secretion;  this  is  best done  by  employing  the  aromatic wine,*
which experience shows to  have  that property, as well as the no
less  advantageous  one of hardening the  surrounding tissues,  thus
preventing them becoming inoculated, and  increasing the size of the
sore.   Let the  patient wash the sore four or five times during the
day with this wine  ; a small  piece of lint  soaked in  it may be laid
upon the sore, and the whole may be covered  with a piece of oiled
silk ;  thus the lint is kept constantly moist;  it will be found well to
wet again the parts before removing the lint, as it might become ad-
herent, and cause the sore to bleed if detached with any violence.
   The patient must keep quiet, but it  is  by no means necessary to
maintain the  horizontal posture, or be confined to his bed; his diet
should be light, but nutritious.
   When perfect cicatrization has been obtained, and no local disease
remains, the  patient may be allowed to resume his usual occupations,
and sexual intercourse may be permitted.
   Under this treatment, simple, uncomplicated chancre will be cured
in a very short space of time, and may be considered as a purely local
disease, requiring no general  treatment, and followed by no secondary
symptoms.    Let us, however,  now turn the attention of our readers
to the  treatment of the varieties of chancre above spoken of under the
term of anatomical  characters.
   1st. Treatment of Phagedenic Diptheritic Chancre.—As this variety
of chancre  depends  upon certain peculiarities  of constitution,  or
general causes,  such as bad  living, low unwholesome situations, and
frequently a disordered state of the digestive organs, the first duty of
the surgeon should be to remove them, and he will place the patient
in the best condition for recovery.   A good nutritious diet, and change
from the close confined air of a damp house,  to the  well-ventilated
ward  of an hospital, have been often sufficient to change the aspect
of very unhealthy sores.  We  have frequently seen a warm bed and
a  stimulating purgative, or an astringent wash, cause, in a few days,
the most aggravated forms of the complaint to take on an improved
appearance ;  sores  which were locally irritated by stimulating prep-
arations have, under the influence of  opiates, become  quite  healthy ;
the same sores,  previously treated by mercury, have become healthy
when  that substance has been left off: hence we can lay down no
general law; we must attempt to discover the cause of the variety,

  * This is a preparation of the French pharmacopoeia, composed of species aromatica
?iv., vinum rubrum lb. ij., alcoolatum vulni rarium ?ij.  As a less expensive wash I
use Decot. Querc. ^viij. Tinct. Catech. ?ss.
                                14 
210                        CHANCRE.
and remove it if possible ;  this being done, the greatest benefit may
be derived from employing lint dipped  in  a concentrated aqueous
solution of opium, which should be  kept constantly applied on the
sore, covered by oiled silk ; the sore should not be dressed too often,
as it is liable to irritate it:  this form of dressing must be  continued
for some time, and absolute quietude  should be  enjoined ; the diet
should be nutritious, and wine or beer may be allowed if the patient's
general health does not counter-indicate them, or if he be in the habit
of drinking to excess.  The use of opium at bed-time may  be  attend-
ed with the best results, when there is  a good deal of local or general
irritability.
   Constipation or diarrhoea should be  treated on general principles,
and tonics may be given with advantage.   The  use of ointments of
all kinds will be  usually found prejudicial, more especially as these
sores secrete a great quantity of pus  ;  and the greasy substances
rarely come in  contact with the diseased surface.   When,  under the
treatment recommended above, the chancre is getting better, the
aromatic wine may be employed, and any superabundant granulations
should be cauterized, and the edges of the ulcer, if very  thin, or if
undermined,  may be excised  with  instruments,  or  destroyed by
caustics ; but it will always be advisable to wait until all  inflamma-
tion has subsided before this is attempted.  The use of local  bleed-
ino- we have  not seen followed  by good effects,  although it  might, in
some cases, be found beneficial, as well as general depletion:  such
cases we believe to be rare.
   2d.  The gangrenous phagedenic sore, the result of acute inflamma-
tion  which has terminated in gangrene, can seldom be checked at
once, occurring as it does  in young persons addicted to  drinking;
here, bleeding, either local or  general,  is  exceedingly prejudicial:
in the early stages these means are very useful in checking the prog-
ress of the inflammation ;  but when the  gangrene  has  commenced,
and  the parts  are struck with  death,  it is useless to suppose that
bleeding will restore vitality, or will check the ravages of the disease.
Instead, then, of venesection, let your  patient keep his bed, attend to
the state of the bowels, let his diet be  of the mildest kind, and let lint
dipped in the aqueous solution of opium  be constantly applied to the
gangrenous part;  cooling drinks may be given, particularly lemonade.
The  gangrene will, in spite of this treatment, destroy the parts which
are most acutely inflamed, but it will not extend further ; consequent-
ly, during the few following days,' a serous  looking  ichorous dis-/
 charge of a very  offensive  smell comes away, mixed with the detritus 
CHANCRE.
211
of the tissues ;  this gradually diminishes in quantity until it subsides
altogether, and the surgeon is surprised at seeing but a slight deformi-
ty result, comparatively to the severity of the disease ; a simple sore
follows, which should  be treated in the usual  manner, and the sur-
rounding oedema which occasionally remains may be advantageously
combated by compression with strips of adhesive plaster.
   If, in this or the preceding sores, any fistulous openings follow in
consequence of the disease extending any depth, care should be taken
that the escape of fluid  be favored by position, otherwise, if it stag-
nate,  it  may considerably aggravate the disease ; it will be,  there-
fore, well to employ  a  small syringe to cleanse the part.
   3d. The Serpiginous Variety of Chancre.—We have already spoken
of several indications which should incline the surgeon to prefer this
or that local  treatment; in this variety, however, we  are obliged to
admit,  that we can give hardly any rules.   Having observed  every
possible  treatment employed that the experience of M. Ricord has
suggested, we have seen cases continue in statu quo, and, after months
have elapsed, get  well by the unaided  powers of nature.  On  the
contrary, we have seen cases get well under a line of treatment
which a month previously aggravated the disease, and yet  the  sore
apparently presented the same characters.   Such being the  case, the
surgeon should be careful how he  attributes the cure of this variety
to any local or general application; let him not be too  sanguine ;  we
have been witnesses of cases like the following, under the influence
of some simple or complicated  treatment;  a serpiginous chancre is
rapidly getting well, when, without any assignable cause, the granula-
tions disappear in  a few hours ; the cicatrix, which was nearly per-
fect, is destroyed ;  and the sore recovers its original size, or even
augments, then returns to its  chronic state,  and defies  all means of
treatment, when we are suddenly surprised at the  promising  aspect
it  assumes, which, perhaps, is  only deceptive.  Notwithstanding, it
must be allowed that  few sores present this character ; usually, if
the state of the bowels be attended to, if the diet be changed, if the
local treatment be  guided by general indications, a cure may often be
attained ;  thus, cauterization may be attempted, or general stimulants
be employed, provided  the sore assumes  a  chronic form; should the
serpiginous character seem to depend upon the stimulating local treat-
ment, an opposite one may be often tried with advantage.  We have
lately seen such sores benefited by employing compression with straps
of the  emplastrum vigo, not  in all  its stages, but when granulations
appear; but if this  practice has  succeeded  in  some cases,  it has 
 212                 /      CHANCRE.

 signally  failed in others, particularly when  no granulations  e^xist.
 Among other  treatment, the sore has been  sprinkled  with starch, a
 layer of  tallow has been laid upon it, as it was supposed that the
 action of the air had an  injurious effect upon it;  but if successful in
 some cases, in others it  has only aggravated the  disease.
   In hospital  practice it is impossible to recommend change  of air,
but we  feel convinced  that a better diet, in a warmer climate, to-
gether with tonics and  sea-bathing,  by  improving  the  health  gene-
rally, would be more advantageous than any local treatment we could
prescribe.
   4th. The Indurated Variety of Chancre.—Unacquainted with the
causes which  give rise to indurated chancre, we are unable  to prevent
its occurrence, or to avoid  those circumstances which predispose to,
or keep it up: but, as we stated under the head of  Prognosis, it is a
very unfavorable circumstance, and one  which we should attempt to
remove as speedily and  effectually as possible.  In the first place, it
predisposes to molecular gangrene,  giving  rise to the  variety  of
chancre so well drawn in Plate IV., fig.  6, which extends  in propor-
tion to the quantity of induration.   In the second place, it is of very
serious consequence, as showing  that  the system is  already, or is
about to  be, constitutionally affected.   Experience has enabled M.
Ricord to state, that secondary symptoms will follow indurated chancre
in eighty-six out of every hundred cases.
   We have hitherto spoken of  chancre  as a local  disease, and have
not recommended any peculiar general  treatment, further than such
as was necessary for improving the general  health, or treating any
peculiar  symptom ;  we  shall now, however, speak of the general
treatment, which we shall show to be as advantageous,  in this variety,
as we  think it to be prejudicial in the last.
   Local Treatment of Simple Indurated Chancre.—If, in spite of cauter-
ization and the employment of aromatic wine, a chancre becomes in-
durated, the first means  should  be laid aside ;  or if consulted for an
indurated chancre, fcauterization should not be attempted, as the very
fact of the occurrence of the induration shows that the disease is no
longer the simple local affection above spoken of.  If we even destroy
the local disease, we have every probability of a constitutional infec-
tion ;  cauterization is, therefore, not  only  useless, but we run  the
risk of being  accused of causing secondary symptoms by our treat-
ment.
   When, however, induration follows the cauterization of a chancre,
 and did not exist previously, the surgeon should  not too hastily sup- 
CHANCRE.
213
pose that the induration  is of the  specific nature above spoken of,
inasmuch as cauterization will, in some constitutions, give rise to it.
An experienced eye or finger will, however, usually distinguish  one
from the other, and  a few days' quietude will prove whether it depend
upon syphilis or not, as the real  induration as  gradually increases as
the false one diminishes.  (See  Case, note p.  188.)
   If the indurated chancre suppurate freely, it may be washed several
times a day with the aromatic  wine : this is not unfrequently attended
with some pain, which soon, however, passes  away ; the sore should
then be wiped dry,  and a piece of lint, spread  with an ointment com-
posed of
                         Calomel, gr. xxiv.
                         Pulv. opii, |j.
                         Adipis suis scrofae |j.
This  should  be changed twice a  day, and  the  sore  may  then be
washed with the aromatic wine ; care should be taken in removing
the dressing,  otherwise bleeding is likely to occur from the wound.
   Under this treatment the chancre will usually heal;  but as the in-
 duration  remains,  the sore is very liable to break out  again on the
 slightest cause,  and assume the phagedenic form we shall presently
 speak  of.  At other times perfect  cicatrization takes place, but a
 cartilaginous  nodule is left, which remains in statu quo,  or, increasing
 in size,  ruptures the cicatrix and gives  rise to an unhealthy ulcer,
 which is not inoculable, but is most intractable.
    Indurated chancre, then, will heal  without any general treatment.
 The empjpymenfof mercury is not absolutely necessary, but, if not
 had  recourse to, we run the  risk of a simple indurated chancre as-
 suming a phagedenic appearance.  M. Ricord, at page 234 of his Re-
 searches (Doane's translation), states, " If, like the physiological school,
 we date the cure of a chancre from the period  at which the ulcer is
 cicatrized, without regarding the consequences, the cure will appa-
 rently be more rapid under simple treatment:  and in hospitals the
 patients are  less  time  under treatment.  But  if^ in order to call a
 patient cured, we  wait  until  all  hardness has disappeared,  we shall
 find an enormous difference in favor of a mercurial treatment.
    " The induration remains in the  first case  a long  time, even up to
 the period of the appearance of the secondary symptoms, which are
 of such frequent  occurrence.   For  myself," continues M. Ricord,
 « while I allow that other remedies, besides mercury, possess curative
 properties ; yet, as one of the most powerful  and the most sure, I
 have recourse to a mercurial treatment whenever a certain degree of 
214                       CHANCRE.

induration accompanies a chancre, prevents its cicatrization, or remains
after its superficial healing, and more especially when by its excess
it gives rise to phagedena."
  When it has been decided, then, that mercury snould be used, a no
less important question arises, as to the preparation, the dose, the
period required for saturating the system, the indications  for leaving
it off, &c.   There  is no  subject on which so much difference of
opinion exists, perhaps, as on this.   In the following pages we shall
be guided by what we have seen, rather than by what we have read ;
but for  further information we  refer our  readers to the treatment of
secondary  symptoms, where we shall dwell more at length on the
action of mercury.  In indurated chancre  we prefer a preparation
which unites the good  effects  of iodine  and mercury, known under
the name of proto-ioduret of mercury.  M. Ricord usually gives it in
combination with henbane, and orders it in one-grain doses, in form
of a pill, to be taken every night, five hours after the last meal.   The
effects are  not at first apparent;  it does not produce colic, like corro-
sive sublimate, nor does it purge like calomel;  at  the end of a week
or ten days he increases the dose, and orders a pill to be taken night
and morning.  The  first visible effect of this remedy is observed on
the induration, which diminishes in size and hardness:  the surface
becomes healthy and covered  with granulations,  and a cicatrix fol-
lows.  Provided these favorable results continue, it  is not necessary
to augment the dose, and the sore usually heals, and all traces of in-
duration disappear.  The pills should not, however,  be immediately
left off;  let them be gradually  discontinued.  However, it is always
well to continue their use some time after the  disappearance of the
induration ; no general rule can be laid down, for the surgeon must be
guided by  the circumstances  of each case.   We do not  recollect
having seen a patient salivated in order to cure  an  indurated chancre,
which is one of the greatest  recommendations of  this preparation.
Far from thinking it necessary to produce  salivation, we  purposely
avoid it; and those who are familiar with the practice at the Venereal
hospital will  agree with us in stating that salivation is of a very rare
occurrence ;  if it should happen, ushered in as  it is by an unpleasant
taste in the mouth in the morning,  a red  and puffy state of the gums,
with  an increased flow of saliva, a fetid breath, a  loaded tongue,
disordered bowels, loss of appetite, and general  feverish  state, the
mercury must be  immediately left off; quiet and repose ordered, with
a light and  nutritious diet;  and a  gargle  containing muriatic  acid
will, usually, soon put a stop to all local and general symptoms ;  or 
CHANCRE.                       215
if the state of the gums require  it, they may be brushed over with a
little  muriatic acid,  by means of  a piece of  lint.  When all the
symptoms of salivation have  passed, the  use of mercury  may be
again resorted to.  It will at once be seen how different is the treat-
ment we recommend to that usually followed.   Strongly opposed to
the general or  indiscriminate use of mercury, we highly approve of
it  in indurated  chancre; but we do not recommend a certain  dose,
which every person should take, be his  complaint cured or aggrava-
ted ; neither do  we think that  the mercury should be continued until
the constitution shows signs of becoming affected by soreness of the
gums.  We, consequently, can not agree with those who believe that
salivation  should be kept up several weeks ; on the contrary we are
guided by the state of the induration and the appearance of the sore,
considering them to be the only sure guide : after the experience we
have had on this subject, we may say that  this is the  only criterion
by which the surgeon can judge.
   Such treatment will not only cure the  local disease, causing the
chancre  and induration to disappear gradually, but will likewise, in
the  great majority of cases,  guaranty  the patient from  secondary
symptoms—we say in the generality of  cases, for we do not put this
treatment forward as an absolute protection, believing that no method,
however long continued, will absolutely protect the constitution from
secondary symptoms.  The mild and rational  one we  have recom-
mended  has, however, this  decided advantage, that  if  secondary
symptoms  follow, they will be of a  mild  form; the  constitution, not
being injured by mercury, will bear it a second time ; but of this we
shall again speak, when treating of constitutional syphilis.
   Excision of the  indurated chancre has been  recommended ; but
when it is remembered that this is often impossible from the situation
of the parts ; that it is  usually impracticable  to remove the whole,
for,  if the smallest  quantity of the  virus  be left, the  whole wound
assumes the character of  a large  chancre ;  when,  moreover, it is
recollected that it has already ceased to be a local disease, and lastly,
that if it were possible to  remove the induration, the  surgeon would
lose one of the  best, guides for the  administration of  mercury—we
reject the plan as prejudicial and useless.
   The Treatment of Indurated Phagedenic Chancre.—As the phage-
dena in these cases depends upon an excessive induration, the most
rational  treatment consists in curing the induration which  gives rise
to it.  This is best done by employing the treatment above recom-
mended ; not that we think mercury good  in  phagedenic sores  gen- 
216
CHANCRE.
erally, but only in  such as depend  upon induration ; here, sublata
causa  tollitur effectus; it  is from  not  paying sufficient  attention to
these  different species of phagedena  that  so  much difference of
opinion' has  existed on the use of mercury in these affections—we
trust we have in some  measure reconciled them.   It is upon general
treatment  alone that we must depend, as the sore is often very irri-
table, and there is  a good deal of general nervous  excitement;  the
use of the opium solution  locally, as  well as the internal  employment
of morphia at  bedtime, are often very  beneficial.  These compre-
hend the  principal  means in  use  for  the  treatment of indurated
chancres,  as well  as the  other  varieties;  we  shall therefore
now pass to
   The Treatment of the Varieties of the Reparative Stage.—When
the chancre  remains,  as  it occasionally does, in a statu quo, any
stimulating ointment may be employed ;  but, above all things, rest and
quietude on a bed or sofa will be of great service ; this alone will be
sufficient  to  attain  our  object.   When an  irregular   cicatrization
occurs, or when  the borders of the  ulcerations are livid, thin, and
bleed on the  slightest pressure, great advantage may be derived from
destroying  them with caustics,  or  they  may be  removed with
scissors ;  a considerable  haemorrhage results, but the chancre will
assume a  healthy character ;  the cicatrization will commence and
proceed from the circumference,  and the ulceration completely dis-
appear.  When cicatrization appears  in various  detached points, it
will be well to  touch the sore with nitrate of  silver ; when the gran-
ulations are large, soft, and bleed on  the  slightest cause,  a superficial
cauterization  will cause them to take on a healthy action.  When the
chancre puts on the appearance of the ulcus  elevatum, and the gran-
ulations are  exuberant, and very red, let the parts  be fairly cauter-
ized,  and when this has been  repeated  once or  twice,  cicatrization
will  commence.   In  these  various varieties we  have found  the
greatest success attend compression by means of  strips of diachylon,
which may be  changed every other day, if there  be  but  little  suppu-
ration ; or  applied  daily,  when the sore discharges  freely.   Such
local treatment, combined with a tonic and nutritious diet, will usually
cure these sometimes troublesome  cases.
   Treatment  of the  Complications of Chancre.—We  have hitherto
spoken of the treatment of simple chancre,  or  of its varieties •  we
now turn to that of the complications, which  may demand a special
treatment, not in respect of syphilis, but in consequence  of situation,
or the co-existence of  some other  disease, which marks  or changes 
CHANCRE.
217
the primary affection, or induces the surgeon to modify the treatment
above spoken of.
  The existence of chancre of the urethra is now put beyond doubt;
we give an example of it situated at the meatus in the annexed wood-
cut; it  likewise  shows  that  chancre may occur  along  the  whole
course of the canal, which becomes the seat of an irregular ulcera-
tion,  secreting  the  virus and  extending   rapidly.   The case  is
described at page 274 of M. Ricord's work  on inoculation.
                       (Chancres in the Urethra.)
  The symptoms are the following :   During the few days following
exposure to contagion,  no unusual phenomena occur, but some irri-
tation is soon felt at the entrance  of  the urethra,  for it is this point
which is usually the seat of the  affection, followed by a slight dis-
charge of a purulent character, tinged with  blood, particularly when
the canal is pressed ;  the urine in its passage occasions some pain,
but this  at first is slight; pressure, however, on parts of the canal
causes suffering, and induration occasionally is felt, confined to a par-
ticular point.  On separating the lips of the meatus, a chancre may
be perceived, presenting all the characters above given, and the secre-
tion of which  produces, on inoculation,  the characteristic  pustule.
Should it occur in an  irritable,  bad constitution,  the chancre may
increase in size, gain the orifice, or destroy the  surrounding cellular
tissue, form abscesses,  or, at a later period, fistula, giving rise to all
the unpleasant  consequences which usually result;  or the chancre
may, by the irritation of the passage of the urine,  become phage-
denic, gain the deeper parts of the canal, form abscesses in the pros-
tate,  and even reach the bladder, which  may be destroyed.   Such a
condition of the parts can  not. occur without acting on the system;
marasmus and a hectic state ensue from the local disease ;  infiltra-
tion  of  urine takes place ; haemorrhage occurs from vessels which
 the gangrene has opened, and the patient sinks.   In other cases, and 
218                         CHANCRE.

these,  happily, are the most frequent, the secretion diminishes by
degrees, and the chancre  heals altogether, or leaves an indurated
point, which causes a diminution in the calibre of the canal, forming
one of  the varieties  of stricture which  is followed  in from  six  to
eight weeks by the occurrence of secondary symptoms.  Hence gon-
orrhoea  has been accused of causing constitutional syphilis, whereas,
in fact, the patient has never had aught but chancre in the canal, the
secretion of which has been mistaken for that of gonorrhoea.
  The diagnosis of this complication may be founded on  the follow-
ing considerations.   The  chancre  in the urethra  may be  often
detected by the  eye ; it usually gives rise to  a  secretion from the
canal on the sixth, eighth, and even twelfth  day after connexion ; it
has a sanious appearance, and inoculation produces the pustule ; pain
is felt at a particular  portion of the canal, usually close to the meatus.
When  induration exists, it is  likewise confined to a point, is well
defined, and cartilaginous.
  In gonorrhoea, redness is merely observed at the meatus ; the dis-
charge from the canal usually follows  exposure to contagion  imme-
diately ; serous at first, it becomes  purulent, but rarely sanguinolent,
and when blood is  found in it, it is rather bloody than streaked,  as
in chancre.  Pain, at first confined to  a  point,  extends along the
canal;  there is scalding and  chordee,  the  induration which  may
follow is not distinctly limited, but occupies any part of the canal,
particularly the deeper portions, and is deficient  in the cartilaginous
feel so characteristic of chancre.
  The prognosis is usually favorable, except when the sore assumes
a phagedenic form;  it is then one of the severest diseases the sur-
geon is called upon to treat.
  The  treatment consists in depriving the urine of its irritating prop-
erties, by ordering abundance of liquids; subduing any local irrita-
tion by  rest and antiphlogistic means ; introducing a pencil of nitrate
of silver into  the canal to  cauterize the sore ;  recommending injec-
tions of aromatic wine, and the nightly employment of camphor in
form of pills, to prevent the occurrence of erections.   These  will be
sufficient to cure the majority of cases.  When abscesses form, they
should  be  at once  opened, as fistulae  are less  likely to result, and
cauterization be had  recourse to immediately; if fistulous openings
occur, they maybe treated  in the manner recommended at page 140.
Induration  will be best combated by general  treatment;  but, above
all things, let the surgeon be careful how he employs bougies, as they
only tend to  irritate the canal, and have no effect in removing the 
CHANCRE.                        219
stricture.  We believe that such cases have been the cause of odium
being thrown on dilatation by some authors.
   Chancre situated on the frcenum is frequently a complication, as in
erection any cicatrix is burst, and it is difficult to cauterize the part;
consequently it is better to divide the fraenum, if the chancre has not
already done it, and treat the sore in the usual manner.
   Balanitis  is  another complication, a disease which is well shown in
plate  II.',  fig.  1 ;  when it occurs in persons who have a wide pre-
puce, enabling the surgeon to uncover  the  glans  easily, and treat at
once  the  chancre and the balanitis,  it is  of little importance ; but
should a chancre occur on the inner  portion of  the prepuce, and  be
attended with  balanitis, at the same time that a narrow opening pre-
vents us from  exposing the glans and treating  directly the disease,
the case  assumes  quite a  different  aspect;  the secretion  of the
chancre, thus  confined in the species of sac formed by the prepuce,
causes inflammation, additional chancres ensue, so that the lining of
the prepuce may become an ulcerating, virulent surface;  the  loose
cellular tissue of  the prepuce  becomes  oedematous and inflamed; a
phlegmonous or an erysipelatous  state succeeds, which often  termi-
nates in  gangrene; a dark spot  appears on the prepuce, usually on
the upper part; an eschar forms, falls off,  and  the glans is observed
appearing through the ulcerated opening ; a fetid discharge oozes out,
composed of the detritus of the gangrenous tissues.   In some  cases
destruction of the prepuce only occurs; in others the glans partici-
pates, and a great portion may be destroyed ; the vessels of the sur-
rounding parts are exposed, ruptured, and haemorrhage follows,  which
it is often  difficult to check.   Such are some of the consequences of
this complication, the  treatment of which we have already described
under the  head of balanitis.
  When there is  a natural phymosis, and the surgeon is consulted at
a late  period,  swelling, redness, and  oedema having occurred, the
same treatment may be pursued, and the patient usually recovers, but
the phymosis remains ;  it then becomes a question whether an oper-
ation should be performed or not.
  If the surgeon  be consulted at a later  period, and gangrene  be
inevitable, we  have seen a director passed between the glans and
prepuce, and the  parts slit up with a bistoury ;  considerable haemor-
rhage follows, which seems to unload the vessels ; but this does not
always check  the gangrene, which destroys a greater portion of the
prepuce.   When  a case presents itself, in which the  prepuce  is
already destroyed, and the glans exposed,  M. Ricord is in the habit 
220
CHANCRE.
of  applying  the  opium solution, and  letting the disease  take  its
course ;  a gangrene usually performs  the part  of the knife,  and a
complete  circumcision results.   He considers  that an  incision can
not be of service, as  no part is  strictured, and  the  tissues divided
present a puffy, lardaceous character ; he therefore prefers waiting
till all inflammatory symptoms have passed away, and then removes
by the knife any portions which inconvenience the patient.
   There  is a complication of chancre  depending  upon  its  being
seated at the opening  of a narrow prepuce;  here the  chancres
assume a linear form, like fissures, or chaps, and are very difficult of
cure,  in consequence of the cicatrix being torn asunder during erec-
tion, and from the urine  excoriating them ;  quietude, cleanliness, and
the use of an ointment of calomel and  opium, are  very beneficial.
Having cured the local disease, the next  question is to treat the phy-
mosis, provided it be permanent.
(Circumcision, as performed by M. Ricord.)
  If the patient will submit to an operation, the following mode, as
delineated in the annexed woodcut, in our opinion,  is the best one.
Without employing any traction, we trace in ink a line on the pre-
puce, which follows the circumference of the base of the glans, and
is a little in front of it.   This being  done,  the prepuce should be
drawn forward and fixed between the blades of the forceps placed in
front of the glans, and behind the line of ink traced  on the prepuce ;
let  the  forceps be then  held  in  this position by an assistant.   Let
that portion of the prepuce which is in front of the  forceps be now
drawn forward by the  left hand  of the  surgeon, while, at the same
time, he with the  right divides it in the oblique direction of  the for- 
CHANCRE.
221
 ceps, which thus protects  the  glans.  In  this operation the skin
 alone is removed ; the mucous membrane is not drawn forward with
 the prepuce and remains intact;  if we do not wish to see a phymosis
 recur, this portion of mucous membrane must be removed.  To effect
 this, M. Ricord employs  a pair of scissors, slitting up the thin layer
 of mucous tissue as far as the base of the glans ; the two  portions
 should  then be successively  held  apart  by a  pair  of forceps,  and
 removed by dividing them at  the  base of the  glans, as  far as the
 fraenum, which is divided  the  last.   M. Ricord prefers  the  employ-
 ment of torsion in these cases to check the  bleeding ; lint dipped in
 cold water is then applied, and it may be advisable to administer an
 enema containing opium in the evening, or to  prescribe camphor pills
 to prevent erections.  A perfect  cure takes place about the twentieth
 day, and the result  is very satisfactory ; there  is no  deformity, nor
 have we to dread a  consecutive paraphymosis.
  Paraphymosis is  another complication which  the surgeon  is often
 called upon to treat.
  Many patients have an  idea that chancres of the  glans and pre-
 puce should be exposed ; hence  they keep the glans uncovered for a
 long time, and employ force in  doing so.  Should there be much
 inflammation, an oedematous  and  swollen state of the prepuce follows,
 and the patient is incapable of reducing the  paraphymosis.   When
the  surgeon is consulted at an early period, applying cold to the penis,
and the employment of gentle pressure, are sufficient to  reduce  the
parts to their normal position ; but if, as often happens, there is  not
only paraphymosis, but ulceration,  and  the stricture of the  glans is
 considerable, when there  is risk  of gangrene  coming on, or when a
paraphymosis has succeeded a natural phymosis, M. Ricord is not in
the  habit  of attempting reduction, which is  always  attended with
great pain, is often impossible, and if effected would only convert a
paraphymosis into a phymosis.  He  passes  a  narrow-bladed  knife
underneath the portion of the prepuce which forms  the stricture, and
slits it up full an inch beyond  the  glans ;  should there remain any
bands which keep  up the stricture,  they should  be successively
divided, as well as the oedematous fold of mucous membrane  in front
of the strangulated parts ;  cold may then be applied, and the patient
will soon recover, but flaps of  the prepuce may remain, which it will
be well to remove at a later period, as they greatly inconvenience
the  patient.   The surgeon must not be surprised at seeing the incised
wound  take on a chancrous appearance, which, however, must be
treated on the principles of chancre in general.
  In thefemale,the situation of chancre may form a serious complication. 
222
BUBO.
                         SECTION II.

                              BUBO.

   M. Ricord has divided  the  first stage of syphilis into two parts ;
 in the former he describes the primary, in the second the successive
 symptoms.  The meaning  of the former term has been already dwelt
 upon; by the  latter denomination, or  successive  symptoms, I mean
 those which are the extension of primary symptoms by continuity of
 surface (de proche en proche) or a simple extension of the  primary
 local symptom.  Under this  head I might consider fresh chancres,
 inflammatory or virulent abscesses and buboes.   As the former sub-
jects have been already described, it remains for me now to speak of
 bubo, which I consider as the  type of the successive affections, to
 the description of which this section will be devoted.
  Definition of Bubo.—In the following pages we shall imply, by the
 term bubo, a circumscribed  swelling of a lymphatic vessel orx gland,
 with or without suppuration.
  By the  term venereal bubo, we understand a bubo  which  follows
 sexual intercourse.
  Syphilitic bubo is a term applied to those swellings  which  are the
consequence of primary symptoms, or may arise  from constitutional
disease, generally termed lues venerea.
  In the present, section we shall treat more especially of syphilitic
buboes following primary symptoms ; the other forms will be only allu-
ded to here, inasmuch as they tend to the illustration and diagnosis of
syphilitic ones, and as appropriate  sections will be  devoted  to their
further description.
  Anatomical Characters of Syphilitic.  Buboes.—The first appearance
 
BUBO.
223
of the affection is frequently the occurrence of an inflamed lymphatic
vessel, commencing at the chancre,  and extending itself along the
trunk of the vessel, attended with swelling,  and presenting to the
finger the sensation of a chord ; this is seen in the annexed cut.   In
other instances, there is no swelling of the lymphatic vessel, but the
lymphatic  gland, which  is  connected with  the chancre, becomes
swollen and red, and  increases  gradually in  size ;  at first it is per-
fectly moveable, and unconnected with the surrounding tissues ;  soon,
however, the tumor is  found to be attached to  the deep-seated parts;
at a still later period  the skin  becomes  connected with the  tumor,
forming, together with  the superficial and deep-seated glans, one uni-
form  swelling.  Among the  working classes it is at this period that
attention is first paid to the affection, from the pain and inconvenience
felt.  In consequence  of  the enlargement of the gland,  the  circula-
tion may  be impeded,  and  a varicose state  of the  limb result,  or
oedema may come on, and cause great alarm to the patient.
  The termination of the disease may be various ;  among the rarest
we may mention delitescence; in  such case, the swelling  and  other
symptoms  abate, the parts take  on their accustomed function, and
are restored to their original state.
  Resolution, again, is one  of  the terminations ;  in this case the
tumor becomes moveable on the surrounding parts, and slowly assumes
its natural  size and  form.
  Suppuration often occurs ;  this stage of the  affection is announced
by shivering,  by the sense  of fluctuation detectable by the finger,
when the pus is seated in a  superficial ganglion, although, when it
occurs in  a deep-seated  gland,  fluctuation is very difficult, if not
impossible  to be detected.  Many young surgeons may be deceived
in the sensation of fluctuation, the elasticity of a swollen  gland being
liable" to be mistaken for fluctuation ; on the other hand, when pus is
bound down by a hard mass  of condensed cellular tissue, fluctuation
is very obscure.  In such cases it is useless to attempt  to discover
its presence by pressing from before backward ; the surgeon should
press horizontally, or from without inward, and by this means a  more
accurate opinion may be arrived  at.   Should the abscess be left to
itself, the  skin covering it becomes oedematous, discolored, gangre-
nous at one point, and  the pus escapes by  a fistulous opening; the
surrounding skin assumes a  livid hue ;  is  thin, and detached to a
considerable extent, or  is perforated with several fistulous openings.
  In other cases, the bubo, when formed, does not proceed to suppu-
ration, but takes on  an  indolent character, becomes indurated, and is 
224
BUBO.
unattended with pain ; it interferes, however, with the functions of
the part, and may terminate in scirrhous degeneration, provided there
is any predisposition on the part of the individual.  Syphilitic buboes
may likewise become  scrofulous, or be complicated  with scorbutic
affections,  or attended with  haemorrhage,  hospital  gangrene, or
present ulcerations  in every respect similar to the  varieties  of
chancre which  we shall not here stop to describe, for bubo is but a
chancre of the  lymphatic vessel, or gland, as we have above stated;
consequently, its secretion, parietes, &c, resemble those of chancre,
and are regulated by the same laws.
   On the other  hand, a syphilitic bubo, commencing as above stated,
may enlarge to  a certain extent, and then gradually subside, and ulti-
mately disappear;  or it may suppurate, and like  any  simple abscess,
go through the different phases of  suppuration, ulceration, and cica-
trization, and present none of the characters which we  have  termed
virulent when speaking of chancre, from which it differs in its essen-
tial feature.
   Causes of  Syphilitic Bubo.—In  our  definition of syphilitic bubo,
we stated it to be a consequence of a primary symptom or chancre ;
let us now inquire how this cause produces bubo.  To do  this, how-
ever, let us recall to the attention of our readers the anatomical struc-
tures which are implicated.
  M. Cruveilhier found that the lymphatic vessels commence on free
surfaces by  a sort of excessively  fine net-work.  Their  connexion
with each  other  is  seen in  the annexed cut.  His investigations,
confirmed by the experiments of M. Panizza of Pavia, as well as
those of M. Fohman, show the  distribution of vessels on the sur-
faces expose^ to chancre.   These  experiments also prove that the
lymphatic vessels, when  injected with mercury, proceed onward to
the glands, accompanying  the superficial veins,  anastomosing  one
with another, but  not increasing in volume.   Having reached the
lymphatic glands, the vessels are lost in the substance of that organ.
   Each lymphatic vessel is composed of  a lining membrane, which 
BUBO.
225
bears a close analogy to that of the veins, and an outer one which is
said to be fibrous, and gives the vessel a great power of resistance.
From  the  experiments  of Abernethy on the  larger animals, the
lymphatic glands are found to be composed of a spongy cellular tis-
sue, in which the lymphatics dilate as they enter, and again pass out
at the other  side of the gland, to assume the same character and
size which they had on  entering them.
  Of course  it is not here our object to show that these vessels are
endowed with absorbing powers j of this' there can be no question;
but as to the properties these vessels have of selecting the substances
they take up, we must be silent, being completely unenlightened at
present on the intimate nature of the function of secretion or absorp-
tion ; but it is not a mere hypothesis to state  that the absorbents do
not, during life, take up  indiscriminately all substances, and it would
seem pretty well established  thatthe  lymphatic vessels often absorb
the elements of  substances rather than  the  substances themselves,
although, under certain circumstances, it seems that they absorb sub-
stances which at other times they appear to  have a repugnance  to.
It is on  such a supposition as  this,  that modern  authors  have
attempted to explain why pus is often absorbed without any unpleasant
consequences, whereas, in other instances, the absorption of a little
pus gives rise to such fatal  effects.
  To return, however, to the subject of this  chapter—it would seem
proved that syphilitic virus, on an ulcerated surface, does not neces-
sarily give rise to successive phenomena, for the occurrence of bubo
is rare in proportion to the number df chancres the surgeon is  called
upon to treat; hence, we shall presently consider the circumstances
which favor or prevent the  occurrence of bubo.
  When, however,  the syphilitic virus gives rise to bubo, the investi-
gations of M. Ricord induce us to believe that it may act in one of
two ways.
  1st.  By absorption.   2d. By irritation.
  In the former  case the virus is directly taken up by the lymphatic
vessels,  and  carried  along them, and,  under  some influence with
which we are unacquainted, deposited on the sides of the lymphatic
vessel, which it destroys ; it  then acts  on the  cellular tissue in the
same way as  when introduced into a follicle, and produce's a chancre,
which causes destruction of the tissues, until it appears at the sur
face, or,  if unchecked, it may be carried along the whole course of
the vessel, until it  reaches the  gland ; here it becomes developed,
                                 15 
226
BUBO.
destroying the surrounding parts,  and eventually appearing at the
surface, as above described.
   2d. The syphilitic virus may not be absorbed, but give rise to an
irritation and  inflammation of a  simple kind,  as any other irritant
may, not  acting in a specific manner.  This  irritation  may extend
along the  whole course of the lymphatic vessel, until it  reaches the
gland, giving rise to the  chord above spoken of; or, by a  sympathetic
action which the extremities of canals have, the  intervening portion
of the lymphatic may apparently be  free from disease, and the simple
irritation of the surface be  communicated to the gland,  on the same
principle that in cases of stone in the bladder  no pain is felt  along
the urethra, but the irritation at the  neck is accompanied with severe
suffering and irritation at the glans penis.   We well know, likewise,
that tickling the palate causes vomiting.
   These various ways in which the syphilitic  virus may act, do not
rest upon  hypothesis.  Inoculation of the  secretion of  bubo  has
clearly proved that  a great  many  buboes exist which  secrete  the
syphilitic virus ; thus proving that absorption must have taken place,
and that it has been brought in contact with the  gland.   A case illus-
trative of this  is related in M. Ricord's work, at page 143 :—
   " A  patient presented himself,  suffering  under  syphilitic  bubo,
attended with  considerable suppuration.   I  opened  the  abscess, but
after the pus had been evacuated from the cellular tissue, I found in
the middle of the abscess  a lymphatic  ganglion  of  considerable
volume, and presenting the feeling of fluctuation in the centre.  I
punctured it, and inoculated the patient with the pus which it  con-
tained, at  the  same  time that I  inoculated likewise with the  pus
taken from the surrounding parts.   While  the  pus taken from the
ganglion  produced a characteristic pustule, that from  the  cellular
tissue remained without any effect.   I made, in consequence of this
case, a series of experiments which no longer  left any doubt on  the
results of inoculation."
   Predisposing Causes of Bubo.—If chancre be the cause of syphi-
litic bubo,  it is a  fact admitted by all observers, that it is only the
direct or  exciting  cause ; in order  that bubo follow, there must be
some predisposing influence, otherwise bubo would be more frequent
than it is  in proportion to the number of chancres.  We therefore
propose now to speak of those circumstances which  appear to pre-
dispose to bubo.
   Age has an  influence in producing bubo.   Infancy is comparatively
free from their occurrence;  we  have not witnessed any cases, but 
BUBO.
227
 M. Ricord has mentioned one in a child of a month old; in spite of
 this exceptional instance, we may say that the quiet  life  and light
 nourishment of children predispose very little to the occurrence of
 buboes.
   Old age  predisposes  but  little to  buboes, in consequence of less
 exposure of the subject, and sluggish absorption ;  but  it is by no
 means exempt.  We have witnessed  buboes occurring  in old people,
 and we have at present under our care a female, of a very  advanced
 age, suffering under a severe form of  syphilitic bubo.
   It is at the adult age that the lymphatic system seems  most liable
 to absorption, and as exposure to the chances of contagion are at this
 period most common, we do not feel surprised that there  exists a
 greater liability to buboes.
   The sex appears to play an important part in predisposing to bubo.
 Statistics show that the male is more susceptible of bubo  than the
 female.   It  might be imagined that this circumstance depends  upon
 the greater fatigue to which  the  male is exposed, compared to  that
 undergone by the female ; such an opinion, however, is not true, for
 experience  proves that women employed at the public  markets,  and
 who carry great burdens,  are rarely affected with bubo, and in a far
 less proportion than in males who, from their social position, do not
 exert themselves.   There would seem to exist  some  other circum-
 stance beyond that of occupation, to explain the greater frequency of
 bubo in the  male.
   Temperament may be considered as a predisposing  cause.  The
 lymphatic temperament appears to be  more liable to bubo  than  any
 other, inasmuch as it predisposes to absorption ; we have  not been
 able to connect the more frequent occurrence of bubo with  the other
 temperaments.
  The hygienic conditions of  the patient, particularly fatigue, irrita-
 tion  of the  part, &c, predispose to  the occurrence of bubo more
 than any  other circumstances.
  The situation of chancre in predisposing to  bubo must  never be
lost sight of by the  surgeon; while  the  artificial  chancre on  the
thigh has never, in  the numerous experiments we have witnessed and
made, been followed by bubo, chancre situated  around the  fraenum,
meatus of the female, or  at the  ischium,  is  seldom unattended by
bubo.  Whatever be the  explanation  of the  fact, there  can be no
doubt that in the last-named situation bubo follows very  frequently.
  The size of the  chancre does  not seem  to have  the same influ-
 ence ; we have  seen very large  chancres  existing  during a long 
228
BUBO.
 period  of time, and yet unattended with bubo ;  on the contrary, a
 small  chancre,  if situated at the fraenum, is very often followed by
 bubo.
   Treatment of primary sores has been repeatedly stated to predis-
 pose to bubo, many surgeons believing that, by  locally treating  the
 chancre, the virus is driven into the system.  There is not in surgery
 a more  incorrect opinion than this, and we feel disposed to lay down
 the contrary principle,  namely, that the more speedily and effectually
 a chancre is destroyed, the less will be the  probability of the occur-
 rence of bubo.   It is true that irritation of a chancre predisposes to
 bubo, but as the nitrate of  silver does not irritate,  but, on  the con-
 trary, acts as an antiphlogistic agent, its  use can not be said to pre-
 dispose to bubo.  However, we do not pretend to state that the use
 of the  caustic will  always prevent  the occurrence of buboes ;  but
 though  it will not, in all cases, succeed in  preventing  them, it will
 nevertheless render their occurrence less  probable  ; and when bubo
 follows  the employment of  the caustic, it  is  usually not virulent, and
 yields readily under proper treatment.
  The idea that when  a primary sore is treated by mercury, there is
less disposition to the  occurrence of bubo,  has of  late years fallen
 into disrepute, as it has been  found that buboes occur during and after
the use  of mercury;  and even Hunter states that mercury sometimes
occasions bubo.  It is  our opinion that mercury has no effect either
in preventing or predisposing to the complaint.
  Symptoms  of Bubo.—The  earliest symptoms  usually show them-
 selves during the second week of the existence of chancre ;  we have
rarely met with them during  the  week following contagion.  They
are often ushered in by shivering, or the first indication of a bubo is
 afforded by  a  pain  in the  part, attended  by heat and swelling,
increased by motion ; there is occasionally  fever, and  the  affection
may take on an acute character, presenting all the local appearances
 described under the head of anatomical  characters ;  or  it may
 assume  a chronic form, and become of a very indolent nature.
  Diagnosis of Syphilitic Bubo.—Did the limits of the present work
permit,  we would treat of the diagnosis of bubo from  aneurism,  ex-
ostosis,  and the affections which  may be  confounded with  bubo, as
 well as  from hernia, when the tumor  is situated in the groin ; but  we
 are obliged to pass over this very interesting inquiry, and to call'the
 attention of our readers to the diagnosis of  syphilitic from the other
 forms of buboes.
  The opinion  of a surgeon may  be  asked previous to or during  the 
BUBO.
229
suppurative state;  we shall, therefore, consider the points on which
the diagnosis may be founded in these two stages.
   1st.  Diagnosis of Syphilitic Bubo,  previous to  Suppuration.—In
such a case the surgeon can only arrive at a rational diagnosis, as it
is  impossible, before suppuration to give  a  decided  opinion  upon a
point which,  though of great importance, has hitherto puzzled the
most celebrated authors.
   When a bubo appears during the second or third week of chancre,
or during the period of cicatrization, particularly if the ulceration be
seated  at the  fraenum, at the meatus urinarius,  or on the ischium  in
the female—if it be confined to a superficial gland—if, moreover, it
rapidly goes on to suppurate—the surgeon will be usually correct  in
calling it syphilitic, particularly if all  these characters are present in
one individual.
   The diagnosis  is not always easy ;  there  are  many conflicting
opinions, so that it is difficult  to decide  upon the true nature of the
case.  Some have advanced that your diagnosis should be based on
the antecedent history of the case, so that when a patient has exposed
himself by sexual intercourse with a prostitute, and a bubo  follows,
it  must necessarily be syphilitic ; in this opinion we can not agree,
for,  as we stated in speaking  of chancre, every ulceration which
follows promiscuous intercourse  is not necessarily syphilitic, for the
same reason  every bubo is not syphilitic ;  although, then, we may
rationally consider a bubo syphilitic which follows a  sore contracted
in promiscuous  intercourse, we should not so stigmatize every bubo
which  follows connexion, unaccompanied by chancre.
   This brings us to the consideration of  a point of great importance,
viz., what is  the nature  of a bubo following connexion, though not
preceded by chancre ?   Observation of a great number of such cases
leads us to the  following  conclusion—that impure  connexion may
produce  inflammation of the glans or prepuce, causing  gonorrhoea
praeputialis,  excoriations,  or  gonorrhoea,  and will  subsequently pro-
duce venereal non-syphilitic  buboes,  which,  consequently,  may be
readily distinguished from the virulent forms.
   There  are, however, cases in  which it  is  sometimes difficult to
distinguish syphilitic buboes from   what the  French  call bubon
d'emblee.  Patients present themselves  suffering under  bubo, yet
denying  they have had chancres, or any  affection  of  the  genital
organs, this is what is called  d'emblee.  Now, in the majority of such
cases on carefully examining the vagina, neck of the uterus,  rectum,
glans, or urethra, a chancre, or traces of  it, will be observed,  clearly 
230
BUBO.
proving that the bubo is a  syphilitic one ; but if this  happen  in  the  ,
majority of instances, it is no less certain that there are cases which
seem to merit the term dbemblee; thus  buboes occur  in  persons who
have  neither object nor wish to  deceive, without our being  able  to
trace  them  to chancre, or  any local affection.  Are  we justified  in
calling them dbemblee ?  We think not, as the following  case proves :
M. Ricord inoculated from  a superficial chancre, and on  the following
morning the characteristic pustule was evident, but the chancre from
which the pus was taken   he  found completely cured ; now had a
bubo  followed, it would have been  called dbemblee, as no traces of
existing disease would have been found ; yet we see how incorrect
this conclusion would have  been.   The few remaining cases of bubo
dbemblee, may, we think, justly be attributed  to scrofulous  enlarge-
ments of  lymphatic glands, produced by any local  excitement,  as
connexion, &c.   That this is the case, is further rendered probable
by the constitution  of  the  individuals, by the indolent  character of
the swelling,  and  by its  rarely suppurating ;  further, by  several
glands being the seat of the disease, and by their never having fur-
nished inoculable pus,  although the experiment of inoculation has
been  often repeated.  It is on  a consideration of the circumstance
relative  to each case that the diagnosis must  be founded ; but if the
preceding observations are borne in mind, the surgeon will not often
fall into error.
  Diagnosis of Syphilitic  Bubo  in  the Stage of Suppuration.—We
have  stated that an open   bubo is  in every respect analogous to
chancre ;  hence, it would be useless to repeat what we said upon the
diagnosis  of chancre, and we refer  our  readers to that chapter.  It is
only when a syphilitic  bubo suppurates  that  we can decide  if the
bubo has been  produced by the absorption of the virus, or by irritation.
  Prognosis of Syphilitic  Bubo.—Many  surgeons  believe that the
mere  existence of bubo is  a very unfavorable occurrence, as  show-
ing that the disease had made great inroads on the system ;  but our
readers  will at once observe, that the prognosis of bubo may depend
upon  a variety of circumstances ; the mere existence  will not throw
any light  on the prognosis ; and our  opinion  must be founded on
other  data.  To this subject we demand the especial attention of our
readers.
  In  forming a prognosis, we must first decide whether  a sore exists
which may have  caused the bubo ;  if so, we should ascertain if it
be a chancre ;  on the other hand,  if the  patient  has suffered or  is
suffering under gonorrhoea,  or any simple  non-virulent affection, then 
BUBO.                         231
the prognosis will  be  always  favorable ; but if we have  reason to
believe that the bubo is a syphilitic and not  a sympathetic one, the
next question to decide is, if it be a virulent  bubo,  or  merely a con-
sequence  of irritation ;  until this has been decided, it is  impossible
to form a  prognosis.
   The prognosis  of bubo, however, is  favorable, inasmuch as  it is
found  by  statistics,  that  in  every hundred  cases  twenty only are
syphilitic, and that  only a portion of these will suppurate.
   The prognosis.of bubo, preceded by or accompanied with chancre,
is, generally speaking, unfavorable, inasmuch as it is probable that
the bubo is  a virulent one ; but let it not be supposed that  other bu-
boes are not likewise very unfavorable  as to  their prognosis, particu-
larly scrofulous ones, which are extremely indolent.  A bubo, how-
ever, which is a consequence of gonorrhoea or simple wound, usually
soon disappears.
   The surgeon will therefore see how necessary it  is, on the subject
of prognosis, to arrive at an accurate  diagnosis of the disease which
has preceded the  bubo, as well as of  its nature; for he will thus be
able, not only to  allay the fears of his  patient, but save his reputa-
tion, by predicting whether a bubo will suppurate or not.
   The probability of the suppuration of a syphilitic  bubo will depend
upon the period at which the surgeon is consulted.   If at a late pe-
riod, when the skin is red and inflamed,  and the bubo assumes an
acute character, whatever may be the treatment employed, suppura-
tion may be expected.   In a good constitution, when treatment has
been  employed early, although a  chancre has preceded  the  bubo,
great hopes may be entertained of preventing suppuration.
   The opinion of the surgeon is often asked  upon the probable dura-
tion of a bubo.   Any opinion that may be  given should be  very
guarded, and  must  depend  upon  a mature consideration  of the cir-
cumstances which have preceded.   Thus, every prospect of a speedy
cure may be held out by the surgeon, when called in early, when
there are no acute local symptoms,  in a good constitution ;  but when
the bubo is suppurating, and  you have reason to consider it a virulent
sore, or when it occurs in a bad constitution,  it is impossible to  pre-
dict the period of the cure.  On this subject, however, we  must refer
our readers  to the prognosis  of chancre, as it  is rather the latter com-
plaint that we have  to consider.
   The termination of bubo in induration depends, in a great measure,
on the nature of the primary sore; thus, if it be already cartilagi-
nous, the  bubo will  probably become likewise indurated.   Should a 
232
BUBO.
bubo occur in a lymphatic individual,  our  prognosis will be always
very unfavorable, more especially if the bubo is indolent, for we have
always equally to dread the consequences of a very acute or chronic
bubo.
  With reference to the probability of the occurrence of secondary
symptoms after bubo, we  must repeat, that as  the tumor is  only
syphilitic twenty times in every hundred cases, secondary symptoms
could  follow bubo only in the same proportion ; experience proves,
moreover, that secondary symptoms do not even Qccur  in that pro-
portion, thus showing what is well known with respect to  primary
sores, viz., that every  chancre is not followed by them.   Observation
on a large number of  cases  has likewise  shown  that virulent bubo,
unattended with induration, is not followed  more frequently by sec-
ondary symptoms than is simple chancre ; a virulent bubo, however,
attended with induration, like indurated chancre, is almost invariably
followed by secondary symptoms ;  consequently, in the prognosis the
surgeon must be guided by the  same principles that were laid down
under the head of indurated chancre ;  constitutional  infection being
observed as  frequently in cases  of external as of internal chancres.
  Treatment of Syphilitic'Bubo.—The prophylactic treatment, or the
means of preventing the  occurrence of bubo, merits our first atten-
tion.  This  is  best accomplished by  considering the  causes, both
direct and indirect, which lead to bubo.  As speedy a cure  as possi-
ble  of the primary sore is of the utmost importance ;  for although, as
we  stated above, bubo does not always occur, although a  primary
sore may exist several months, nor after the existence of large sores,
still, as bubo is a direct  consequence of  chancre,  it should be our
object to  cure the latter as soon as possible,  as no individual  can be
guarantied from bubo  as long as a chancre exists  ; and  our  readers,
we  hope, are convinced that the speedily curing chancre by local
means does  not render the occurrence of bubo more imminent.
  But the surgeon must not depend alone upon a speedy cure of the
primary sore; he should consider  and choose that treatment which
is least likely to  irritate  it,  and this  is undoubtedly the use of the
caustic in cases of simple chancre.  To persons  unacquainted with
the action of nitrate of silver, it might seem paradoxical to state that
its action is antiphlogistic, but we  have already, we hope, proved that
this is its true mode of action.  On the contrary, we  should avoid all
stimulating applications, or lay them  aside if they have  been used;
absolute  repose should be recommended,  or if the patient's occupa-
tions do not permit this, we must enjoin him to use as little  exercise 
BUBO.
233
as possible, recommend a suspensory bandage if the sore be on the
penis, and use the other means recommended against the occurrence
of the complications of chancre.  If, in spite of these precautionary
measures, or  if the surgeon be  called to treat a bubo at its com-
mencement, it is indifferent at this stage, as far as the treatment is
concerned, to diagnose accurately the nature of the bubo; cold water,
ice, repose on a sofa or bed, with slight clothing, are among the most
potent means for bringing about delitescence of the swelling which
has lately commenced;  cold applications, however, should  not be
persisted  in,  provided  they cause pain, or  when, as  in  some few
cases, they  tend to  augment  the swelling.  Under these  circum-
stances, or if an individual will not submit to any restraint, the  best
means  of treatment is the employment of  compression,  either by
means of  graduated compresses of linen, fixed in their proper posi-
tion  by the figure-of-8  bandage, or  a bandage or truss  of  an  oval
shape, which was invented by a pupil of M. Ricord's, and which he
constantly employs with the most signal success.
                    (Truss for compressing Buboes.)
  It consists, as seen in the woodcut, of a pad of an oval form;  to
the inner part of this oval pad is fixed a strap, which passes  around
the thigh, and then goes through a pulley on the external edge of the
pad; it is then brought back and passed around the loins, and having 
234                          BUBO.
 gained the front of the  abdomen, and then  the  groin, is ultimately
 attached by means of a buckle to the pad, thus enabling  the surgeon
 to employ compression  to any extent.
   The application of the bandage will be readily understood with the
 aid of the accompanying woodcut.
   Employed at an early period, and in the way above recommended,
 compression will  be found  a very advantageous treatment,  and will
 often occasion the disappearance of these  swellings, or effect what
 the French call their abortion.
   Abortive Treatment.—The  surgeon, however,  is often consulted
 when the bubo has already made considerable progress ;  there is red-
 ness of the skin,  considerable  heat  and swelling, but no inflamma-
 tion  is perceptible ;  at this period the usual antiphlogistic  means
 must be employed and vigorously followed up, viz., general bleeding,
 the use of tartar emetic internally, the local  application of leeches,
 the employment of cold washes or ice,  &c.  If fomentations  be  em-
 ployed, they should be continually changed, and thus  warmth  and
 moisture  constantly maintained ;  in place of  poultices of linseed
 meal, the common arrowroot made from the potato, and prepared  as a
 poultice by the addition of boiling water, is far preferable ;  it is not
 liable to become rancid and thus irritate the skin, it never becomes
 hard, and has the further advantage of causing continually an oozing
 of moisture; during the night it is particularly advantageous ; during
 the day we prefer lint dipped  in warm water,  and laid  on the bubo,
 taking care to cover it  with oiled silk, and to  change the lint every
 hour ; by these means we have obtained the happiest results in speed-
 ily and effectually relieving all local inflammation.  It nevertheless
 happens that although the  acute symptoms are removed, a sub-acute
* state  continues, or the  surgeon is called to  treat an indolent bubo ;
 in the practice of the venereal  hospitals we have met with many such
 cases, and we have seen the following treatment followed by success :
 During the daytime, let the swelling be covered with an emplastrum
 vigo cum mercurio and compression  by means of the truss be made,
 as recommended in the preceding pages; in the evening  let the
 bandage and plaster be removed, and let a drachm of blue ointment be
 carefully rubbed on the swelling  before a fire during a  quarter of an
 hour, and place an arrowroot poultice over it;  on  the  following day
 the compression and frictions may be repeated, until all swelling has
 subsided.  In case of  the failure of these means, recourse must be
 had to a more vigorous treatment.  It is at this stage that we have
 seen much benefit derived from covering the tumor with a blister, and 
BUBO.
235
 when the epidermis has been thus  removed, gently placing the blue
 ointment on the parts, which may be covered with a poultice •  when
 the blistered  surface has  healed,  a  second and third blister may be
 applied, and the  same dressing repeated.  The mercury, in all these
 cases, is employed rather  as a local resolutive application than  as  a
 specific remedy,  consequently it is  our object rather to place the
 ointment on  the  tumor than to  occasion  its  absorption from the
 chancre, and  thus make it pass through the  affected gland—the point
 that Hunter seems to have had in view; of course, should salivation
 ensue, the employment of  mercury should be instantly laid aside, and
 the usual means  of treating ptyalism  be  had recourse to.
   In all the plans previously recommended,  it will,  we hope, have
 become apparent that it is our object to cause  the resolution of the
 tumor by absorption, and prevent suppuration ; experience, however,
 proves  that these much-wished-for ends can not always be attained.
 When  bubo follows  a chancre, and when,  consequently, we have
 every reason to suppose that absorption of the virus has taken place,
 and has been  carried into a ganglion, all our endeavors to promote
 resolution will too frequently fail; still, under such circumstances, it
 is better to  act as if the bubo were caused by irritation, and not de-
 spair of dissipating the swelling, for  we are no  longer living  in the
 good old days of  humorism, when it was supposed that that surgeon
 was the best,  who by all the means in his power would assist nature
 in chasing all the peccant humors from the body.   For this purpose,
 in place of  dressing a blistered surface with the blue ointment, let a
 piece of lint dipped in a solution  containing twenty grains of corro-
 sive sublimate to  one  ounce of water  be  applied, and kept on the de-
 nuded skin for two hours, or a shorter time if it cause great suffering
 to the patient  (a  circumstance almost constant) ; let  a  poultice on
 which some laudanum is poured, be applied  and frequently changed ;
 in consequence of this caustic application an  eschar  will be formed,
 and when it falls off, the caustic may  be again employed according to
 circumstances.  Under  this treatment, indolent buboes will get rap-
idly well.  When employed in virulent swellings, the pus is  often
seen oozing through the cauterized part, and on the separation of the
eschar the true nature of the virulent  bubo is  at once seen, forming,
in fact, a chancre  which is brought into view by the destruction of
the walls of the abscess.   Blisters, then, and caustics, may be said
either to promote absorption, if that  be possible,  or to  hasten the
opening of  a virulent  abscess, before  it has had time  to undermine
the surrounding structures.   There is, however, a great objection to 
236
BUBO.
 the use of the blister and the corrosive sublimate ; they cause  great
 pain in their application, and leave considerable cicatrices, which are
 indelible  marks of the disease ;  consequently, the surgeon should use
 them with discrimination,  and only in  cases where all other means
 have failed.
   When  a patient presents all the signs of fluctuation in the  swel-
 ling—when the skin is thin, livid, &c.—the methods  recommended
 above are worse than useless, by the loss of time  occupied  in their
 employment;  the virus within extends  itself on all sides, and,  when
 opened, the abscess will be found very extensive.  To avoid  these
 consequences, the surgeon should open the abscess on the very first
 symptoms of the occurrence of  pus ; provided the case  be virulent,
 an opening should be made, for  it would be useless to expect absorp-
 tion.   The  incision should be made in the direction of the greatest
 diameter  of the tumor.  In the inguino-crural  region, it  is in  the
 direction  of the inguino-crural fold ; in the case of suppuration of the
 vertical glands of the thigh, it is in the direction of the axis of  the
 limb that  the incision should be  made.  Incisions on these principles
 do not expose the patient so much to subsequent burrowing or secon-
 dary abscesses, or cause crucial  incisions to become necessary at a
 later period.
   If it be an important question to decide on the proper direction of
 the incision, it becomes a no less one to consider its length ; in  small
 abscesses, a simple puncture is usually sufficient, particularly if  there
 be no reason for supposing that it  is not a virulent bubo ; in  such
 cases a large incision is unnecessary, but when there is a large quan-
tity of matter, when  the skin over the abscess is  livid, blue, and thin,
 when we  suspect its virulent nature, and that it has undermined to a
 considerable extent the surrounding parts, a free incision is absolutely
requisite; for  in  such cases we can not  expect that  the  skin will
become attached to the parts below.  The same principle holds good,
likewise, in cases of fistulous openings  which extend on either side;
they should be freely opened, for unless  this is done, cicatrization will
not take  place.  It is quite unnecessary to press out the pus ;  such
pressure gives rise to pain, and the use of the tent is only requisite in
cases of non-virulent buboes, as  in others the virus  will inoculate  the
cut surfaces, and prevent closure of the opening.
   Treatment of Suppurating Syphilitic Bubo.—When the surgeon is
consulted  at this period, or  when a bubo has  been  opened, the treat-
ment must vary with the circumstances of the case.  In the majority
of instances, the treatment is similar to that recommended for chancre 
BUBO.
237
and its complications.   Should inflammation, phagedena, or gangrene,
be present, the specific nature of the bubo should be lost sight of, and
the usual treatment of those affections  employed ;  this having  been
effected, we should turn to the treatment of the specific disease ; care
should be  taken  that  the  virus does  not  remain in contact  with
the surfaces which secrete it; this is avoided by  the use  of baths,
washing the part  often, and the employment of  the aromatic wine ;
position may often be useful in allowing the secretions to pass away.
Such treatment,  combined  with cauterization of  the  abscess,  will
usually succeed in bringing it to a happy termination, and  cicatriza-
tion  will follow, healthy granulations  filling up the cavity of the
abscess.
   This,  however, will  occasionally be  retarded by an indolent state
of the bubo, by the skin presenting livid, thin edges, or being under-
mined by the disease ;  in the latter cases it is useless to expect that
granulation will spring up as long  as these portions  of  the  skin
remain around the abscess ;  their removal is therefore indispensable.
This  may be  effected  by snipping them off with  a strong pair of
curved scissors.   Patients have often a great objection to the use of
instruments, and they may be very reasonably replaced  by employ-
ing the Vienna paste,* which, by virtue of its caustic properties, not
only removes the  superfluous portions  of skin, but likewise causes
the surrounding parts to take on a healthy action.
  When the edges of the suppurating bubo ulcerate, when it extends
daily, or remains stationary, M. Ricord  fills the  abscess  with the
powder of cantharides,  and orders a blister on the  bubo ; the follow-
ing morning, if induration exists, the  edges of the  blistered surfaces
are dressed with lint, on which mercurial ointment  is spread, and the
abscess is washed with aromatic wine; should it be a simple bubo,
common dressing or applications of white wash to the blistered  sur-
face, and the aromatic wine to the abscess, are sufficient.
   This treatment, with the powder of cantharides,  is not so painful
as might be imagined; healthy granulations spring  up, and the whole
character of the sore is changed, and it will be often necessary to
check the exuberance by the nitrate of silver ; in consequence of the
extent of the disease, cicatrization will  often take  place  imperfectly
or irregularly ; the usual means of lightly passing the  caustic  over
the surfaces will be found advantageous ; when the cicatrix is  livid
and indurated, it should be destroyed by repeated and partial applica-
  * The Pate de Vienne is composed of five parts of caustic  lime, and six of caustic
potash, with sufficient spirit to make a paste. 
238
BUBO.
tions  of the Vienna  paste, and  a more healthy surface will  be the
result.
   Should induration  of a specific kind follow a bubo, the general con-
stitutional treatment with  mercury must be  had recourse to, and  be
guided by the same principles as were laid down in speaking of indu-
rated  chancre.
   In  scrofulous constitutions, the tonic and general treatment must be
had recourse to.   Change of  air, a nutritious  diet, tonic  medicines,
particularly the various preparations of iron,  together with local stim-
ulants, should successively or  conjointly be had recourse to.
   Lastly, in chronic  indolent swellings of  the  superficial  or deep-
seated glands, neither  local  nor general treatment  will  suffice  to
remove the swollen state, or to remedy the various obstructions to
the venous and absorbent  system.  In such cases  recourse must  be
had to the pale de Vienne; a  superficial  layer is  laid on, and when
the eschar falls  off, another  and another may  succeed; replace it,
until at length the whole mass of enlarged  glands has disappeared.
This process is often indispensable, although very painful, and is far
preferable to excision, as recommended by some authors
   To maintain poultices or dressing on the bubo, or  even to employ
compression by means of lint, I can strongly recommend a bandage,
invented,  I believe,  by Messrs. Evans  and Perkins,  of Mortimer
street, London ; its application is well  seen  in the annexed woodcut.
(Inguinal Bandage.) 
SECONDARY SYMPTOMS.
239
                         CHAPTER  II.

                          SECTION I.

                     SECONDARY  SYMPTOMS.

   Definition.—Under  this  term  we comprehend those  various
 morbid phenomena which appear  on the skin, mucous  membranes,
 or in the eye and  testicle, the consequence  of absorption into  the
 circulation of syphilitic  virus, giving rise to  a constitutional affec-
 tion which is hereditary, or, in other  words, capable of transmission
 from the mother to the child, but incapable of inoculation.
   Synonymous Terms.—Secondary symptoms have been variously
 designated by different  authors.   Some   writers group under  the
 term  syphilis, not only  what we  now understand  as  primary,  but
 likewise secondary symptoms,  without distinguishing   them either
 from  one another, or from other diseases.  This is not surprising
 when  the difficulties  attending the  subject are  considered, or when
 the erronepus notions then entertained upon medicine are weighed.
   The same  observations apply to syphilitic affections, a term which
 includes indiscriminately everything which resembles the disease  we
 are describing, and one which, as at  the present day, has often  no very
 definite meaning.
  Morbus pustularum, la verole,  la grosse verole, are likewise  sy-
 nonymous terms ; more modern writers have spoken of lues, constitu-
 tional syphilis, accidents secondaires,  or constitutionals, as  distinguish-
 ed from the local, primary effects of syphilis.   We shall employ the
 term secondary symptoms, as  it enables us at once  to  classify the
various effects which we are about  to describe ; and  it  has the ad-
ditional advantage of being generally accepted.  We shall, however,
attempt to give a more distinct character  to the  affection we are about
to treat of, and  avoid  that vagueness  of expression which has dis-
tinguished some writers on this interesting division of syphilis. 
240
SECONDARY SYMPTOMS.
   History of Secondary Symptoms.—If we admit that primary
symptoms were described and  known to authors long before the dis-
covery of America, &c. (as we have elsewhere wished to prove),
we might naturally expect that  secondary symptoms likewise existed;
and from the description in the Bible, as well as in the Arabian,
Greek, and Roman authors, little doubt remains that they formed the
major part of the diseases of the skin then so prevalent;  we  may,
however, add that  they do  not seem to have been attributed or be-
lieved  to bear  any relation to primary  symptoms ;  or, if known,
they were confounded together in an unintelligible manner.
   It was toward the close of the fifteenth century that we find second-
ary symptoms described as depending upon syphilis ;  the light at
once thrown upon the  diseases in question may be accounted for  by
the existence of predisposing  causes,  which, as at the present day,
are found not only to aggravate, but change altogether the physiog-
nomy of the disease.
   We owe to Fernel,  however, in 1556, the first accurate description
of secondary symptoms : he first pointed out the relation that second-
ary symptoms bore to the primary, and it is  this distinction which
has so greatly assisted and contributed to an accurate  knowledge  of
the former.
   In 1784, Hunter, adopting the classification of Fernel, further sub-
divided  secondary symptoms  into sympathetic  and  virulent.  The
virulent he again classed under two heads.
   1. Those which appear during the early period of the constitutional
infection.
   2. Those which are observed at  a much later period.
   In the  former he placed eruptions on the skin and affections of the
mucous membrane ; in the latter, diseases of the periosteum and  of
the bones.
   It is, however, M. Ricord who has recently introduced a classifica-
tion of constitutional syphilitic affections, which we are confident our
readers will consider the most perfect hitherto proposed.  Following
Fernel, he has separated primary from secondary symptoms, and has
shown us how to  distinguish them; adopting also the  views  of
Hunter in some points, he has  differed from and improved  upon that
eminent surgeon's  classification, and the  second  division of Hunter
he  has preferred to place in a separate order, and called  them ter-
tiary symptoms.  The reasons for this deviation from the  doctrines
of our great master will be given in their proper place.
   General Observations  on  Secondary  Symptoms.—Previous 
SECONDARY SYMPTOMS.
241
to describing  secondary symptoms, it will be wed to devote a few
pages to some general considerations.  In our definition we have
stated them to be the consequence of absorption into the circulation
of the syphilitic virus, or to depend upon a poisoning of the animal
economy by the virus, which we have described in the first chapter
of this part.
   It might appear that this opinion, now generally received, is capa-
ble of demonstration.  Such, however, is not the  case ; no  one,  to
our knowledge, has ever attempted to inject the virus into the circula-
tion.  The probable  consequences of such an experiment would be
so severe that no medical man would undertake it, nor would any
one be justified in thus experimenting upon his fellow-creatures ; and
as the syphilitic virus has no perceptible  effects on animals, we are
deprived of two of the most valuable adjuncts in our investigations.
Medical men have been content to collect such observations as daily
experience  furnish, to prove that secondary symptoms are the result
of absorption of the virus into the general system.
   A long-continued  observation, and  accurate  inquiry, in a large
hospital, as well as extensive private practice, lead M. Ricord to state
that a case of secondary symptoms, dbemblee, never occurs.  The excep-
tional cases depend upon hereditary infection, or from inattention on the
part of  the  patient  to his antecedent history, or to his ignorance of
what chancres are, &c.   In every case in which  he has been  con-
sulted, chancre either existed, or some traces of it could be seen ;  in
fact, the exceptional instances may be reasonably  accounted  for,  as
in the bubon d'emblee.  This is now so generally  admitted, that we
shall not stop to prove it further, but take it for  granted that secondary
symptoms are always preceded by a chancre situated in some part of
the body.   It is no less true, however, that every  chancre is not fol-
lowed by secondary  symptoms ; were this not happily the case, they
would be still  infinitely more common than they are.
   Predisposing Causes of Secondary Symptoms generally.—Observa-
tion of many thousands of cases shows that these  consist in circum-
stances not immediately connected with the individual, or apparently
dependent on his constitution.
   It cannot have escaped the  observation of those of my readers who
have seen much of syphilis, that the temperature of the  air has a con-
siderable influence on the production of secondary symptoms.   Rapid
changes from  heat to cold, as  witnessed in persons leaving the warm
wards of  hospitals for their own damp cold dwellings, place this be-
yond doubt.  Travellers state that the passing from cold to  warm,
                               16 
242
SECONDARY SYMPTOMS.
and from warm to cold climates, produces a great  disposition  to the
same effect.
   Clothing, particularly such as is slight and insufficient to maintain
an  equable temperature, has been accused, with reason, of predispo-
sing to secondary symptoms.
   The use of spirituous  liquors, highly savored or insufficient food,
excitement of all kinds, moral or physical, are some of  the most fre-
quent predisposing causes.
   Among the circumstances appertaining to the  individual, we may
first speak of age.   It rarely happens that a child is born of a mother
suffering under secondary  symptoms, without becoming affected at
birth, or  soon after, particularly if exposed to cold.  When the pe-
riod of infancy has passed, as the child  is  seldom exposed  to  conta-
gion, the  occurrence of secondary symptoms  is  very  rare.   From
similar circumstances, and the torpid state  of the lymphatic system,
they are rarely met with at  an advanced period of life.
   Sex.—It is hardly necessary to say that men are more liable than wo-
men, in consequence of the former exposing themselves to the chances
of contagion more frequently ; but we think the statement is  no less
true, that if  the same risks  were run by the two sexes, the  female is
less predisposed than the male.   This assertion is supported by the
cases we have observed in the  Parisian  institutions.   In  the male
hospital, cases of secondary syphilis are very common ; in the hos-
pital of l'Oursine (the female one), during  our  duties there, out of
four hundred in-patients, we observed few cases of secondary affec-
tions.  The same  remark we made in  visiting the foul wards at St.
Lazare,  devoted to the  treatment of the prostitutes of  Paris.  The
reason, we think, is the following : the female, though frequently the
subject of chancre, is yet, from her sedentary and quiet  life, less ex-
posed than the male to the causes mentioned above.  We are further
borne out by the fact, that  common prostitutes are much more fre-
quently attacked with secondary symptoms, than that large class of
unfortunate females, consisting of poor married women,  to  be found
at l'Oursine.
   Temperament.—-Its influence, as a predisposing cause, is very evi-
dent, and  some authors state  that the  lymphatic is the one  which
most particularly disposes to them.  That this  is  often the  case is
true, but. those who have attended to the subject must be aware, that
the same individual, in the course of the year, may contract chancres ;
the first will pass away,  the second may be often attended with sec-
ondary symptoms,  or  vice versa.  Again,  how often do we see the 
SECONDARY SYMPTOMS.
243
strongest men attacked, and the feeblest  escape ;  it must  however
be allowed that a great portion of secondary symptons occurs in per-
sons who have been reduced by illness, or some other cause.   Sur-
geons who are called upon to treat secondary symptoms can  not but
have remarked the number of  their patients presenting that  clear
complexion which has been attributed to  scrofulous subjects.   I do
not,  however, assert  that  secondary symptoms  are confined to  such
individuals ; but on  being consulted for  primary  sores  by patients
with dark  hair,  clear  brown  complexions, or that beautiful transpa-
rency of skin, I have too often  predicted the occurrence of indura-
tion, and the subsequent train  of secondary affections.
  The reader will not forget, that in speaking of the various anatom-
ical characters of chancre, and of their prognosis,  we stated that the
simple chancre, as well  as  the gangrenous  and phagadenic  ones,
were rarely followed by secondary syphilis ; on the contrary, that the
indurated chancre  would be attended  by it in  ninety-nine cases out
of one hundred.   We  stated,  however, that the virus being always
the same, the difference in the form of the  chancre  must depend upon
the nature of the constitution.   What this may be, we are unable to
say; observation alone shows that the constitution or condition of
surrounding tissues, or  the unknown  element which causes indu-
ration, is analogous to that which  subsequently produces  secondary
symptoms.  The importance of this, as indicating a line of treatment,
has b.een already noticed,  and further  researches, it is to be hoped,
will clear up these doubts.   In the absence of anything certain, we
will not speak of the conjectures which the subject has given rise to.
  If secondary syphilis,  in consequence of the  predisposing causes
above referred to, arise from absorption of the virus, by what system
of vessels does the  process  take place ?  To this question  we think
observation may furnish a satisfactory reply.  When the virus is taken
up by the lymphatic vessels, as we remarked under the head of bubo,
it is either carried along the vessel into the first lymphatic gland, or,
being checked in its course, it occasions the development  of  a  lym-
phatic or glandular bubo.   We stated, moreover,  that under either of
these circumstances, the  virus  remained unchanged,  as is proved by
inoculation.   What prevents  its further progress ?  Why can it not
pass beyond the first gland, and  what decomposition or change does
the virus then undergo ?  We  are at a loss to decide, unless, as some
have advanced, the elements of, and not the virus is absorbed.  This
view is not improbable, but is  a simple hypothesis  ; nor shall we in-
quire if a bubo be the  means of expelling from the system the peccant 
244
SECONDARY SYMPTOMS.
virus.  One thing is certain, that  bubo in no way betokens the prob-
able occurrence of  secondary syphilis.  Often  have we observed
persons afflicted with  the  largest,  most acute,  or chronic buboes,
without ever after  being subject  to secondary symptoms.  On the
other hand, we daily witness secondary syphilis coming on in per-
sons who, we are certain, have never had buboes.  It is true that the
secondary  disease  often comes on during the existence or after the
cure of bubo.   In  such cases, we think we are far from justified in
attributing  them to the bubo, as observation on a large  scale shows
that there is no direct relation between them.
  If, then, our opinion be correct, that the lymphatic system does not
absorb the virus, and carry it into the economy, we necessarily must
suppose that absorption is effected  by the veins.  The experiments
of  physiological writers have clearly  proved these vessels to  be
endowed  with  the function of absorption: veins,  we believe, have
no  power of selection (if we may be allowed the expression), as the
absorbents have, nor do they tend to alter the qualities of substances,
as the lymphatics evidently do.   Lastly, the effects produced on the
system by the absorption of the  virus bear a great analogy  to the
deleterious effects  produced by the injection of poisons into the veins.
At  the present day the comparison is feeble, but in the fifteenth cen-
tury, when that famous  epidemic  reigned, we learn that livid patches
appeared, that the  ulcers on the skin were haemorrhagic ;  everything
in  fact bespoke a  liquefaction of the  blood, such as is occasionally
witnessed even at  the present day.  In  the absence of experiments,
all must be conjectural as to the quantity, quality, and period neces-
sary to produce the  contamination of the system above alluded to.
   The period at which secondary symptoms appear after the occurrence
of the primary ones, deserves to arrest our attention.  It is impossible
to limit exactly this  period.   The earliest period at Avhich they may
occur, is eight days  after  the  appearance of primary  sores.  M. Ri-
cord relates such a case.   It  happened  in  a tailor, who, at the end
of  the week after the occurrence  of chancre, had well-marked second-
ary symptoms.  M. Cullerier has likewise mentioned a similar case.
 Excepting, however,  such instances, which  are rarely met with at
 the present time, although we believe them to have been  very com-
 mon in the fifteenth century, secondary symptoms usually show them-
 selves about six weeks or two  months  after  the appearance of the
 primary sore.   Of the importance of knowing this fact we have been
 more  than once convinced :  patients  come into hospital  six weeks
 after the occurrence of an indurated  sore; mercury is given, and  in 
                      SECONDARY  SYMPTOMS.                 245

 a few days a brilliant display of secondary symptoms breaks out, oc-
 casioned, as  some think,  by giving mercury.   M. Ricord has  often
 shown us the natural  course of the  disease by abstaining from any
 treatment, and the well-known secondary affections soon appear.
    Can this period be delayed ?  It can, as  we have had ample oppor-
 tunities of observing.   When due precautions are taken, no excesses
 or exposure to cold submitted to, weeks may pass over, and no second-
 ary symptoms  appear; but, under the influence of predisposing
 causes, they  suddenly break  out.   The employment of  mercury in
 insufficient or injudicious  doses  appears  to have the  same effect;
 the disease is  retarded, and we have  seen it appear some months
 later,  and have  been  unable to  attribute  it to any other cause.  It
 results from the preceding observations, that  the absorption of the
 syphilitic virus induces a syphilitic temperament,  a peculiar state of
 system which care holds  in abeyance ; the germ exists, but  some
 extraneous cause develops  it, and  must call  it into action ; as a fall
 on the knee, or  inflammation of the chest, develops white swellings
 or  phthisis, so does exposure of the surface to  cold, or  insufficient
 diet, cause the development of one of the forms of secondary syphilis,
 which we shall presently describe.
   The length of time that this  syphilitic temperament may  exist
 without giving any evidence of its presence by the occurrence of the
 disease, we are unable to decide j  but  let it not be supposed that we
 belong to that school who think that secondary symptoms may break
 out twenty years after the cure of the  primary  affection ;  all we can
 say on this  point is, that care and non-exposure to the predisposing
 causes, or an insufficient mercurial treatment (we shall hereafter state
 what we mean by this term), may  retard the development of seconda-
 ry syphilis.   M. Ricord states that the exact period of this suspen-
 sion of the disease, or incubation, can  not be  limited; but  he has not
 met with  a  case which  ever led  him  to suppose that syphilis  can
 break  out after a lapse of years ;  and  as those who state that  this
 has occurred do not furnish us with their observations, as the chances
 of self-deception are great, and as no  such cases have been personally
 observed,  without absolutely denying the possibility, he is little  dis-
posed to credit them.
  In our definition we  stated that the term secondary symptoms was
employed  to designate the  morbid  phenomena which appear on  the
skin, mucous membrane, eye, testicle, &c.   Let  us now  direct  our
readers' attention to each separately.
  The researches of modern anatomists have proved beyond a doubt, 
 246          SECONDARY SYMPTOMS ON THE SKIN.

 that there exists a great analogy between  the skin and  the  mucous
 membrane.   Physiologists have  likewise established  analogy of
 function  between them, and  modern surgeons,  in a variety  of their
 rhinoplastic operations, have  proved on the human body, what  was
 long known  to  the comparative anatomist, that skin  may be, as it
 were, transformed into mucous membrane,  and mucous membrane
 assume all the characters of skin.   Pathology daily shows  that the
 influence of disease on the skin reacts on  the mucous  membrane, as
 in cases of burns ; on the  contrary, that irritation of  the  mucous
 membrane  reacts on  the  skin, as in eruptions following the  use of
 copaiba, &c.  In fevers, particularly in typhus,  the co-existence of
 the rosy eruption, or  of petechise, together with the  lesions of the
 mucous membrane, have not escaped notice ; and in small-pox it is
 now well  known that the pustules may appear on the mucous mem-
 brane, as  well  as on  the skin.  This analogy, then, between the
 diseases of the skin and mucous membrane  is in no case more strong-
ly marked than in secondary symptoms ;  they may  be  traced on the
penis and on the prepuce, gradually  passing  one into the other; on
the mouth we have often witnessed  this  transformation,  and  a good
example is to be seen in Plate V., fig. 4.
                        SECTION  II.

             SECONDARY SYMPTOMS  ON THE  SKIN.

  The syphilitic affections of the skin are very varied and numerous,
yet, by  following the classification  of  our  countrymen  Willan  and
Bateman,  we  trust  we  shall give such a distinct and  succinct de-
scription of them, as will enable our readers readily to distinguish
this large class of important  diseases from those which  depend upon
other causes.
  Various as they are, they may all be  reduced to one of the follow-
ing forms :—
                 Exanthematous affections.
                 Papular affections.
                 Vesicular affections.
                 Pustular affections.
                 Tubercular affections. 
              SECONDARY SYMPTOMS ON THE SKIN.         247

   By far the most common and earliest in appearance are__
   Exanthemata.—During the existence of  the primary symptoms,
or some few weeks after their disappearance, and generally in con-
sequence of exposure to some of the predisposing causes mentioned
above, the patient is surprised at  observing a larger or smaller por-
tion of the  body  covered  with an  exanthematous  eruption, which
sometimes assumes the form of measles ;  so general is the affection
of the skin, at other times, distinct patches appear,  of a more or less
circular form.   At their commencement these eruptions are of a rosy
color ; the  surrounding skin is of an  unhealthy  appearance,  of  a
dusky yellowish hue ; on pressure  the spots disappear, but return im-
mediately.
   The whole surface may be covered at once, or successively : this
exanthematous eruption may pervade the abdomen, lower extremities,
arms, face, and back.  It may disappear from one part and shift  to
another, or reappear again on the same portions of the body in a few
days.  These spots, however, soon lose their rosy color, and daily
become more and more dusky, until they assume a coppery hue, which
is always best marked  in  the most dependent parts of the  body ; it
seems to arise from something more than simple congestion, as pres-
sure does not remove it.
   These exanthematous eruptions may disappear without any treat-
ment, or under the use  of various agents, or may pass into the papu-
lar form.
   PapuljE, like  the exanthemata,  may  appear on  the  skin  without
having given rise to any general disturbance of the system: often,
however, the general health may be observed to suffer ;  the face may
have presented an unhealthy, pale, or earthy appearance ; the eye
may have lost its  vivacity, and the patient loses flesh : these premoni-
tory symptoms are sooner or later followed by an eruption of papulae,
more or less general;  they, however, first usually appear on the ab-
domen ; at  their  commencement rosy, they  gradually assume the
coppery hue.  On passing  the finger over the affected parts, they
will  be found to present a certain elevation above the surface of the
skin, with a sensible hardness, and are grouped in clusters, or dis-
seminated irregularly  here and  there;  it is this  condition of the
papulae which has received the name of lichen.
  It may exist as a simple disease  a long time, or it may disappear,
as did the exanthemata, or the points of the papulae will become dry
and whitish, the base will shrivel, and, instead of a papula, a surface
covered with little thin scales is seen, very distinct from the adjacent 
248          SECONDARY SYMPTOMS ON THE SKIN.
 sound  skin ;  these  scaly  surfaces may be quite distinct, or several
 may coalesce, forming  a continuous surface,  covered with silvery
 scales, which are reproduced as soon as they fall away, or are rubbed
 off.  This  appearance has  given rise  to the  division squama,  but
 which  we  believe to be no other than the drying and exfoliation of
 the epidermis, and reproduction of little silvery scales on the papules
 (See eruptions in plates VI. and VII.)
   Those who have specially written on  skin diseases, have, as  it ap-
 pears to us, rendered more difficult an  acknowledged difficult subject;
 they have attempted to create distinctions between lepra and psoria-
 sis, which,  in our opinion, are both terminations of a  papular  erup-
 tion.   The  lichen above described may become dry  at its summit,
 scales may  form, fall off, and be reproduced, and this process may
 gain the base, and extend itself  in an irregular manner, constituting
 what authors call psoriasis.  On the other hand,  the base of  the
 papula may become  scaly, the centre or apex remaining in a natural
 condition ; the result  is, that a circle  is formed of these little scales
 surrounding and  surrounded  by  healthy skin,  and  as  this circle is
 somewhat prominent, from a slight swelling of the dermis now secre-
 ting the scales, it  has been considered  sufficiently characterized  to be
 termed  lepra.  On the same individual,  lichen,  psoriasis,  and lepra,
 may be seen ; and we may here  observe that the little white border,
 described by M.  Biett as characteristic of the syphilitic affection, is
 often'wanting.
   This scaly state of the diseased skin  is very often exceedingly
 rebellious, remaining for a long time stationary; the progress of the
 circles deserves,  however, particular attention.   As they  extend  at
 their circumference,  the centre heals; thus the  circle  enlarges,  until
 it has reached the size often of a shilling ; the regularity of the circle
 is  often  interrupted  by the fusion  of  a  second  one,  and  thus two
become united, forming a figure  of 8, or  3,  or  5.  When they are
 about to heal, the scales fall off, and instead of  the  white  scaly sur-
face, the  circle is only to be distinguished  by the  difference in the
 color of the skin, which, after a lapse of time, assumes all its healthy
characters.  A good idea of this may  be derived  from  plates  V.
 and VII.
   There is a form of lepra occurring on the  palms of  the  hands and
 soles of the feet, which deserves particular attention  ; portions of the
 epidermis, of a circular shape, become  white,  hard, or horny, and
 fall off, but are soon replaced by others, which successively fall away,
 causing great inconvenience  to patients.   This condition of parts is 
SECONDARY SYMPTOMS ON THE SKIN.           249
often accompanied with crevices, or a chapped state of the interstices,
which become irritated by any foreign substances that may be placed
in contact with them, and  they pour out a  secretion which forms
crusts upon the surface ;  in  fact, the palm of the hand  becomes so
horny, that the  patient is in part  prevented from making use of it.
We have  observed this variety particularly in bakers, grocers, masons,
&c.   We have every reason to consider it a form of lepra, which
takes on this character from the condition of the epidermis in these
situations.
   Vesicular Form.—This variety of syphilitic eruption has never
presented itself to  our observation.  M.  Ricord  states it  is of very
rare  occurrence; it  resembles any  other  vesicular  eruption, such as
chicken-pox, but is  more chronic in its progress, and surrounded with
a coppery tint, and  patches  of discolored skin remain after the ab-
sorption of the limpid fluid contained in the vesicle.
   Pustular Form.—Our  readers will  be much  deceived, if  they
suppose that  by the term pustular form we wish to  speak of an acute
affection of the skin, such  as is found in small-pox,  attended  with
full-formed pustules filled with a yellowish fluid.
   Such cases have rarely come under our notice ; most  frequently
pustules follow as a sequel of other eruptions, bad treatment, want of
proper attention to cleanliness, or  some  other cause ; and at a later
period, after the occurrence of the primary sores, a yellowish serum,
which  soon  becomes  thick  and consistent,  is  seen raising up the
epidermis on the centre of the various eruptions previously described ;
the pustule does not put  on  the characters seen in the  pustule of the
drawing of artificial chancre ; it is often covered at the commence-
ment with scales, and then seems to be the result of an inflammatory
action beneath the spot of lepra.   In other  instances, it seems de-
veloped in a  papula, which becomes converted into an organ secret-
ing pus ;  scabs form  upon  it, which increase in diameter in  con-
sequence  of the additional  secretion of pus, becoming hard,  brown,
and surrounded by a livid or copper-colored areola; these scabs may
assume  a  monstrous size, being at  their  base as large as  a shilling,
and  projecting above the skin  at  least half an  inch;  on removing
these masses of scabs superimposed one above the other, and often
covering large portions of the body, a dirty, sanious, and  ulcerating
surface  will  be observed occupying their base ; the edges are often
callous, and extend underneath the epidermis ; hence  the  ulceration
is larger than it at first sight appears to be.   This form of eruption is
usually  very chronic in its course, and  shows  little  disposition  to 
250
SECONDARY SYMPTOMS ON THE SKIN.
heal; the ulcerations remain for a long time stationary, or when they
show a disposition to heal, cicatrization  takes  place slowly ;  a livid
condition of the skin succeeds, a material loss of substance is evident,
and white cicatrices are the result.
  It is especially under these forms that the general health suffers ;
the skin is dusky, the  countenance is shrunken, the  capillary circula-
tion is imperfectly performed, nutrition goes on badly, purpura often
supervenes; general prostration  of strength,  together with loss of
appetite, and rheumatic pains, indicate that the  constitution is severely
suffering,  and  it is not until the health improves that the sores heal.
It was probably under such severe forms as these that  the  epidemic
of the fifteenth century showed  itself, but it is happily only from time
to  time  that we now see this disease in persons of bad constitution,
or who have ruined their health by excesses.
  It is  to this form  of scab that  the  term rupia  has been  given,
which, as we have seen, is merely the consequence of the formation
of scabs ;  however, there is another form which we have occasionally
witnessed under the same circumstances ;  large bullae, containing at
first a thin, serous, and  then a  sanguineous fluid, of a most fetid  na-
ture, based on an ulcerating surface, are seen on  various points of
the body ; they form crusts, and follow the same course  as the disease
last  described;  they  indicate a more impoverished condition of the
system than  even  the  pustular  form, and are  often attended with
serous or  sanguineous effusions into the various cavities of the body.
  Before  quitting the pustular form, we must  not omit mentioning  a
variety which occurs on the  scalp, and which we call impetigo; it
apparently commences at the bulb of the  hair,  showing itself by  a
small pustule ;  a crust is formed around  the root of the hair, which,
as often as rubbed off, is reproduced by a thick viscid secretion mat-
ting the  surrounding hair together; this  condition of the  scalp is
usually confined to a few spots, but the  whole hair  becomes affected,
loses its lustre, gets dry, falls off, and the  patient  may become bald.
The glands in the  neck may often be sympathetically  enlarged, par-
ticularly those behind the ears  and at the  base of the  jaw; it often
accompanies the other forms of secondary symptoms.
  Tubercular Form.—In describing the previous forms, we have
followed  what we believe to be the most natural course, that of  suc-
cessively  describing those  eruptions which  succeed one  another.
Following the same plan, we ought to have described the tubercular
form after the papular ; but  the following reasons have induced us
to leave the tubercular form to the last.   If the reader  will carefully 
SECONDARY SYMPTOMS ON THE SKIN.          251
examine plates IV. and V., he will observe the transformation which
insensibly takes place between the diseases of  the  skin and  mucous
membrances through the tubercular form, and consequently, we have
reserved the description of it, that our account of the one should im-
mediately follow the other, although at the expense  of subverting the
order we have previously traced out.
   The tubercular form, in the sense which it is used  by writers on
the diseases of the skin, viz., "consisting of little hard tumors more
or less  superficial,  accompanied, most  frequently,  wTith  a peculiar
color of the skin ; capable of resolution, or remaining in an indurated
state ; or, lastly, becoming the seat of ulceration—in the latter case
crusts form on the surface," is rarely met with  as a distinct form ;  it
is more  frequently a  papular  eruption  in the beginning, and after a
greater or shorter lapse of time it  degenerates into a tubercle, having
the characters above  described; it appears  on  various  parts of the
surface, and may be often  seen on the face, nose, or at  the  angles of
the mouth,  but  more  frequently shows itself soon after the primary
sore  on  certain  parts of  the  body,  to  which  it appears to have a
preference such as around the anus, the  labia, the groin, the scrotum,
the lining of the prepuce, the umbilicus, between the toes, and, lastly,
though very rarely, in the  arm-pits.   (See plate VII.)
   This peculiar form of secondary syphilis has been  more particularly
described by the French writers ; as it  is of frequent occurrence, is
very characteristic, and has not yet been paid  sufficient attention to
in England, we  shall dwell at some length on it.
   The  French  call   it  tubercule muqueux, papules muqueuses,  or
pustule plat;  for  reasons  which  will soon  appear, we shall call it
mucous tubercle,  although in England it is called condyloma.
   The reader may form a  very clear notion of it from plate VII.  In
appearance  it will vary according  to its situation ; usually of  a more
or less circular form, it presents a slightly firm  tumor, rather  elastic
than  hard, more or less elevated  above  the surface  of  the skin; at
first  it is pale, but, exposed from  its situation to friction, it becomes
shortly of a vermilion tint: the  surface is  somewhat  similar  to a
mucous  membrane ; it secretes an acrid matter, which causes and
maintains great local  irritation, and is of a very offensive odor; the
epidermis which covers it becomes excoriated,  and the  tubercle may
present  the appearance  of a blistered  surface, as is well shown in
plates IV. and V.  The mucous tubercle may  be isolated, as I wit-
nessed lately in a female under Mr. Lawrence's care, who presented
one in the axilla, and  gave the only  intimation of secondary symp- 
252          SECONDARY SYMPTOMS ON THE SKIN.
toms ;  frequently, however, they occur in groups, and then the secre-
tion  of one irritates the other.   Our plate shows a severe case, but
we have witnessed  examples in which a large portion of the thighs,
as well as the whole external organs of generation, vagina, and neck
of the uterus, have been  entirely covered with a  crop of tubercles,
attended  with such local irritation and offensive smell that the female
presented the most disgusting sight  we  have  ever witnessed ; of
course the  rubbing of one  part against  the other caused pain, but the
general health seemed little  affected.   By inattention  to cleanliness
this disease has  a great tendency to extend, but when care is taken
to wash the parts and prevent the  accumulation of the secretion, the
affection will remain stationary.  Under proper treatment this disease
gets  rapidly well, but when left to itself it  does not seem to have any
tendency to cause ulcerations which, like those following the pustule,
extend in depth; here there seems a tendency to superficial excoria-
tion, rather than  ulceration.  The process  of cure  is somewhat
singular :■ like lepra, to  which it  bears  a close  resemblance,  the
centre first shows marks  of  healing ;  as cicatrization takes place in
the centre, the excoriating margin, which is elevated above the sur-
rounding skin, extends until it has assumed the size of a half-crown,
and it may then  suddenly  stop and the  circle get rapidly well, but for
a long time after a livid purple or  coppery-colored spot remains, and
affords the  only  vestige of the disease  ; such was the case in the in-
stance of the  woman above cited.   The  circles  may intersect one
another, giving rise to various varieties of cicatrization.
   Such are the course and termination of the mucous tubercle ;  it,
however, often presents varieties, as we shall now proceed to describe.
Instead of beginning as  we have just shown, it may arise on any
point of the body which has been  the seat of chancre, and which is
irritated and moistened by the  secretions of the parts ; we have wit-
nessed such an origin at the base of  the penis or the scrotum ; M.
Ricord calls this a change of chancre in situ into the mucous tubercle.
It appears, likewise, that a chancre on one part of its surface may be
converted  into a mucous  tubercle, while the other may continue to
secrete the virus.   Such cases as these have led to the notion that
the  mucous tubercle  is contagious, but from the  experiments of M.
Ricord it is now satisfactorily proved that, unless under these circum-
stances,  mucous tubercles can never be transmitted from one adult to
the other, notwithstanding all the attempts that have been made.  The
chancre, when it has lost its virulent character, and is covered with
granulations, may, under any irritation, take on the character of the 
SECONDARY SYMPTOMS ON THE SKIN.          253
ulcus elevatum, as we mentioned at the commencement of this part;
it will then be very difficult to distinguish it from an isolated  mucous
tubercle ; but this is of no great importance.*
   Complications.—We have thus described the whole of the symp-
toms of the skin called secondary; the reader would,  however, be in
error did  he believe that they are always to be met with in the form
we have described them; instead of one form being present, it hap-
pens occasionally that various part of the body may at the same time
be the seat of the varieties described as papular, pustular, or tuber-
cular ; as a consequence of various complications,  the characters of
the  eruptions may be modified.   We have frequently had occasion
to observe the various affections called secondary masked by a gene-
ral eruption of itch, for the idea that two diseases can  not exist in  the
economy at one and the same time has long since  become exploded,
and we now  say that itch is a complication of syphilis, and no longer
believe in a syphilitic itch.
   From any  local irritation eczema may break out on the surface,  and
the consequence will be, that this acute affection of the skin will for
the time throw into the background that which depends upon syphilis.
We have often witnessed a general  eruption of  Urticaria  coming on
during the progress of papular syphilitic eruptions.
   When lepra and psoriasis  are habitual to some individuals, should
secondary symptoms supervene, of course that depending upon syph-
ilis may be much modified,  and  its  distinctive  characters lost;  we
have, moreover, witnessed the  train of  eruptions  which attend  the
French  typhus fever superadded to and  aggravate  the secondary
syphilitic affection ;  in fine, there  is no  disease which may  not
supervene, and alter materially the characters of secondary symptoms.
   As the reader, however,  is now aware how  much depends upon
the syphilitic constitutional disease, he will be enabled to avoid falling
into the error of calling everything syphilitic which comes en after a
primary affection.
   There is, however, a complication which deserves particular atten-
tion, and which,  if not recognised,  leads  sometimes to the gravest
errors ; we speak of the occurrence of primary symptoms.  Should a
primary sore  or chancre exist,  or should chancres be contracted while
the system is laboring under the constitutional form of syphilis, it is
  * I believe this transformation in situ of the chancre into a  mucous tubercle is a  form
or variety first described by Evans  in his " Practical Remarks on Ulceration of the
Genital Organs," under the term Venerola Vulgaris, out Ulcus Elevatum, and more
recently by Mr. Skey, in his lectures reported in the Medical  Gazette.  Our view of
its nature, however, is very different  from that taken by these gentlemen. 
254
SECONDARY SYMPTOMS ON THE SKIN.
hardly to be called a complication, provided the chancres be confined
to the genital organs.   But  if the ulcerations or  pustules, the con-
sequence of secondary symptoms, become inoculated with the virus
proceeding from chancres existing on  the genital  organs, or  on any
part  of the body, such accidents may be justly called complications,
for we may have secondary  and  primary symptoms existing on and
covering  the  skin.  We have been witness of these facts more than
once, and we think them worthy  of general attention.   It is probably
such  instances  as these which have induced the late  Mr.  Wallace
of Dublin to believe secondary symptoms occasionally inoculable.
  If, however, the possibility of secondary symptoms becoming prima-
ry once, through the direct contact of the virus coming from a prima-
ry sore, be now put beyond a doubt, the reader must not imagine that
this  frequently  occurs, or that  every suspicious ulceration which
follows secondary  symptoms is, in fact, a primary sore or chancre:
we have lately witnessed a case which proves how much the  surgeon
may  be deceived.  In M. Puche's wards at the Venereal hospital, a
patient had a very severe form of pustular  secondary symptoms, the
consequence of chancres cured, as the patient stated, some  months
before.   On examining the patient some days after, we  found several
serpiginous sores of the size of half-a-crowm  crowded together on the
back of the shoulder, a point of the body where we had previously
observed the large pustules before spoken of.  Every  one who saw
these sores agreed that they had a most suspicious appearance ; they
resembled  perfectly a large chancre.  The  supposition  that they
were chancres was, moreover, borne out by the existence of primary
sores on  the penis, the consequence of  connexion a few weeks pre-
viously.   Inoculation, however, proved that  these sores on the back
were not primary, but truly the result of secondary  symptoms ; this
case has, however, impressed more fully than ever upon us the little
confidence that can be placed upon physical characters  to distinguish
primary from secondary ulcerations.
   Before quitting the  subject of complications of secondary ulcers, we
must not  forget to state that scrofula, scurvy, as  well as any inflam-
matory affection, may completely alter their physiognomy, as well as
materially modify their prognosis.
   Diagnosis.—We shall, in this section, attempt to give a resume
of the general points in the diagnosis  which have been mentioned in
the preceding pages, believing that by this means the reader will gain
a clearer notion of the subject;  it will, moreover, enable us  to make 
SECONDARY SYMPTOMS ON THE SKIN.          255
a few  observations which could  not  consistently  find  their place
in the simple description.
  In forming a diagnosis on  any supposed  secondary-symptom, the
surgeon will,  of course, never  neglect  to  inquire into  the previous
history of  the  patient; this will aid him materially, but let it be re-
membered  that, unless care be taken, it may tend equally to deceive
him.  It is not only necessary that a chancre has preceded, but  that
it should have occurred within a certain length of time, otherwise the
relation between the cause and effect is not  apparent.   There are
persons, who, when they find that  chancre has ever existed, consider
every morbid symptom during the  life of the individual as due  to that
cause ; we have above stated that  this is not our  opinion.
  When we learn that no  chancre, but only gonorrhoea, in the male
or female, has preceded, provided  other reasons indicate it, we may
often suspect  that chancres  have  escaped the patient's notice, daily
experience demonstrating  that chancre  may exist  in the urethra in
the  male, or in the vagina or  neck  of the uterus  in the  female, and
yet  only give  notice  of their presence by  leucorrhoea.   Hence  we
must not rashly conclude, that although a chancre has  existed, the
symptoms under which a patient is laboring  are syphilitic or seconda-
ry ; or when no primary symptom, but only a leucorrhoea, has been
observed, deny the symptoms which bear the mark of syphilis to be
really  specific, because they are  not corroborated  by the patient's
antecedent history.
  The next point upon which the  surgeon will form his  diagnosis is
the  occurrence of concomitant symptoms, or, in other words, upon the
existence of other symptoms  which are more characteristic.   Let  us
take an instance :  if he be doubtful of the nature of lepra, or psoriasis,
or any pustule  or  ulceration,  his  opinion may be often confirmed  or
corroborated by the existence, on other parts of the  body, of the papu-
lar lenticular eruption, or by  the presence around the  anus, or else-
where, of  the  mucous  tubercle, as these  eruptions are peculiar  to
syphilis ; hence their presence or  absence must have great weight in
aiding the diagnosis.
  In tracing the various forms of  secondary symptoms, we had fre-
quently occasion to notice that they often presented a peculiar dusky
or coppery hue, and this is by some authors considered as  characteris-
tic ;  when  present, it  may aid us very materially, but it should like-
wise be borne in mind that  it may accompany  any other affection
quite foreign to syphilis, and  thus  deceive the most  experienced eye ;
when this copper-colored appearance is absent, the  eruption may still 
256          SECONDARY SYMPTOMS ON THE SKIN.
 be syphilitic, as at their origin almost all secondary symptoms are not
 accompanied with this livid  tint, which only exists when they have
 lasted some  days or weeks.
   Little dependence can be placed on the mere circular shape, color,
 or thickness of the scabs, but, taken with other characters, they may
 assist the surgeon in arriving at a just opinion.
   Data on which to form an  opinion have been taken from the treat-
 ment by mercury, which, both  in  primary and secondary affections,
 was considered as  the touchstone.  We shall return  to this  point
 in  speaking  of the treatment; but we may here add, that although
 mercury be  of the  greatest  benefit, still secondary syphilis can be
 cured without it, and that, under certain circumstances, it will fail in
 curing some  forms.
   To sum up, then, the surgeon, aware of the difficulties which beset
 the subject, must be guided  by  circumstances ; a knowledge of the
 disease will often cause the judicious practitioner to be in doubt, where
 a  less practised one would  at once  condemn or  acquit.  Doubt is
 sometimes the result of knowledge ; here hesitation can do no harm,
 as time will usually clear up  doubtful points, and a rational diagnosis
 will only wait for further proofs to convert it  into a  positive one.
 This must be always the  case, until some one gives us  a boon, like
 inoculation, to distinguish with certainty what depends upon primary
 sores, and what on secondary.
   Prognosis.—When we  see an otherwise  healthy individual, soon
 after the occurrence  of secondary symptoms, which have broken out
 a few weeks  succeeding the cure of chancre by simple local  means,
 we may usually promise him  a speedy cure, provided  he will, for a
 few weeks, take those precautions  which we shall hereafter  recom-
 mend.  We may truly say  that there are few  affections which get
 well so rapidly, and yet which, when left to themselves, produce such
 serious  consequences.  But  too  often  our  prognosis is not  of this
 cheering nature ; the individual we have  to  treat is a debauched
 character, his constitution  is  impaired  by poverty, or some disease
foreign to syphilis;  he consults us at the latter stages, when already
the complaint has existed many months, or when it has followed the
injudicious use  of mercury  for primary sores, so that the system is
impaired, the  bowels disordered, and there is  a distaste for the further-
employment  of the mineral.  Lastly, when the patient will not sub-
mit to any fixed plans of treatment, but is determined to pursue his
pleasures; when he  exposes  himself to cold, and commits  all  kinds
 of excesses—then must our prognosis  be unfavorable ; and  it would 
SECONDARY SYMPTOMS ON THE SKIN.          257
be well for the surgeon, could he avoid altogether patients of this
description.   As we spoke of  the prognosis under the head of each
form of secondary syphilis, as well as under that of complications, we
think it unnecessary to revert to  these points, but  shall pass on at
once to the consideration of the
  Treatment of  Secondary Symptoms.—Had we not  already
described  the means of prevention, we should have  recurred to it
here ;  but enough  has been said  under the head of chancre.   By
taking precautions  against the occurrence of chancre, we necessarily
prevent secondary  symptoms, which are one of its consequences.
  If we are, or should be, so solicitous to prevent chancres, we ought
likewise to be equally anxious to curtail their progress; to strangle
the disease, as the French call it, while it  is still local, and by all
the means in our  power  counteract  those  causes which  we have
stated  to be  the predisposing ones ;  these  are means which must
occur to the most superficial observer, and the  best plan of carrying
them into effect we must leave to his judgment, thinking it would be
futile to mention them.   By the most simple  precautions, then, the
occurrence of secondary symptoms may be  often prevented—an  ob-
ject heartily to be desired.
  Under the head of Prognosis of Chancre, particularly that of the
indurated  form, the reader will find  this subject  treated  at  length;
and  that the employment of mercury is recommended, not only as a
cure for the induration, but likewise as a preventive against secondary
symptoms.  The reasons why mercury is useless for the same end
in other forms, is likewise there fully explained.
   Should, however, all  our means of prevention  fail, or  if  we  are
consulted  when secondary symptoms have already appeared, it will
be our duty to direct our attention to the
   Curative Treatment that medicine  offers.   In these cases
the first care of the medical man is  to remove, as far as lies in his
power, all the predisposing causes, or all such as may keep up  or be
likely to aggravate the disease.  Similar attention should  be paid to
the complications, which  must be treated on general  principles ; in
fact, let secondary symptoms be reduced to  their simplest expression,
as  the French say.  Had this principle been always kept in view,
we feel assured that humanity would  have had cause  to  rejoice.
Should any severe complications exist, let the original  disease be lost
sight of for the moment; there is no hurry to treat it, more especially
when other and more urgent symptoms exist; but, above  all things,
                               17 
258          SECONDARY SYMPTOMS ON THE SKIN.
let us caution our readers against believing that at this stage a specific
treatment is  required ;  unfortunately, syphilitic  patients have  been
too often treated on exceptional principles, and  the  non-observance
of the ordinary rules of medicine have led to the worst consequences.
  Although we are not  pupils of the non-mercurial school, still we
must render it the  credit of having impressed on surgeons the neces-
sity of treating syphilis  by simple means ; it is true that its disciples
have  been led into exaggeration ; that  they are unable  to maintain
what they advanced ;  but science is much indebted to them, and this
same  exaggeration has been perhaps of great use ; and Mr. Rose, if
he now lived,  would perhaps allow that he  purposely  exaggerated
the employment of simple means.
  Should our patient be plethoric, blood may be  taken from the arm ;
if he has been exposed to privations, let his diet be mild or generous ;
if his digestive organs are impaired,  let them be attended to, and
then let his diet be regulated according to his constitution and previous
habits.
  As long as  any  of  the acute  or  severe complications exist, the
surgeon  need  not turn  his  attention to  the specific diseases, which
will be found to have diminished very materially in intensity.   Many
persons believe that by the most simple treatment the specific disease
will altogether disappear.  That there is much truth in this statement
we have every reason to believe, but  the sword  of Damocles is sus-
pended over the patient's head, and he is exposed to a recurrence of
all  his  symptoms,  after a  shorter or longer time,  with redoubled
vigor ;  and granting that they disappear slowly, they reappear speedi-
ly and  severely.   Such are the reasons which induce  us to agree
with the followers  of Broussais in some, but  to differ from them in
other  points.  During the time  that we  are  treating the  secondary
symptoms, it should be our intention to eradicate from the  constitution
any syphilitic  tendency.   To the description of the proper means of
doing this,  we shall devote the following pages.
  Baths.—When the extent of the skin is considered, and when we
reflect on the influence that a due performance of its functions  must
have on the economy, we are not surprised at  the  effects that baths
may produce,  not only on skin diseases, but on the system at  large.
Those who have followed the practice at the Hopital St. Louis, must
well remember the success which attended the treatment  of M. Biett,
but they must have been been equally struck with the  quantity of
baths which he ordered  in that establishment, which furnishes many
thousands  annually.  The  advantages to be derived from them is 
SECONDARY SYMPTOMS ON THE  SKIN.          259
daily being appreciated in England, but their  exorbitant price will,
we fear, prevent them from being generally employed.
   When there is no irritation of the skin, the tepid bath is alone re-
quisite, and it may be repeated twice a week.   When, however, there
is a determination to the skin, or  any acute affection of the  general
integument, we should  strongly recommend  that a pound or two of
gelatine be added, and that the patient remain in the bath half or even
three quarters of an hour every other day, and this space of time may
be gradually increased to two or three hours; the temperature being
kept up by the addition  of warm water, or  by covering the bath with
a blanket.
   In  the papular  eruptions,  and  particularly in lichen, one  or  two
pounds of subcarbonate of potash may be added to the bath with  the
greatest benefit.
   In the  more chronic forms, when, instead of allaying inflammation,
it is our object to excite the  action of the skin, particularly in cases
of lepra and psoriasis, the addition of half an ounce of corrosive sub-
limate, gradually augmented to two or even three ounces, will be
attended with good effects ; but this remedy must never be used when
any ulcers are present, as its poisonous effects are of the worst  de-
scription.
   Equal  benefit may be derived from the use of a bath in which is
dissolved the sulphur et of potash ;  should much irritation result, gela-
tine or bran may be  added.
   The state of the bowels likewise must be  attended to.  We have
more  than once alluded  to the sympathy existing between the stomach
and the skin ; constipation should  be removed by gentle aperients,
but the employment of brisk purgatives ought  to be avoided as highly
prejudicial, particularly if the surgeon has the  intention, at a later
period, of giving mercury.
  The pharmacopoeia contains a variety  of substances which are
supposed to have an action  on the skin, and to produce diaphoresis.
Such are sarsaparilla and guaiacum ; the diet should be  light, and, to
produce the beneficial effects expected, the patient should keep his
bed during their administration.
  We shall not here speak of the advantages that iron, quinine, or
opium, may offer  in  persons  of scrofulous, feeble habits, in curing
nocturnal or rheumatic pains.
   Treatment of the Secondary Symptoms by Mineral Preparations.—
Having never seen the various preparations  of gold  employed, we
shall  avail ourselves of the remarks of M. Ricord on this subject. 
260         SECONDARY SYMPTOMS ON THE SKIN.

   In  secondary symptoms, gold  is the remedy on which  the  least
dependence can be placed.  The greater part of the symptoms reputed
to have been  cured by its preparations are far from bearing unequivo-
cal marks of the constitutional disease of syphilis, and when they are
given in well-characterized cases, or under circumstances when the
other  means, and particularly mercury, have failed, I  am doubtful
whether any benefit derived has not been rather due to the suspension
of mercury, than to the administration of gold.
   Gold, then, and its preparations are, in my opinion, a means to be
employed  when nothing else can  be  done.   As this is my personal
opinion, it can in no way affect  the interesting researches published
on the subject.
   The preparations of silver, under all the  forms I  have employed
them  in, according to the indications given  by Professor Serres of
Montpelier, have appeared  still  more uncertain  in  their effects, as
those  who have followed  my hospital practice can  testify.  When
employed  against primitive as well as constitutional  syphilis, begin-
ning by small doses, and increasing them  gradually up to the enor-
mous  dose  of sixteen  grains  daily, I  have been  unable to produce
other  effects than irritation of the  digestive organs,  a consequence
which has  induced me to abandon its use.
   Mercury.—The employment  of mercury  in its various forms, for
the cure of syphilis, is not of modern date; the advantages  of its
preparations were for so long a  time recognised,  that it was  heresy
to doubt their  efficacy, and it was the remedy employed to the ex-
clusion of all  others ; but that its administration was always followed
by success, admits of some doubt.  However, the necessity for em-
ploying this mineral was  admitted on all hands, syphilis and mercury
went hand in hand ; and even in works of the present day we find it
stated, that when mercury does not produce  its  beneficial  influence
on  the disease, the latter is of so rebellious a nature that no fault
ought  to be found with the preparation; that it should  be persisted
in, and the quantities employed should be in proportion to the severity
of the disease. However, as observation became more accurate, a
few hardy  practitioners (many of which do honor to our own country)
began to throw doubts on the advantage of  its universal  administra-
tion.   This opinion  found at first little  credit among  practitioners
generally: in vain were the lamentable accidents  of  loss of portions
of the face cited as proofs of  the inefficacy  of mercury in controlling
the disease ; a bad constitution was assigned as the cause, and converts
to the new doctrine followed  slowly.   Truth, however, here as else- 
SECONDARY SYMPTOMS ON THE SKIN.         261
 where, prevailed over prejudice ;  it began to be admitted that mer-
 cury would not cure all cases of syphilis, and it  was  asserted that
 the remedy was not even necessary.   In proof of these assertions
 the practice adopted in various countries was cited, and  history show-
 ed that the  disease had been cured without mercury for many ages.
 Two doctrines now prevailed;  the  one  absolutely declaring that
 mercury was the sine qua non in the treatment of syphilis ; that the
 cases said to have been cured were not those of true syphilis, but a
 bastard complaint,  having some points of analogy with it; and that
 in the cases of true disease, where  the remedy failed, it had not been
 employed in sufficient quantities.   The other doctrine continued to
 gain  ground, viz., that  syphilis could be cured  without having re-
 course to mercury ;  that  this supposed remedy was more prejudicial
 than useful; that, it caused all the mischief which it was intended to
 cure, and should therefore be excluded from all judicious practice.
 In consulting those authors who have written  on syphilis during the
 present century, this opinion is the  most generally received, notwith-
 standing that  many of those upholding the opposite doctrines are in
 high  favor  with the public.  In face,  however, of these opposite
"opinions, backed by names of great authority, the eclectic school arose ;
 on the one hand, they admitted  that  the administration of mercury
 was often attended with advantage ; history and daily practice proved
 this ; but, on the other, they held that syphilis was capable, in many
 instances, of being cured without mercury, and yet the  patient never
 suffered from  the  ill  consequences said to depend upon a non-mer-
 curial treatment.  Not contented, however, with these generalities,
 the eclectic  school began to observe the natural history of the disease,
 and carefully note what were the  cases  treated by  simple  means,
 which got  well  without  having recourse to  mercury.  The same
 clinical investigation enabled them to  watch those cases  which re-
 sisted simpler means,  and which improved immediately under mer-
 curial preparations ; they too first  pointed out the  injurious conse-
 quences of  mercury, under what circumstances it occurred, as  well
 as the means of cure.   It is to this  school we belong, and it is clini-
 cal observation, founded on and supported by  the opinions of others,
 which forms the basis of the treatment of syphilis  by mercury, to
 which we now call the attention of our readers.
  When the means previously described are made use of in seconda-
 ry symptoms, the major part will disappear ; this, however, will take
 place very gradually, and many symptoms will persist, in spite of all
 we can  do.  When even they yield  and disappear, they frequently 
262          SECONDARY SYMPTOMS ON THE SKIN.
return either in the same situation, or break  out  again after a short
interval, and often in  an aggravated form, on exposure to any of the
predisposing causes ; thus we have every reason to expect, that  al-
though the local disease be cured for a time, the general infection is
not removed; in fact, the syphilitic diathesis  remains ;  and when the
flame again bursts out, it is no longer so amenable to  our means  of
repressing it.  These are our reasons for considering the other means
of treatment  as valuable adjuncts, but  do not induce us to place im-
plicit confidence  upon them, especially when we consider that we
possess such a valuable  medicine  as mercury, which, given under
proper restrictions, seldom  produces  any unfavorable  symptoms or
effects which we can  not always remedy or prevent.
  There is no age or  temperament which counter-indicates its use ;
the sex does not prevent us employing it, although there are circum-
stances which should render us more circumspect.  In relation to
the period at which  mercury may be employed, experience  shows
that the sooner after the occurrence of the disease the  more efficient
it is, and the  less likely is it to return  ; for once it has gained a right
of possession, the more difficult it will be to expel it from the consti-
tution :  neither climate, nor  the  state of the season,  need deter us
from its use.   When mercury is used, it should be employed for a
specific purpose, and we should only leave it off when that has been
gained, or on the occurrence of any of the ill effects to be  mentioned
hereafter.  When the symptoms which  it is  our intention to combat
improve  under its use, the plan and the  dose we employ should not
be augmented, but steadily persevered in.   Should  the disease re-
main stationary, the dose may be augmented, or, should circumstances
require it,  the preparation may be modified j  the surgeon,  however,
must  be guided by individual cases,  as there is no form or dose ap-
plicable to all constitutions.
  On the action of Mercury in curing  secondary symptoms, theories
have not been wanting; but in  the present  day we  believe it  far
more useful to watch carefully its effects  on the system, than to bring
forward hypotheses as to whether it decomposes  the virus in the
blood, &c.   On one point  observers are pretty generally agreed, viz.,
that the exaggerated  effects of  mercury, such  as fever, diuresis,
diarrhoea, irritation  of the  skin, salivation, or certain nervous affec-
tions, are never beneficial, but should  be carefully watched  for and
avoided.  Before proceeding further, let us call  the reader's attention
more particularly to some of these, and especially to 
SECONDARY SYMPTOMS ON THE SKIN.
263
SALIVATION.
  On this subject we can not do better than extract the following ad-
mirable description from the work of M. Ricord :—
  " Salivation is a rare occurrence previous to teething, as  mercury
up to this period acts rather on the digestive organs, or on the skin.
It occurs readily in females, in persons of lymphatic temperaments,
in scrofulous habits, and especially in persons predisposed to scurvy ;
in fact, we observe it in all those who appear  to possess blood defi-
cient in plasticity.  Habitual constipation and decayed teeth especial-
ly predispose to it.  Changes of air, particularly when  these  occur
suddenly, have a  tendency to produce it.   Soluble  preparations of
mercury  excite  salivation more  easily than  those which are  in-
soluble."
   The quantity of mercury necessary to produce it is relative to indi-
viduals.—Salivation usually occurs during the first week of the  ad-
ministration  of the  mineral, and may follow twenty-four hours after
the  first dose, more commonly after  the  fifth day.  It is  liable to
occur after every augmentation of the dose ; but when salivation does
not occur at the commencement of the  treatment, it has little tendency
to set in at a later period.
   When salivation has not appeared eight or ten days after the sup-
pression of mercury, its  occurrence  is not  to be dreaded.  Cases of
this nature may justly  be  attributed  to ulcerative stomatitis,  which
may be readily mistaken for that which is  caused  by mercury.
   Mercurial Salivation,  Mercurial Stomatitis,  or Ptyalism, does  not
commence in the salivary glands ; at first they are but sympathetical-
ly  affected,  as  has  been proved  by pathological  anatomy.   The
augmentation in  the quantity of  saliva is the first  symptom  which
strikes the observer ; but it is the mucous membrane which is primari-
ly  affected.   The latter becomes partially or generally  swollen,  and
is  affected  with inflammation,  partaking of  the  oedematous  and
erysipelatous characters.  The patient perceives  a feeling of heat
and redness, as well as  a coppery taste in the  mouth ; the  teeth are
raised in the gums, moveable, and seem to the patient to be  separated
by some  foreign  body ; he believes  that they are longer than usual;
the tongue swells, and  this sometimes occurs to  so great an  extent
that it is incapable of being contained in the mouth, and may receive
 indentations from the teeth.   The gums and lips likewise swell, and
 the mucous membrane may become tumefied in the interval between
 the lower  and upper jaw.   In proportion as these symptoms are 
264
SECONDARY SYMPTOMS ON THE SKIN.
aggravated, so is  the saliva  found  to  be viscous  and abundant, and
to have what is called a mercurial smell,* a sort of metallic odor, that
may be perceived to some extent in other inflammations of the mouth,
but which in these cases is very well  marked,  and which may be
found previous to the occurrence of ptyalism.
  Wherever the swollen mucous membrane is pressed upon, ulcera-
tions, which are very much  disposed  to  bleed, succeed to the black
pseudo-membranous exudation on the  gums ; this  appears  to be the
result  of  gangrenous or diptheritic  inflammation.   As the disease
advances, the tongue may become gangrenous in  particular portions,
or in its totality; the mucous membrane of the gums may be sphace-
lated, so that, when cicatrization  occurs, the  mouth is closed; the
cheeks may be completely laid bare, the teeth fall out, and the bones
become carious or necrosed.
  Nevertheless, except in cases of a systematic obstinacy, at present
unpardonable, from rashness in the treatment, or under circumstances
of idiosyncrasy, which  are  very rare, severe cases of salivation are
so uncommon that I have seldom the opportunity of showing one  at
my clinique,  at the Venereal hospital, during  the course of the year.
More commonly the  salivation is partial, or becomes so as soon as it
is noticed, and  when we can check its progress.
   The lower gums first show indications of the  affection,  or it  ap-
pears on the  mucous membrane around  the dens sapientiae, more par-
ticularly when  it pierces late.  The  gums of the upper  jaw  subse-
quently become affected, particularly such as are placed  behind the
middle incisors; the borders of the tongue, the  cheek, and internal
part of the lips, become attacked  at a later period.   The palate and
back portion of the  mouth seem to establish a boundary to the affec-
tion which  is  seldom passed, except  in very rare  instances.   An
observation that I have  made repeatedly, and which I leave for future
observers to verify, is, that  partial salivation is  most frequently ob-
served on that  side of the mouth on which the patient lies.
   Salivation is rarely preceded by fever ;  the primary symptoms are
those observed in the mouth ;  but fever, though absent in the majority
of  cases, may, nevertheless, attend  it, particularly in the severer
cases, and may continue under a hectic form, when the patients have
severely, and  during  a long  period, suffered.   In  addition, other
symptoms, such as sleepiness, swelled  face, erysipelas, enlargement

  * In the twelfth number of the Experience for 1837, will be found some curious in
vestigations of M. Gmelin. which prove that mercury is present in the saliva.  I have
repeated these experiments without success.—P.  Ricord. 
SECONDARY SYMPTOMS ON THE SKIN.          265
of the glands of the neck, affections of the stomach or intestinal canal,
oedema of the glottis, and all the direct or sympathetic consequences
which flow from them, may occur.
  Salivation usually runs its course rapidly, and attains its height in
a few days ; but  provided the employment of mercury be persisted in,
or even when the disease is left to itself, or when it is kept up by
certain  accessory  causes, such as certain scorbutic affections which
have pre-existed or determined it, it may assume a chronic form, and
last an  indefinite  period.  However, in the ordinary run of cases,
when the cause which gave rise to it has been removed, and a proper
treatment been employed, seldom do we observe it last many weeks,
and most commonly we can  check it in a few days.
  Salivation frequently terminates in a  rapid resolution, more  com-
monly ulcerations follow, and gangrene sometimes succeeds.  Death
may result as  a consequence of mortification or  weakness brought on
by  vast suppuration ; by the excessive  flow of saliva;  or  from the
absolute impossibility  of  the  patient's  taking nourishment: such,
however, at the present day, very rarely occurs.
  The Diagnosis is usually very easy.  When  the  symptoms above
described  immediately follow a course of mercury, it is to this mineral
that we may reasonably attribute them.  Mercury is, in fact, the best
touchstone of  salivation, as the disease increases  if it be continued,
and gets rapidly well  when the  preparation is  altogether  omitted.
If some few syphilitic symptoms in the  mouth happen to be aggrava-
ted by its use, the greater part rapidly improve  under the use of this
powerful  agent; while, it always augments, and never cures, those
affections  which it has  itself  produced.  If,  on the other hand, we
take into consideration the situation of  the  syphilitic lesions of the
mouth and throat, their distinct character, their  chronic course, the
freedom from the  oedematous or erysipelatous  state of which we
have  spoken, accompanied,  as they are,  with  an induration very
different from that puffy  state of the mucous  membrane depending
upon  salivation ; the antecedents, the accompanying symptoms, and
the particular circumstances  under which  these lesions arise, and
when, above all, we add the effect of mercury itself, we shall be al-
ways able to arrive at least at a rational diagnosis, if not an absolute
one ;  in either case sufficient  to guide us in the employment of mer-
curial preparations.   The rigorous diagnosis in cases of aphthae or
simple ulcerative stomatitis is  not necessary, as any effects analogous
to those produced by mercury counter-indicate, as long as they last,
the employment of that mineral. 
266
SECONDARY SYMPTOMS ON THE SKIN.
   The Treatment of Salivation ought, in the first place, to be prophy-
 lactic.  Our primary object should be to remove the cause which has
 given rise to it, if that be in our power.  Diminish the doses of mer-
 cury, or give them at longer intervals, or suspend the employment of
 the  mineral  altogether.   As  preventive means, we should mention
 keeping the mouth clean, the use of  astringent gargles, and  the em-
 ployment of aperient  medicines.  Such  means,  if they do not alto-
 gether prevent, will at least  diminish, the  effects  of the disease.
 When, however, salivation has  commenced,  and  at whatever period
 of the disease we may be consulted, we  should employ that remedy
 which is the most powerful, and which never fails us:  this is, touch-
 ing the affected parts with pure muriatic acid.   Let the affected parts
 be touched daily with the acid, by means of a little piece of lint wrap-
 ped around a probe, care being taken that  the acid does not come in
 contact with the teeth.   When no  ulceration is  present, little pain
 will  be felt, but when such exists, the pain will  be  severe but mo-
 mentary, and the ulcerated surfaces  will bleed on each application ;
 the mouth should always be washed  out after the  use of this remedy,
 and  the  benefit which follows  will become in  a  short time  ap-
 parent ; the patients, instead of dreading, will claim a repetition of
 the treatment.  When no ulcerations exist, an astringent gargle may
 be prescribed ;  in other cases, one that is only slightly acid.  Lemon-
 ade is the most agreeable drink.  Circumstances  may arise in which
 aperients, leeches to the  base  of the jaw, and bleeding from the arm,
 may be requisite, and  the food should be in proportion to the patient's
 strength.
  It does not, however, suffice that the surgeon should be impressed
with the belief that mercury may be advantageously used in secondary
symptoms, that it should  be persisted in  as  long as it tends to cure
them, by improving the constitution, by exciting  the appetite, by re-
moving the  leaden appearance of the countenance,  by causing  the
 gradual disappearance of the symptoms.   We say, all this does not
 suffice to fulfil all the  indications, and prevent ill consequences ;  the
practitioner should be prepared to employ judiciously the divers prep-
arations of  the mineral, according to  the urgency  of the case, or the
particular form present; the best means, then, of doing this, it will be
our object to point out in  the following pages.
  Mercury in its various forms may be made use of  in two  ways :
first, either by causing it to be  absorbed  by the  skin, according to
 the endermic method, or  by its internal  administration.  There is a
 third plan, however, which we might allude to, that of  absorption by 
SECONDARY SYMPTOMS ON THE SKIN.
267
the lungs.   Although the Chinese still employ the latter at the present
day, this treatment is not had recourse to in Europe.
   Mercury may be administered externally in a variety of forms and
doses.   We shall only allude to such as are in general use.
   Mercurial ointment employed in frictions is a very valuable prepara-
tion, and has justly met with the approbation of surgeons.   It is par-
ticularly useful when we wish to bring the patient under the influence
of mercury very rapidly; it is likewise strongly recommended in in-
duration of secondary sores.   It is advantageous when the  intestinal
canal is unable to bear mercurial preparations, as not unfrequently
happens.
   The following simple rules may be borne in  mind during its  ad-
ministration.   The quantity used should not exceed a drachm, which
may be  rubbed in on the inner part of the calf of the leg or  thigh be-
fore the fire every other night; on the alternate days a bath should
be taken:  by this means there will be little  disposition to  irritation
of the skin, as the ointment  does not become rancid, and absorption
will be promoted.   The frictions should be made alternately on the
lower extremities.   They should be in the direction of the hair, as
the disease called  eczema  pilaris is thus avoided.  Instead of the
bare hand, a pig's bladder may be soaked in warm water and turned
inside out, and the hand thus enveloped  in a sort of glove  produces
less irritation, and the patient's fingers are not soiled.
   M. Cullerier has proposed  the plan of placing a drachm of the
mercurial  ointment in the arm-pit on going to bed, and desiring  the
patient  to sleep without  his shirt;  absorption will be thus produced
rapidly; this is more especially useful when any eruption or ulcers
exist on the legs, as the system becomes  affected without  any local
irritation.   Although  mercurial ointment is a valuable preparation,
still the dirtiness of it precludes its general employment, as conceal-
ment may be often necessary ;  but  when these objections do  not
exist, the surgeon may very beneficially employ this mode of treatment.
  Mercurial Plasters.—We have often had  occasion to observe  the
good effects  resulting from mercurial plasters, particularly one em-
ployed by M. Ricord,  called  emplatre de vigo sparadrappe ;  in  some
instances its effects have been  general, curing the  disease,  and  pro-
ducing an  effect on the gums,  after  the other  preparations have fail-
ed ;  usually, however, the beneficial results to be expected are purely
local.  When applied in strips, on chronic ulcers, on those papu-
lar  eruptions which assume a  chronic   form,  such as the corona
veneris and many others, it removes them, as by charm, a short time 
268          SECONDARY SYMPTOMS ON THE SKIN.
 after its employment.  We have  not  any remarks to  make on the
 employment of ointments composed of calomel or corrosive sublimate,
 as in secondary affections they are seldom to be used, and we  have
 spoken already of the use of the latter in baths, and of the rules which
 should regulate its administration.
   Fumigations.—This plan of administering mercury is not of modern
 date, and is a very powerful means ;  the following directions are laid
 down by M. Ricord.  Fumigations should be made every other day,
 employing  cinnabar at first in one-half-drachm doses, gradually aug-
 mented to two or three daily.  The patient should  have fasted five
 hours  before employing the fumigation,  and  immediately  after he
 should  retire to bed, as by these  means  absorption is favored; but
 no plan can be more prejudicial when the skin is irritable.
   Various  preparations of mercury  may  be employed  internally;
 among others, we may mention the blue pill, one of the most effica-
 cious preparations in the Pharmacopoeia; it has the advantage of crea-
 ting  but little disturbance of the digestive organs.  It may be given
 in doses of five, or ten, or fifteen  grs. daily;  however, on the first
 symptoms of diarrhoea coming on, it should be suspended.
   Calomel and opium, in the proportion of two  grains of the former
 to a  quarter or half  a grain of the latter, is a preparation often pre-
 scribed with advantage, when we wish to act speedily on the system ;
however, the tendency it has  to  produce salivation is  an objection
 against its employment, and we have rarely seen it given.
   Corrosive sublimate, as  an internal remedy,  should, we  think, be
 excluded from general use.  It has a great tendency to produce colic
 and  gastric intestinal irritation; and, although we  have seen it em-
ployed on a large scale in France, we have observed  few patients
 who  have been able to submit to it long enough to produce a complete
 cure  ; for this reason we prefer the
  Proto-ioduret of  Mercury.—This  preparation  is one now  very
 generally employed, particularly in the various forms of  secondary
 symptoms; it rarely  produces  any  gastro-intestinal  irritation, and
 still  less frequently salivation;  and when the first symptoms of the
 latter appear, a suspension of the  remedy causes  them to disappear
 immediately.   It should be  employed in  doses of  one  grain at the
 commencement,  in  the  form of pills ;  the dose may be augmented
 according to the rules we have elsewhere given ; that is  to say, if the
 symptoms  gradually  disappear under the employment of a  certain
 dose, continue it; if they remain stationary, increase it every five or
 six days, as experience shows this plan to be better than to gradually 
SECONDARY SYMPTOMS ON THE SKIN.          269
augment it.  The dose thus daily taken may amount to six grains,
and the  quantity required may be  often  as much as  two hundred
grains.   The exact quantity to be  taken  can never be accurately
stated ;  it must  of  course  depend upon a  variety of circumstances.
When the secondary symptoms have yielded, it  should not be laid
aside  at once.  The dose should  be gradually diminished, and then
left off, when we have reason to believe the  syphilitic diathesis has
been  removed, for it  is from inattention to these circumstances that
patients  are  subject to relapses.  When any one of these  prepara-
tions has disagreed and been laid aside, provided the symptoms be
not cured, some  other  form of mercury must be  used,  and  it often
happens that in a short time after the system will bear a preparation
which previously disagreed with it;  but this  must  be left  in  great
measure to the discretion of the surgeon.
   Before quitting the subject of the treatment of secondary symptoms,
we may pass in  review the treatment of the  various forms; merely
indicating,  however, those which require any modifications from their
form,  situation, &e
   In affections of the skin, which are  accompanied  by much local
irritation, or which assume an  acute form, gelatine  baths are very
useful ; in  cases of chronic skin  diseases, those which contain sul-
phuret of potash, or corrosive sublimate, should be employed.
   In  cases of papular  eruption, local frictions, with calomel, blue
ointment, or applications of the plaster composed of mercury and vigo,
may be employed with the greatest success, particularly when we wish
to cure rapidly those  on the forehead.  We can not here pass over
in silence the use of the tar ointment, composed of tar and lard;  in
lepra  and psoriasis this is attended with the happiest results.  The
patient should rub the parts affected  daily with the ointment,  and his
sheets and shirt should not be changed—he lives thus in a tar atmo-
sphere, and the surface is constantly kept covered with grease ; it is,
in truth, a  most unpleasant position, but we have seen  eruptions of
simple as well as syphilitic psoriasis yield in a  few weeks, which
had resisted all other means.  It  is  stated  by M.  Biett that such
treatment will not prevent a relapse ; this we believe, but we should
nevertheless employ it.
   The  mucous tubercles likewise require a  peculiar treatment;  al-
though  cleanliness and the general  administration of mercury alone
suffice, still  the  following local  treatment may be employed.  Let
the tubercles be washed twice a day with the solution of the chloride
of soda, of  such  strength as to produce a pricking in the  parts ;  when 
270
SYPHILITIC AFFECTIONS
dry, let calomel be sprinkled upon them, and dry lint kept  between
the excoriated  surfaces.  In a few  days  the benefit will become
visible, and a cure will take place.   The disease of the patient repre-
sented in plate V., fig. 1. was thus cured in fifteen days.
                        SECTION  III.

      SYPHILITIC AFFECTIONS OF THE MUCOUS MEMBRANE.

  Every portion of mucous membrane which the eye during life can
observe is, like the skin, subject to become the  seat of secondary
symptoms ; thus the lips, inside of the cheeks, tongue, fauces, and
throat, furnish the  most unequivocal and characteristic features of a
constitutional  affection ;  not only the  margin  of the anus,  but the
inside of the  intestine  itself, may be the  seat  of the disease ; the
lining of the  prepuce may likewise  give undoubted evidence of the
same fact, as  seen in plate IV.  The use of  the  speculum daily
makes us acquainted with the  fact, that the vulva, vagina, and neck
of the uterus, are the seat of lesions  which may with justicebe attrib-
uted to constitutional syphilis.  To the description of these we shall
now direct the reader's attention, and we hope to be able to furnish
a more complete history of  the secondary affections of these parts
than has  hitherto  been given,  for  it is a subject on which we have
bestowed particular attention.
  As it is in the mouth and throat, however, that we have been  enabled
to watch the course and  progress of secondary  symptoms most fre-
quently, we shall more particularly allude to them in those situations,
but our observations will apply to every syphilitic affection of these
parts.

     SYPHILITIC AFFECTIONS OF  THE MOUTH AND THROAT.

  The interest which must  attach itself to the  subject  of syphilis
particularly when the mouth or throat is the seat  of the affection, and
the few pages  that have been devoted to its description and treatment
in works on venereal diseases,  will,  I trust, be a  sufficient excuse  for
bringing forwrard here this regional sketch. 
OF THE MUCOUS MEMBRANE.
271
  Some  pathologists, and Cruveilhier among the number, have ex-
pressed surprise at the tendency of syphilitic disease to break out in
the  throat; but when the anatomical relations of the throat are con-
sidered, when the great number of blood-vessels there met  with is
borne in mind, when it is remembered  that the mouth is supplied
with nerves  from numerous  and different sources,  and  when we
recollect the  sympathies existing between the throat and  mouth and
the  various part  of  the economy—when we call to mind, likewise,
the  influence  that puberty exercises on the  genital organs and those
parts contained in the throat, we can not be much surprised that in a
disease  like  syphilis it should  so often become affected as it  is.
The throat, from its functions, is  frequently exposed to changes  of
temperature,  and  first  feels  the effects of all  excesses ; these cir-
cumstances, however, will be further alluded to in speaking of the
various  forms of the affection, which I shall  at  once proceed to
describe.
  Clinical observation proves that syphilitic  affections of the mouth
and throat present  various appearances, have separate  terminations,
give rise to different prognoses, and require each a peculiar  line of
treatment.  I shall then follow what I believe to be a natural division
of the subject, which I hope will possess  the further  advantage  of
rendering clear and concise a very difficult  part of pathology.
  These affections  may be divided into three classes—
  1. Primary affections ; 2. Secondary affections ;  3. Tertiary affec-
tions of the mouth and throat.
  The following cases will, I think, prove  that primary  affections
of the mouth and throat do exist;  and as  I am not aware of the
details  of any others in any work, I  transcribe them in  full from my
case-book.

                      PRIMARY AFFECTIONS.

  Case I.—On the  26th of February, 1839, a man forty  years of
age, of dark complexion, and small in stature, presented himself at
M. Ricord's out-patient  room  at the Hopital du Midi, and  requested
that professor's opinion on the treatment of a chancre existing at the
root of  the penis ;  accidentally, as it were, he  called  M. Ricord's
attention to something unusual which he felt on the fraenum of the
tongue.   On  examination, a sore of a size of a  small split pea was
observed in this situation, perfectly circular  in  shape ;  the mucous
membrane seemed as if it had been punched out;  at the bottom of 
272
SYPHILITIC AFFECTIONS
 the ulcer a yellowish matter was seen;  the edges  were  somewhat
 raised, and surrounded with a scarlet-colored areola.   The  mucous
 membrane in every other part of the mouth was perfectly healthy.
   On account of the suspicious appearance of this  sore, M. Ricord
 admitted  the  patient, and desired  his  house-surgeon to  interrogate
 him as to the cause of the affection.   The patient gave the following
 account of himself.   A fortnight previously he went to a masked ball
 with  a prostitute, drank freely during the evening, and acknowledged
 not only having had connexion with this female in the usual way, but
 admitted that in a moment of laisser oiler he exposed his  tongue to
 the chances of contagion.
   The appearance of the sore, and the  confession of the patient, led
 M. Ricord to consider this as a primary syphilitic affection;  but still
 aware of the difficulties which such cases present, and wishing to
 come to a positive and not a rational diagnosis, he determined upon
 testing it by means  of inoculation, and consequently inoculated  the
 left thigh with the secretion of  the sore on the fraenum linguae; on
 the following morning  the characteristic pustule* began to appear,.
 went  though the regular  phases of the artificial  chancre, and conse-
 quently left no doubt in the mind of M. Ricord that  the sore on  the
 tongue was a chancre contracted in the  disgusting manner above
 alluded to.  The chancres on the penis and fraenum, as well as that
 which resulted  from  the inoculation of the virus, were allowed to
 remained without any local or  general treatment, to enable the pupils
 to watch the natural course of the disease.
   I find in my case-book the following note :—
   March 9, 1839.  The  ulcer on the fraenum appears cured, the ap-
pearances  described  as  existing on his entrance have disappeared,
 and there remains only a pearly-white cicatrix.  The artificial chancre
is of the size of a split pea, the bottom covered with a yellowish sub-
 stance, and the edges of  a bright redness.
   The caustic was applied to the cicatrix on the fraenum (to-day, 9th
of March), to the artificial chancre, and that on the root of the penis ;
aromatic wine  and lint  ordered to be kept constantly applied on the
ulcers.
   March 21.   This patient went out perfectly cured.
   Case II.—M. Ricord has kindly communicated to  me the follow-
ing particulars of a case on which he was  lately consulted :—
   A patient presented an indurated sore on the mouth, accompanied
 with a lenticular eruption on the abdomen, leaving no  doubt in  M.
                          * See  page 176. 
OF THE MUCOUS MEMBRANE.
273
Ricord's  mind  that this man was suffering under secondary symp-
toms ;  he denied,  however,' ever  having had chancres on the penis,
but, on being pressed, admitted that  he had  exposed his  mouth to
contagion with a female who had come likewise to consult M. Ricord
no traces of disease were present on the external organs of genera-
tion, but  by means of the speculum a sore was distinctly seen on the
neck of  the  uterus.  This female presented, likewise, traces of a
lenticular eruption on the abdomen.
   Case  III.—Some months previous  to the occurrence of the last-
mentioned case, a poet of some celebrity  consulted M. Ricord for a
sore throat;  on looking into the throat, a distinct ulcer at the back
part, unaccompanied with any other disease of the mouth, was evi-
dent ;  around this  sore there was some redness, but otherwise the
mucous membrane appeared quite healthy; no  enlargement of the
glands of  the  neck was  present.   On questioning this patient, he
avowed that in a moment of exaltation he ran the risk of direct con-
tagion.  The thigh was inoculated with the  secretion of the sore on
the  pharynx, and  an artificial chancre followed on the  inoculated
point.
   A mild  nutritious diet was ordered, the ulcer was cauterized, and
the patient got rapidly well without the use of mercury.
   Since my  return to London I have met with  two cases  of what I
believe to be primary syphilitic affections of the mouth.   The first
 example presented itself on the under  lip of a dressmaker ; in size it
 was about as large as a shilling, and had all the characters of sores
 of that  size  on  the organs  of  generation.  The  existence of  all
 syphilitic  affections,  past  or present,  was denied, and, as far as my
 examination went, there were no traces of syphilis.   This  patient
 attributed the sore to the habit of putting pins in her mouth.  It be-
 gan, like a  pimple,  three weeks previous to her admission  into the
 hospital.  Inoculation  was  not  attempted, but  the gentleman who
 treated her, believing this to be a syphilitic sore, prescribed blue-pill
 twice a  day, and  the patient left  quite  well.
   The second case occurred in a young man who acknowledged tha
 it was probably a chancre; it became indurated, and after cicatri-
 zation the under lip was twice its natural size in the centre.  Mer
 cury was given, and the swelling and induration rapidly yielded.
   Mr. Lawrence  has  permitted me  to  mention that a case of this
 nature fell under his case some time  ago.   A  young man consulted
 him for a sore on the lip, which, observed  Mr.  Lawrence, presented
                                18 
274
SYPHILITIC AFFECTIONS
so much the characters of chancre, that I did not scruple to tell my
patient, that if the sore had been on the penis, I should have declared
it to be lues.   The patient then avowed that my suspicions might be
well founded, as he had exposed  his mouth to the chances of conta-
gion with a prostitute.
  M. B. de Leury, the surgeon  to  those prostitutes under the  care
of the police in Paris, told me that from time to time he meets  with
primary sores on the mouths of these unhappy creatures ; and this is
not surprising, when we learn from Parent  Duchatelet" Sur la Pros-
titution,"  that " II est peu  de vieilles  prostituees  qu'on ne puisse
ranger parmi les tribades."—tome i., p. 165.
  The preceding cases show that the  anatomical characters of prima-
ry sores on the mouth and throat  are  similar to chancres occurring
on any other part of the body; they likewise prove that in good con-
stitutions the disease may limit itself, and get well under very simple
means ; but should  phagedena or gangrene attack this specific  sore,
the course of the affection may be altered, and it may take on all the
severity that chancre, complicated with gangrene  or phagedena,  else-
where assumes ; the  soft palate may be  moreover destroyed, and
necrosis of the surrounding bones take place, with all the consequen-
ces which these accidents may entail.
  The cause of the affection I have traced, in the above and in some
other cases, to direct contact of the mouth with a  chancre, and inocu-
lation has shown that the sores were  identical;  but  I believe  that
mere contact of the  secretion of a chancre and a sound surface,  be it
mucous membrane or skin, is not alone  sufficient, in  order that the
virus produce its specific effects.   I  believe, judging  from what I
have observed elsewhere in investigating  inoculation,  that it  must
remain  a sufficient length of time on the mucous surface to destroy
the epithelium ; should it have introduced itself into a mucous follicle,
the lining probably is destroyed before the pustule becomes developed ;
should, however, the virus have come in contact with an excoriated
surface, or one  deprived of epithelium, mere  contact  seems to be
sufficient, as a chancre will  be  immediately developed.  The  above
opinion is confirmed by the impunity with which many  persons have
swallowed pills containing syphilitic virus mixed with bread crumbs ;
and this leads me to mention, that if  the virus be mixed with much
foreign matter, the probability is that it will produce no  effect, unless
there is a lesion of continuity.  These remarks are  not  without prac-
tical importance, as they  tend to explain the reason why primary sores
 are uncommon in proportion  to the number of  cases of exposure to 
OF THE MUCOUS MEMBRANE.
275
contagion, and from the accessory conditions which are necessary for
the occurrence of the disease.
   The  immediate cause, or syphilitic  virus, may (as probably hap-
pened in the above-named cases) come  directly in contact with an
excoriated or abraded surface, or at least with one deprived of epithe-
lium ;  I believe that this is the usual means of contagion.   Previous
writers, who have admitted the  existence of  primary  sores  on the
mouth,  think that the virus may be transmitted through the medium
of various agents.   Thus, Cullerier believes that tobacco-pipes, drink-
ing-glasses, &c, may transmit the disease from one  individual to
another.  Of course it is not my intention  to question the truth of the
facts  advanced ; but  in  my long study of  the  disease in hospitals, I
have never seen a case which might reasonably be attributed to such
a source ; it  is  true  that  patients will often attempt to explain the
presence  of these  sores by tobacco-pipes, &c, to conceal the true
means by which the disease has been contracted ;  but  I have,  after
gaining the confidence of the patient, too often learnt that this was
only a fiction to  conceal  the source of the affection, as well as the
depravity  of the  patient.
   I believe that this means of transmission is possible, but that  it is
very rarely met with, from the following circumstances :  1.  Chancres,
or rather primary sores on  the mouth, are very rare, for reasons stated
above ;  hence the possibility of  transmitting the virus from them by
means of  glasses and tobacco-pipes must be very rarely  met with ;
for we are no longer under the impression that chancre on the penis
can infect or render contagious  the  other secretions of the body, or
that the breath of an individual can infect  another by whispering, or
that a kiss may be the means of conveying  the virus, unless a chancre
exist on the lip.
   Should, however, a chancre exist on the mouth, and the secretion
soil a pipe or glass, that  pipe or glass may communicate  the affec-
tion ;  but  even  this must  be rare, for  the virus will become mixed
and diluted with  sajiva, which, although it does not destroy the effect,
will  nevertheless diminish the probability of  its  action;  and if  no
excoriation of the mouth or abrasion of the mucous membrane exist,
probably (from what we see elsewhere) no chancre will follow even
the introduction into the mouth of the contagious principle.*
   These reasons induce me to ask if certain writers have really seen
primary affections of the mouth and  throat ?  I am well aware of the
high authorities  whom I  criticise; but although they describe  the
              * Vide Ricord, Trait6 des Mai. Vener., passim. 
276                 SYPHILITIC AFFECTIONS
affections of the mouth as primary, they still seem  in doubt  on the
point in the observations they make, 'and allow that the diagnosis is
very difficult, in some cases almost impossible.
   Mr. Colles states, in his valuable treatise on the venereal disease,
that these primary syphilitic sores on the mouth are not of uncommon
occurrence  in  Ireland, and that he knows of no disease which is
more  contagious—not even the itch.
   I have carefully read over the cases which he  has given, but I am
obliged to  acknowledge myself unable to decide upon their  nature.
I have seen in the Foundling hospital at Paris a disease so similar to
what  he has described as syphilis, and which the French, in its ulcera-
tive stage, call muguet, that I am almost inclined  to think he has been
mistaken in his diagnosis.
   This disease, which Monsieur Guersant has so well described in
the French dictionary of Medicine, reigns epidemically, may attack
the mouths of persons of all ages,  though usually seen  in  children,
and may be  communicated to the nipples of nurses ;  and M. Guersant
thinks that  the sores which arise on the  nipples are the effect of a
direct and mechanical action, which determines a local inflammation
of the same nature—a result  which may be compared to pseudo-
membranous irritation arising on a finger which is constantly sucked ;
although (continues the same author) it is epidemical, still  it  is not
contagious, for notwithstanding the children  drink out of the  same
cups in the hospital, 1 have not remarked that  it is  communicated
from  one  to the  other.  I would ask,  therefore, Mr. Colles, if the
cases he has described may not have been ulcerative muguet, occur-
ring epidemically in families, submitted  to the  same influences  of
damp, clothing, and food.*
   Symptoms.—These,  I  think,  have been  described at  sufficient
length in  the above  cases, and  as they resemble  those  of  simple
ulceration, I have nothing to add;  they are usually slight, unless in-
flammation or gangrene attack the sore.   Under these circumstances
they may become very severe.
   Diagnosis.—When a sore exists on the lip or  tongue, I  need not
state  that its character may be easily studied ; but when the surgeon
(and  I of course address myself now to the young surgeon)  is con-
sulted for some affection of the throat, as is often the case in hypo-

  * The same observations may be made relative to the cases of John Hunter, which
he believed were not syphilitic, but which he classed under the title, " Diseases resem-
bling Syphilis," which his learned commentator, Mr. Babington, like Mr. Colles, says
he has no doubt were syphilitic. 
OF THE MUCOUS MEMBRANE.
277
chondriacal patients, it is not always easy for an inexperienced eye to
decide if an ulceration exist, more especially if the patient be suffer-
ing, or has had syphilis, and complains of the throat.*   I had an  op-
portunity of seeing a case  which impressed this on my memory, in
the month of February, 1839.
   A young  man complained of great inconvenience in his throat, and
consulted M. Ricord, fearing  that  he should lose  his palate.   He
stated that,  several months  previously, chancres had appeared on  the
penis  a few days after connexion with a  female  who  was diseased;
notwithstanding the employment  of mercury and sarsaparilla, a hard
point remained in the situation which the chancre had  occupied, and
was excised by a country surgeon.  The wound healed in a few days,
and he has  suffered no  further inconvenience from the complaint until
lately, when he has felt inconvenience in his throat.
   On  looking  into the mouth,  the mucous membrane  is  perfectly
healthy, but at  the posterior part, and on  the amygdalae, the following
appearances are seen :  the surface, instead of possessing its natural
color, viz., a rosy tint, like  that of the lips, presents a mottled charac-
ter ;  some  parts  are  white, and  others  red, and pus  is irregularly
spread over the  whole.    Some persons  who witnessed this appear-
 ance of the throat for the first  time, considered  that an  ulceration was
present, and the  history of the  case seemed  to render  it  probably
 syphilitic ;  but on wiping the  parts with lint on a probe, and viewing
 the throat in a good light, vessels were seen traversing these supposed
ulcers.  Not unfrequently these same  appearances have presented

   * To gain a good view of  the throat, the surgeon will do well to employ Dr.  Holt
 Yates' Speculum Oris. This useful little instrument was introduced to the profession
 by Dr. Holt Yates of London in the  year 1826, since which  time he and others have
 been in the habit of employing it, both  in private and public practice,  with great ad-
. vantage, in all cases in which an accurate and extensive view of  the fauces was re-
 quired.  To the surgeon it is of essential service in the removal of tumors, or when
 called upon to perform any similar operation about the tonsils.  By its aid, not only may
 the jaws be distended without inconvenience to the patient, and the adjacent parts pro-
 tected  from injury, but the operator  is enabled to see what he is about, take his  own
 time, and to have both his hands at liberty.
   The facility of observation and precision which it affords to the medical attendant in
 important cases is incalculable ;  and being made of silver, the most fastidious person
 can not object to its use. The instrument is perfectly simple, and tells its own story.
   It consists of a graduated hoop, with a sliding button, so placed that it may be regu-
 lated according to the age  of the patient and other circumstances.  Being gently
 pressed upon  above and below by the teeth, the spatula, which is concave, and slightly
 inclined downward toward the extremity, depresses and protects the tongue, and thus
 an extensive and uninterrupted view of the fauces is obtained.
   Any gentleman wishing to see the speculum may do  so by applying to Mr. Ferguson,
 surgical-instrument-maker to St. Bartholomew's hospital, London. 
278                 SYPHILITIC AFFECTIONS
themselves  to  my  notice, and it  has been  only by looking for the
vessels that I  have been able to decide if an ulcer really existed or
not; it was, I believe, Boyer who  first pointed out  the error the sur-
geon may fall into,  and the means of avoiding it.
   The young surgeon should be aware that the glands on and around
the tonsil  are  sometimes very large, and when  their  secretion is
adherent, this natural  state of the  parts may be mistaken for ulcera-
tion ;  in  such a case, the use of a probe  covered with  lint will re-
move all doubt as to the nature of the appearance.*
   I may likewise state  that  stimulating gargle, aperient medicine,
and a nutritious diet, will  in  a few days  cure these simple cases of
irritation, or the mottled state of the throat.
   Primary syphilitic affections of the mouth and throat  may be mis-
taken  for various simple affections of  these  parts.   I have already
alluded to  the  Thrush in a  state  of  ulceration, which, although in
ordinary cases it may be easily distinguished, still in a great number
can only be known by a consideration of the cause, form at the com-
mencement, general symptoms, knowledge of the epidemic, or spo-
radic cases, &c.   Still,  however,  if the surgeon bear in mind that a
chancre  is unattended with any affection of the gums or  mouth, that
it  is usually isolated, that it occurs in persons otherwise in a perfect
state  of  health, and is  unattended with any general symptoms;  on
the contrary, that the aphthous disease termed Thrush attacks sev-
eral parts of the  mouth,  and particularly the gums and throat, is pre-
ceded  and  accompanied by fever, disorder of  the digestive functions,
and of the other mucous membranes, and frequently with affections
of the skin, which assumes a purple  appearance, and may terminate
fatally by wasting of the patient's  strength in a short space of time;
that it occurs in moist,  damp, or  ill-ventilated situations, either spo-
radically or epidemically, and consequently  must not  be confounded
with the contagious nature of other diseases—I say, considering this,
he will pause before attributing the affection to syphilis, the primary
form of which is very rarely met with in this  situation.
   This  affection might be  sometimes confounded  with  ulcerated
aphthae of  the  mouth, the consequence of indigestion, or ulcerations
of the gums brought on by decayed teeth, or caused  by tartar accu-
  * It may seem puerile in me to lay so much stress on points  which may appear so
easy of decision; but I frequently see cases in which ulcers are overlooked; few
patients know how to open their mouths; others place their tongue in such a position
that it is next to impossible to see  anything.  I find that the manner of opening the
mouth,  and keeping quiet the tongue, should be learned previous to the use of the
spatula, which often produces a convulsive  action of the lingual  muscles. 
6F  THE MUCOUS MEMBRANE.
279
mulated  around them ; but it is  only necessary to allude to these
causes, to prevent any one mistaking the effects for those of syphilis.
   Primary affections  should  be distinguished  from the  secondary
ones ;  but I  shall defer the consideration  of  this  subject for the
present, until I have treated of the latter.
   Prognosis.—It is of no little importance to form a correct opinion
of the nature of an ulcer on the mouth or throat, as the prognosis
will materially  be  altered  by it.   A  chancre  on  the  mouth  of a
healthy individual  will, by proper treatment, speedily get well, and
in this respect  differs  greatly from  all other affections.   Should  it
occur in a person of bad or broken-down constitution, either from bad
living or dissipated habits;  should it become complicated with gan-
grene or phagedena, the situation of the parts must lead the  surgeon
to dread the loss of the palate, exposure and necrosis of the bones,
and their consequences.
   On the probability of the occurrence of secondary symptoms, the
same rule holds good, here, as in other parts of the  economy;  they
are to be expected, not in proportion to the number, size, or length
of time of the  existence of  the  chancres,  but in proportion to the
number of cases attended with induration.   What the relation is be-
tween induration and secondary symptoms I  can not stop here to in-
quire ; but it is a fact well supported by statistics and daily observa-
tion, that secondary symptoms will follow simple chancre in  a feeble
proportion, whereas scarcely  one person will  escape  constitutional
syphilis, who  suffers  from indurated  chancre:  it  was  for  these
reasons, probably, that our great master, Hunter, refused to designate
as syphilis any sore which was not indurated.
   Treatment.—The first  indication to be followed is  the  removal
of any cause which can  increase or keep up the affection.  In the
first instance we need not pay any attention  to the specific disease ;
if inflammation be present, the usual antiphlogistic remedies  must be
had  recourse  to ;  if there be decayed teeth in the gums, they  must
be extracted ;  if any disease of the digestive tube exist, it should  be
combated with the usual  remedies : having, then, reduced the affec-
tion  to its  simplest state, the surgeon may turn his attention to the
specific disease, which in the previous pages I  have induced him to
believe is local, is  a surface secreting a specific  virus, and  conse-
quently to be  destroyed as  soon as possible.  The  best  agent for
doing this is a finely-pointed stick of nitrate of silver,  with which the
ulcer should be lightly cauterized, and the operation may be repeated
as often as the little eschar falls off, until cicatrization be complete. 
280
SYPHILITIC AFFECTIONS
   In the majority of cases no other  treatment is requisite ; should
induration exist, this treatment must be varied ; cauterization is then
of little  avail;  cicatrization will not  occur, or if it does, the sore is
liable to break out on the slightest irritation.  Mercury, which in  the
former case I objected to, is now of the greatest  benefit.   Under its
use  all  induration ceases, the sore cicatrizes kindly,  and secondary
symptoms will most probably not follow.   However, the best plan of
employing  mercury; the reasons for employing it in frictions or in-
ternally ;  the preparations  which  are preferable;  the dose ;  the
quantity necessary for  the cure of the affection; the  abuses  in  its
administration; and the ill consequences to which it gives  rise—are
points which I have treated of very  fully, when speaking on  that
subject,  at page  260, to which I must refer my  readers for further
information.

  SECONDARY SYPHILITIC AFFECTIONS OF  THE  MOUTH AND
                           THROAT.

  If the primary form of syphilitic affections of the mouth and throat
be rarely met with, and have been, by those authors who consider it
a common affection, confounded with other diseases, it is no less cer-
tain that  the secondary form which I am about to describe is of every-
day occurrence, and has  been very well  depicted by authors who
have written  upon syphilitic affections of the throat.   The  diagnosis
and  treatment have  not, however, been noticed  in the manner  that
the subject deserves; and trusting that I may be  able to throw some
light upon this affection, I shall  treat  of it  as  if nothing  had  been
written upon the subject; taking my  descriptions from nature, and
illustrating my views by cases which have fallen  under my own
notice.
  I extract the  following case from my note-book :—
  February 1st, 1839.—The  patient who occupies the bed marked
twenty-eight  in the second ward at the Hopital du Midi, presents  the
following symptoms:—
  No eruption on the abdomen or extremities;  on the scalp two or
three impetiginous sores are observed.   On the  penis an  indurated
sore completely surrounds the base of  the glans.  The throat is red,
particularly at the  back part, on the  pharynx and uvula.  We  ob-
serve on the  tonsil of each side  a whitish  semicircular character of
the size of a silver  penny, giving the  tonsil the appearance of an  ex-
coriated  surface.  Lint wrapt round  a probe, and  rubbed  over  the 
OF THE MUCOUS MEMBRANE.              281
surface, does not remove this tenacious pearly-white substance.   The
amygdalae are somewhat swollen ;  the speech is little altered, degluti-
tion good, and  no pain in the throat, but the patient complains of a
constant source of irritation there.   (See plate VI., fig. 1.)
   The patient gives the following account of himself.   Has enjoyed
excellent  health.  A year ago he  contracted a gonorrhoea,  followed
by chancre and bubo.  Was  treated for these complaints in the Vene-
real hospital during the month of  August, and left cured in the com-
mencement  of September.   Since that  period  has repeatedly con-
tracted fresh chancres, and has treated them with the aromatic wine.
The indurated sore on the penis he states to have  existed about two
months ; has employed no treatment, except the local application of
the aromatic  wine, which he finds diminishes and has benefited vastly
the sores.
   Has been liable to the uneasiness in his throat for some time ; can
not exactly say how long, and attributes it  to exposure to cold.  He
is a wagoner.
   M. Ricord ordered this patient a simple  gargle, and to continue
the aromatic  wine as a local  application to the chancre ; wishing to
show his pupils the effect of a warm atmosphere and good diet.
   February  15. The  condition of the patient has not altered.
   March 11.  This patient now takes four pills, containing each one
grain of the  proto-ioduret of mercury daily ;  he commenced with one
on the 15th of February.
   March 18. Went out perfectly well to-day.
   The preceding observation may give the reader a good idea of what
I believe to  be a secondary sore-throat; an  affection which may be
met with very frequently in private and  public practice, and into the
history of which I shall at once enter.
   The Anatomical Characters  of  secondary  syphilitic affections
of the mucous membrane are, generally speaking, very characteristic.
A redness appears on the  surface ;  the centre of the red circle be-
comes pale,  extending in size  until it  attains  that of a sixpence.
Very often several points  take on this character, and coalesce ; thus
neither  the  circular nor semicircular appearance  persists, but the
affected points present an irregular  patch of whitened epithelium,
which resemble the skin on a washerwoman's hands, or the appear-
ance of the finger which has been covered with a  poultice.  If  any
attempt be made to remove this whitened patch, it will be found very
adherent to the tissues beneath ; and I have never been able to satis-
fy myself as to its nature,  viz., if it be simply the epithelium altered, 
282
SYPHILITIC AFFECTIONS
or if it be a secretion superadded to it.   I am induced to lean to the
latter  opinion, as the centre of this bleached surface may be raised
above  the  level  of  the  surrounding  healthy mucous membrane.  In
many persons only one of these patches of a circular shape, as thus,
0 is  met  with.   One circle may intersect another, so that a patch
of mucous membrane may contain several imperfect circles, as VA^ ■
It is only the mucous membrane here represented between the lines
that is affected, giving the throat the appearance of containing so many
semicircular bands of swollen mucous tissue, and this appearance we
have in vain sought for in other diseases.  These patches are spread
in great quantities over the mouth, gums, tongue, pharynx, or  uvula.
Usually there is  no  redness of the  mucous tissue around, but compli-
cations may supervene.   Thus I have frequently witnessed an ery-
thematous blush  surrounding each patch ; ulcerations may take place
on the whitened  surface, in the form of points, which unite, and the
entire  bleached  appearance is destroyed, or only remains at the cir-
cumference, in the shape of a grayish fringe.  I have often witnessed
these  white patches remain in a stationary state during entire months,
particularly when the patient  is  not exposed  to cold or damp, and
even under simple care they may disappear, but such a circumstance
is very rare.  They  usually  become, sooner or later, the seat  of
ulceration,  which destroys the surrounding part, and the sore,  which
at first  extends only in circumference, at a later period, particularly
in bad constitutions, gains in  depth, and assumes a dirty unhealthy
character;  inflammation or gangrene may seize upon it, or if neg-
lected, it may become what I shall hereafter describe as the tertiary
form of sore-throat, causing destruction of the deep-seated tissues, and
a loss of the palate, nose,  &c.
  These are the anatomical  characters of the affection ;  such is the
course of the disease ; and it will  be at once seen that, commencing
at the surface, it gradually gains the deeper  tissues ; but it is  a
peculiarly  chronic  affection,  unless some  complications interfere
with it.
  Situation of  the Patches of Ulceration.—This subject is not
without its interest  in several points of view;  most, frequently the
patches are observed on the amygdalae, or on the sides of the tongue,
or close to  the fraenum on its under surface ;  they are met with, though
less frequently, at the corners of the mouth, and  they here soon as-
sume  the appearance of scabs, which are very  characteristic, and
liable to bleed when the mouth is examined.   Sometimes they are met
with on the dorsum of the tongue, here assuming an elevated charac- 
OF  THE MUCOUS MEMBRANE.             283
ter, like the condyloma around the anus.   There is at present (Octo-
ber, 1840) a case of this description under the treatment of Mr. Law-
rence,  at St.  Bartholomew's hospital.  More rarely this  form of
disease  is seen on the back part of the pharynx;  on the  uvula  it is
so rare that I can recollect but a very few cases, although it may oc-
casionally occur, as I witnessed  a case lately in  Lazarus' ward.
The importance of these observations  will appear  hereafter, in treat-
ing of the other form of syphilitic sore-throat.
   Causes.—In  tracing back the history  of  patients affected  with
this disease, it will be found that, in the adult, chancre has preceded
or co-exists;  in  the infant, on the contrary, a chancre will be rarely
discovered as the antecedent, but the  mother  will be found to  bear
traces of primary sores, or it will be ascertained that she is suffering
under secondary symptoms, which she has transmitted  to the infant
during utero-gestation.
   Although we thus  trace the disease to chancre, or to  constitutional
infection, it  is no less true that all chancres do not necessarily  give
rise to this affection.  Fortunately for  humanity, the greater number
of primary sores are not followed by these appearances, but observa-
tion proves that, in a great majority of  indurated primary sores, these
appearances will be observed ;  and on  interrogating the  patient it will
be discovered that an indurated chancre has preceded them.
   Usually, however, the  indurated chancre seems only to  give a pre-
disposition to the  affection, or rather to give  rise to a state of the
constitution  which has been called a syphilitic diathesis.   In  fact,
the appearance  of this  identical symptom seems to  depend  upon
chancre as the cause ; but  to give rise to its development, various
exciting agents are necessary:  these seem to consist in exposure to
cold,  damp, or  moisture ;  fatigue ; improper or insufficient food;
excesses of all kinds, &c.   Every surgeon must be fully aware that
a patient who has  been the subject of an indurated sore, although he
has taken no mercury, or employed any so-called  specific remedies,
may with proper care escape sore-throat for  some months ;  but no
sooner does he expose himself to  any of the  exciting  causes above
spoken  of, than he  observes these appearances  in  the  mouth and
throat.   Such are  the reasons which induce me to admit  a syphilitic
diathesis, which gives jise, under certain circumstances, to secondary
symptoms, on the  exposure to exciting causes,  in the same way that,
in a scrofulous constitution, health may be preserved  during a long
period,  provided various precautions be taken; but should cold, un-
wholesome food, or an accidental  fall  or blow  occur, a train of  local 
284
SYPHILITIC AFFECTIONS
and general symptoms follow, which betoken phthisis  or  a white
swelling.
  The consideration  of the influence of exciting causes  is very im-
portant, as explaining some exceptional cases of this  affection  that
appear a long period  after the chancre.   We can usually detect a
distinct and natural  relation  between  the  primary and secondary
symptoms :  thus, during the existence of an  indurated chancre, this
affection often appears ; in other cases it is some few weeks after its
cure :  when the chancre has been imperfectly treated with mercury,
the  time which  elapses may be longer.   However,  the affection of
the  throat may be usually said to  appear six weeks or  two months
after the appearance of an indurated chancre.
  Age, professions, and sex,  will only act  as predisposing  causes,
inasmuch as they cause excitement  of  the mucous membrane ;  thus
the  child, from the fact of sucking,  is greatly predisposed; persons
who use tobacco-pipes are very liable to it:  for here, as in those who
play upon wind-instruments, there is a great call  upon the secreting
apparatus of the mouth ;  and in the  treatment of such diseases these
points  should not be lost sight of.
  The Symptoms of the affections are, in  the commencement very
trifling, only a slight irritation or swelling ;  should, however, inflam-
mation follow, the  usual symptoms of inflamed sore-throat will occur,
and the general symptoms may run high.
  Concomitant Diseases.—The affection I am  describing rarely
occurs alone.   I have already mentioned that an indurated primary
sore often exists on the penis, while, at the  same time,  an  affection
of the  scrotum,  anus, or genital organs in the female, which is called
in France mucous tubercle, and in England condyloma, often precedes
or co-exists with it.  A lenticular eruption  is often visible  on  the
abdomen ; on the  scalp  an  impetiginous affection occurs, as in the
case mentioned above ; the  hair  falls off, having previously become
dry; the glands in  the  neck are often  enlarged ; in fact, all  the
symptoms described  as secondary may be present.   The importance
of these affections I shall now show in speaking of the diagnosis
of the  disease.
  Diagnosis.—When one or more of the white patches, circular in
form, or assuming  the  semicircular  character, are seen on an hyper-
trophied portion of the mucous membrane, unaccompanied with sali-
vation ; when   the patient admits  having lately had, or still bears
traces of, an indurated chancre ;  when various well-marked seconda-
ry  symptoms are  evident on the patient; when these have been but 
OF THE MUCOUS MEMBRANE.
285
little benefited by care and  local applications—few persons will be
found who  deny that the symptoms are produced by syphilis, and
perhaps, with me, they will call the disease a mucous tubercle of the
mouth, the consequence  of general and constitutional infection.
  Were it in all cases as easy a matter to diagnosticate the affection,
the study  of the subject  and  the  treatment of the  patient would be
veiy easy  ; but those who have seen much of these  diseases are fully
aware that cases present many difficulties,  and  it is to the study of
these that I propose now calling the reader's attention.
  It is  frequently found in practice, that  in  consequence of some
disorder of the stomach, or from the use  of mercury, aphthae or sali-
vation has  occurred ; the mouth may thus present an appearance
which masks the disease, and the anatomical characters  above de-
scribed  furnish no guide, as it is impossible, from the appearance of
the mouth alone, to give  an opinion ; it is well in such a case  to wait
a few days,  to treat the  salivation by a gargle composed of muriatic
acid and  infusion of  roses, and  touch  the gums with a camel-hair
brush dipped in the concentrated hydrochloric acid.   This local treat-
ment, combined with a gentle aperient  every other morning, and a
light and  nutritious diet, will cure  aphthae and salivation; but the
characteristic mucous tubercle will now  become  evident, for  this
local treatment will not  remove it, and thus the diagnosis will be-
come clear.
  With relation to the history of the case, considerable difficulties
often prevent us from  forming a diagnosis ; patients, intentionally or
through ignorance, or inattention  to the previous  complaints, state
that they  have never had  chancres, much less indurated primary
sores.   The absence of  chancres should  not prevent us from judging
from the other symptoms.  Let it ever be  borne in mind that chancres
may heal  in a few days, that they may be contracted  in unnatural
intercourse, and consequently may exist  on other parts  of the body
as well  as on the penis, that they may be contracted from wounds on
different parts of the body, by scratches,  &c. ;* thus the denial of the
patient  is  not a sufficient reason to make us conclude that  chancres
have never existed.!

  * See page 197.
  t A short time ago a patient  was admitted under  the care of Mr. Lawrence in Faith
Ward, with one of the best-marked cases of syphilitic affection of the tongue I ever saw.
Believing, I presume, that she  could deceive the practised eye of that eminent surgeon,
this female wished to appear indignant at certain questions being asked as to her pre-
vious complaints, and stoutly denied the possibility or pre-existence of chancres; find-
ing this, Mr. Lawrence passed on quietly, telling her that she should improve, for her 
286
SYPHILITIC AFFECTIONS
   Other forms of secondary symptoms are not always present, and in
such cases we are deprived of one of the most valuable guides the
surgeon can possess.  On the other hand, the practitioner should be
well convinced that  to come to  a correct diagnosis on the nature of
syphilitic affections of the mouth, the symptoms by which he judges
should themselves be correctly diagnosed as syphilitic ; thus, should
aphthae on the mouth be mistaken for the mucous tubercle, should a
sore on the penis, without  sufficient reason, be considered syphilitic,
or should the chancre have existed years previous to the appearance
of the affection—lastly, if  the supposed secondary symptoms are not
well marked, viz., if no lenticular eruption or mucous tubercles about
the anus or scrotum  be present, a very  cautious  opinion should be
given, for there are two very great faults which surgeons fall into ;
the one sees syphilis everywhere, the other  seems to shut his  eyes
to symptoms which can be rationally and truly connected  with the
disease; but I trust I  have  said enough to show the necessity of
weighing each symptom,  and  giving  it only its proper value ;  each
individual sign must be compared with and corrected by the other,
and practice will  assist us  in forming a correct decision.
   Prognosis.—It may be inferred from the description abo.ve given
of the course of the disease, that  the  prognosis is favorable ; provi-
ded no excesses are committed, or the patients do not  expose them-
selves to cold  or damp,  the disease will not  assume a worse  aspect
for many months, but will,  on the contrary, by care and  the simplest
treatment, gradually subside.   I  have  frequently witnessed  such
cases ; the relief, however, is but delusive, and the disease returns
again and again, each time committing greater ravages, and in this
way years will pass  over.   If, however, the  case be seen at the
commencement, there is no form of secondary  symptoms which can
be more speedily cured;  but.  the patient should  be given to under-
stand that in the more advanced stages, when the relapses have  been
frequent  from  want of  any treatment, or from an injudicious one, the
case will be always more difficult to cure, and the chances of  further
relapses  greater ; in fact,  there are cases  which it  becomes  very
difficult to treat in consequence of constitutional peculiarities, viz., an
intolerance of mercury, and other  circumstances  I  shall not stop
here to speak of.   In fine, it may be stated  that the disease is more
readily cured in proportion to the early period at which we are called
tongue was a sad telltale; the patient, feeling the truth of this witty and sensible re-
mark, on the subsequent visit acknowledged the existence of a very little sore some
months previously, and she left the hospital well in a few weeks. 
OF THE MUCOUS MEMBRANE.
287
upon to treat it, and to the mildness of the other secondary symptoms
which accompany it;  at  later periods, I have witnessed one or two
of these patches on the mouth which persist, but  these are observed
when the patients have neglected themselves at the commencement.
Their existence, however, annoys the patient, and vexes the surgeon.
Lastly, the general health of the patient most not be lost sight of in
forming a prognosis.
  Treatment.—The first indications which result from a considera-
tion  of the  causes, symptoms, and  complications, are to  withdraw
your patient from everything which can be considered an exciting
cause ;  to put  him upon a mild but nutritious diet, to combat any in-
flammatory  symptoms  by  ordering  antiphlogistic means.  Having
thus  paved  the  way, the surgeon may feel called  upon  to employ
mercury.  Notwithstanding all  that has  been written  against  this
mineral, it is the only remedy that can be depended upon in all cases  ;
and so much am I assured of this,  that I  have  seen the very men
who  declaim most bitterly against it,  obliged to  have recourse to it
after all other remedies have  failed.  I admit most readily, however,
that  this affection will  often get apparently well without  mercury;
but as the patient is liable to relapses on slight causes, it is far better
to commence  immediately a mercurial treatment, which, as I stated
elsewhere, is attended with no bad results,  when properly adminis-
tered.   For this  purpose, blue pill may be given once or twice  a
day,  or the proto-ioduret of mercury in one-grain doses ;  however,
from causes which I am' at present unable to explain, this latter prep-
aration  produces  a great degree of  colic, and although I found it so
useful  in  France, I have been obliged to leave it  off latterly and ad-
minister blue  pill.  The mouth or throat may be gargled with the
following:—
                  Acidi Hydrochlorici diluti §i.
                  Decoct. Cinchonae corticis |iv.
           M.
   The  length of time  that the mercury must be  continued, and the
manner of giving  it in  increased  doses, are so  fully treated of at
pages 260-268, that I shall not here again allude  to them.
   Were the syphilitic affections  of the mouth and throat confined to
the two forms we have described in the preceding pages, much hu-
man suffering would be saved, and  the duties of the medical practi-
tioner considerably simplified ; but such is not the case ; the severest
form still remains  to  be  described, and will form the  substance of
the next section, under the title— 
288                 SYPHILITIC AFFECTIONS
 TERTIARY SYPHILITIC AFFECTIONS OF THE MOUTH AND THROAT.

   This third variety in the  form of syphilitic  affections may  com-
 mence in any of the following ways :—
   1.  Most frequently (in shattered constitutions, or in persons redu-
 ced by the combined effects  of  dissipation and  bad treatment) some
 pain is felt in the throat or tongue ;  there  is a  thickness of the
 speech, which  at first excites but little attention;  on examining the
 affected parts, the medical man will not fail to  observe  more or less
 redness and swelling confined to a particular portion of the mucous
 membrane, and the parts present all the characters of the  formation
 of an  abscess ;  this point will soon take on an erysipelatous redness,
break, and expose  a  tawny-colored slough.  See plate VI., fig. 1.
 A probe will  detect the extent of the ulceration,  which, if situated on
the back  of  the  pharynx, may expose  the bone, having previously
 destroyed the periosteum ;  when seated on the  roof of the palate, a
portion of the  palate-bone will be  found carious, and a communica-
tion to exist  between the nose  and mouth; the peculiar fetid smell
will, moreover, convince the surgeon of the destruction of the bone,
of which  large portions often come away.  The  disease, however,
does not seem confined to the mouth ; in a great number of cases an
 erysipelatous redness and thickening is perceived  at the root of the
nose,  not, however, larger than a  shilling  in circumference ; these
pursue the same course as  on the palate, break, and expose the
 diseased  bones.  Not  unfrequently, pustular eruptions, forming the
 scabs  of rupia,  appear on the extremities, and the general emaciation
 continues ; the countenance  has  now a cadaverous appearance, and
 the pulse bespeaks the general feebleness of the patient, who, if not
 relieved by proper treatment, sinks under the  combined effects  of
 colliquative sweats, diarrhoea, great suppuration, and  want of sleep
 from severe pain in the bones and joints, and loss of appetite.  Such,
 I  believe, is  a concise sketch of  the most frequent form of tertiary
 syphilitic sore-throat, with its accompanying symptoms, not to be mis-
 taken when once witnessed.
   It may, however, commence in another way; the secondary  form
 of syphilitic affection of the mouth or throat described in the prece-
 ding section may become aggravated, and the superficial ulcerations
 be converted into those excavated tawny sloughs which are  described
 in the last page, and they may produce such a destruction of  parts
 as to lay bare the bones, which,  however, do not necessarily ex-
 foliate.   These forms  are frequently met with  on the dorsum of the 
 
&Z+H 6%
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OF  THE MUCOUS MEMBRANE.
289
 tongue,  see  plate VI.,fig. 1.   They form also on the tonsils or the
 hard palate, and are covered with detritus of the ulcerated parts, and
 viscid saliva, forming a picture of disease which seems more exten-
 sive than it really is.   The progress of the affection and concomitant
 disease are similar to that of the first form just described.
   In cases which are far  less numerous, the  patient perceives  little
 lumps gradually form in the substance of the tongue, which becomes
 irregular on its surface.  To the feel, these little  tumors are  very
 hard,  varying in size  from that of a pea to a hazel-nut; at  first
 chronic  in their progress, these masses become soft, suppurate, and
 open by fissures ; the edges are often everted and  indurated;  livid
 chasms run in a perpendicular or transverse direction on the tongue,
 which is covered with a viscid secretion; the organ is very much
 fettered  in its  movements from its  increase in size, and deglutition
 and articulation  are interfered with.
   Now, although one or other of these forms may  be found alone as
 described, cases are met  with in which they  occur together; more
 frequently, however, one form predominates, thus showing that  they
 are varieties  of  one and the same stage of syphilis, a fact which I
 shall not further attempt to prove.
   History.—If patients laboring under these forms are interroga-
 ted, the surgeon will not fail to  discover that chancres have preceded
 them ; in the few exceptional cases, the patient may not have obser-
 ved them, or may be desirous of  concealing the  fact,  but in ninety-
 nine out of every hundred cases  the previous existence of chancres
 can be ascertained.   It is  not, however, sufficient merely to ascertain
 that primary sores have preceded;  the surgeon should not fail to in-
 terrogate the patients on the period which has elapsed and the symp-
 toms which have followed.  The apparent striking contradictions be-
 tween their  answers will not  fail  to astonish the  young  surgeon.
 Thus one class  of patients will tell you that several years ago (say
 four or five) they contracted chancres ; a period of four years elapsed
 when the  present symptoms  broke  out; during that interval not a
 symptom of disease was apparent, and they enjoyed excellent health.
 Another class will state  that  some time  ago (two  years) a chancre
 existed; at the  end of three or four  months, secondary symptoms of
 a marked character appeared,  which  were relieved from time to time,
 and  then broke out again ; thus  months passed on, occupied with
 alternate attacks and cures, until the present affection showed itself.
 On questioning further these two classes of patients, the former will
generally tell you they took  mercury; the latter did not, or only in 
290
SYPHILITIC AFFECTIONS
 small  quantities ;  and it  would appear  that we must attribute this
 immunity from disease for some years to the mineral preparation.
   In one and the other class a point of resemblance ;s almost univer-
 sally found, viz., that many months or  years  have elapsed since  the
 occurrence of chancres ;  in the exceptional cases (as I met with one
 lately) there had been a primary sore which had healed some months
 only, but  two years previously there had existed likewise a chancre.
 The surgeon, bearing this in mind, will,  I  think, find my position
 true.   Hence there is a difference, not only between  the characters
 of the secondary and tertiary affections, but likewise as to the period
 of their appearance after the primary sore.
   Under the head of History I may say a few words on the frequency
 of these affections ; they are to be met with very often in practice ;
perhaps, however, not so  frequently as formerly;  but, in  relation to
 the number of persons who contract chancres, the disease in ques-
 tion  is  fortunately rare.   What, then,  are the predisposing causes 1
 will become the next question.
   If the appearances on the penis or the statements of patients can
 be relied  on, the chancre which leaves an indurated mass after its
 cicatrization is the one followed most frequently by secondary symp-
 toms, and subsequently by the tertiary.   It has  often struck me that
 the chancres must have  been phagedenic, for we perceive consider-
 able cicatrices on the prepuce of patients laboring under  tertiary
 symptoms : and it is, moreover, to be noted that secondary symptoms
 have not here preceded.   Can it, therefore, be stated that  phagedenic
 chancres do  not cause  secondary symptoms,  but predispose to ter-
 tiary 1  I am uncertain, but I incline to the  idea that the  same con-
 dition  of the system which predisposes to phagedenic  primary sores
 does  so equally  to  tertiary symptoms,  and not  to the  secondary.
 Years of experience can alone clear up this point.   Constitutional
 disposition, excesses  of  all kinds,  poverty,  insufficient clothing,
 scrofula, intestinal affections, any depressing passions, seem to  act
 as predisposing causes ;  but again  I repeat, happily these affections
 are  relatively rare ; although they are to be met with from time to
 time.
   Diagnosis.—I shall first consider the diagnosis of this  the tertiary
 form of syphilitic  affections from the two preceding ones, and shall
 then indicate  the points of difference of the tertiary form from those
 diseases with which it may be and is confounded.
   Few of my readers will  be at a loss to distinguish between a pri-
 mary sore on the mouth  or  throat,  and  the affection I am now de- 
OF THE MUCOUS MEMBRANE.               291
 scribing; inoculation  and the history of the two affections will at
 once enable them to  distinguish it.  If, however, phagedena or in-
 flammation  attack the throat, the distinction will  for the moment be
 difficult.
   The appearances, the period after the primary affections, the concomi-
 tant affections, are such  striking points  of difference  between the
 secondary and tertiary affections, that I think there are  few of those
 who have read the preceding pages but will admit  the  distinction I
 have here attempted to depict.   However, as these are  novel points
 in surgery, I shall here recapitulate them.
   When the mouth or throat  presents that  superficial bleached ap-
 pearance, that excoriated condition of the mucous membrane, which
 ultimately becomes extensively but not deeply ulcerated ; when  this
 character has  been preceded by  a chancre for  some  two or three
 months, and is attended with the  scaly or tubercular papular eruption,
 together with condyloma on  the  scrotum or vulva, and little impair-
 ment of the  genera] health, the surgeon will not, I  should think, have
 much difficulty in distinguishing this as a syphilitic affection,  and  will
justly style it the secondary form of sore-throat.  See  plate VI., fig. 2.
   If, on  the other hand,  the  disease, commencing in the submucous
 cellular tissue, periosteum, or bony structure, ultimately  destroys the
 mucous membrane of the mouth or throat, giving rise to a deep ex-
 cavated tawny ulceration, or  if tubercles form in the substance of
 the tongue,  which cause rents and ugly transverse  fissures in  that
organ ;  if, moreover, some two years have elapsed  since the occur-
rence of the  primary sores ; and if, together with the above symp-
toms, rupia  and  ill-conditioned  sores occur on the  extremities, to-
gether with an impaired condition of the general health, the practitioner
will  be in no doubt as to the nature of such an affection, and I think
he will with me call it syphilitic, but distinguish it from what I have
above called secondary, and recommend that treatment which I shall
presently advise.   See plate VI., fig. 1.
  The diagnosis from  other affections, not syphilitic, is not always
so easy ; it  is a very generally-received opinion, that all ulcerations
about the throat are syphilitic ; and  I have been often astonished at
hearing this  opinion from  men holding high positions both in France
and in England.   In the present  instance it will, I think, be neces-
sary to make a few observations on the subject.   In what  respect,
I would ask, do the tissues which form the walls of the mouth or
pharynx differ from those of other parts of the economy? I am acquaint-
ed with none :  hence, if (as is generally admitted) every other part of 
292
SYPHILITIC AFFECTIONS
the body be liable to various  forms  of ulceration, which  are  uncon-
nected with syphilis, so  may be the throat.   I am personally unac-
quainted with any cause which can  give an  immunity  to the  throat
from the lesions which are common to other  parts of  the body, and I
therefore think this  opinion  unsupported (though pretty generally
received),  that all ulcerations  of the throat must  necessarily  be
syphilitic.  I have heard, however, an objection whispered, if such
ulcerations exist, surely we must have seen them !
   I might  reply, as has been done on similar occasions, you are not
omniscient; there  are many things which  you may not have seen,
and yet which exist.   I, however, waive such a reply, and would say,
if you have not seen such cases, it is not from want of opportunities,
but from paying insufficient  attention to  the history  of patients, and
to having preconceived notions on the subject.  I have often heard a
patient examined who denied altogether the existence of syphilis, nor
could the surgeon either meet with traces of a cicatrized sore, or any
concomitant disease whatever; yet he regarded syphilis as the cause,
the reader  will judge  with what justice ;  and then this  same surgeon
will assert that no other disease  ever does or can occasion ulcerated
throat.
   Let the  reader or  the skeptic peruse the following cases, and say
if he has not met with many similar ones which prove the truth of
what I  have  advanced, namely, that  other diseases  may produce
severe forms of ulcerated throat.

    Case I.—A. B.  No. 11. Salle 7.   Hopital des  Veneriennes.
                       February 8th, 1839.

   Complains  of sore-throat; on examination, some redness  of the
amygdalae  is apparent, but unaccompanied with ulceration ; on firmly
depressing the tongue on the right side, at the back of the pharynx,
a dirty secretion is seen, which,  on being removed with  a probe, dis-
played an irregular  sloughing  surface, extending as far  down the
throat as was visible.
   The patient gives the following history of himself:  A wagoner
by trade, he has enjoyed good health to the  moment  the present com-
plaint began.  His  family not subject to scrofula.   In the month of
 February  last (twelve months ago), while driving his  team to Paris,
 he was seized with a severe sore-throat, which he  paid little atten-
 tion to; but about Easter it became so much worse,  that  he was con-
 fined to his bed for fifteen days.  Gargles and leeches were  applied. 
OF THE MUCOUS MEMBRANE.
293
Since that period his throat has never been completely well, but he
has pursued his avocations as  usual.  The patient  states that his
master was seized  with a  sore-throat  about the  same  period as
himself.
  A short time since,  this patient was recommended to  come to
Paris,  and  entered  the wards of  La Pitie  under M. Piorry ; but
that gentleman, finding little  benefit follow  his treatment, saait the
patient to  M. Ricord.
  The patient  denies ever having  had  any venereal  complaint, and
at first did not know what it  meant until this was  explained:  there
is no apparent reason for his telling an untruth.
  I omit  the observations  I made at the time on this  case, or on the
success of the treatment.
  Feb. 26.  This patient went  out to-day.   The ulceration has com-
pletely cicatrized ; there is, however, some thickness in his speech.

  Case II.—V . . .  Eighteen  Years of Age.  Salle  7, No.  27.
          Hopital des Veneriennes.  February 6th, 1839.
  This patient  is a boy—very young-looking for his age ;  of a pale,
languid habit of body ;  complaining of his throat.  After well rinsing
out the mouth and throat,  and  before a good  light, I examined  care-
fully the  affected parts.   The  uvula is completely  destroyed; the
amygdalae are  likewise in  great  part  wanting;  the  back of the
pharynx  is  covered with  a thick ropy mucus, which, on being re-
moved by means of a probe and lint, shows  a  partly ulcerating, partly
cicatrizing  surface,  covered with  large flat fungous  granulations,
irregularly scattered  over the throat, and looking very irritable.  The
pulse is feeble, and the appetite bad.
  The patient states that  previous  to his  twelfth year he enjoyed
excellent health, when he  was affected with fistula lacrymalis of the
left side.   Has never  had either  clap  or  chancre, and the genital
organs are very small; no traces of chancre to be  observed.  He
has lived in Paris five years with his parents ; is well fed and lodged.
A twelvemonth after the occurrence of the  fistula, for  which he was
treated by M. Recamier, his throat first became bad ;  for this he took
sarsaparilla  and pills, two daily, for a long time (he says from Octo-
ber to March).   He  left the hospital in March cured, and remained
so for eighteen months.  He again  entered the Hotel  Dieu, and was
treated from October to January ; not being successful this time, the
case was  considered a fit one for the Venereal hospital, and  he was
sent to M. Ricord. 
294
SYPHILITIC AFFECTIONS
  I find in my note-book, on the 22d of February, this patient  was
dismissed for refractory conduct, very nearly well of his complaint.
  Should my readers now admit the existence of chronic ulcerations
of the throat following acute inflammatory affections, or if they con-
sider that I have adduced proof of a scrofulous affection (a thing not
unfrequently to be seen in institutions dedicated to strumous diseases),
they may expect  to learn what are the means by which they can be
distinguished from the tertiary form above spoken of.   To these dis-
tinctions I shall now particularly  allude.
  When the patient  denies  the pre-existence of primary sores, and
his assertions are borne out by other appearances which corroborate
them, such as the absence of cicatrices, of marks of  secondary  or
tertiary symptoms, past or present, we have  negative evidence  of
great importance in arriving at  a correct diagnosis.
  I may here observe, however,  that  the  pre-existence of chancre
does  not enable  the surgeon  to arrive at  the  conclusion,  that the
affection  which the patient is at  present laboring under is syphilitic.
In  the present day,  to arrive at a correct opinion, more is required
than the pre-existence of syphilis, for we do not say post hoc, propter
hoc ;  and I have seen several  cases of patients who have acknowl-
edged that they had primary sores, yet I have believed the affections
to  be  scrofulous, for reasons to be stated  below ;  hence neither the
non-avowal of patients of having had chancres, nor their acknowledg-
ment,  will of itself influence our diagnosis.  Caution in either case
must be used.
   The positive evidence of  an  ulceration being scrofulous may often
be derived from the general condition of the patient, his age, and the
position of the ulceration on the  back  part of the pharynx, although
at a later period it may extend to other parts of the throat.
   The history of the case, and the  little probability of  its being
scrofulous, from  the  conditions noted  above, will  induce the  belief
that an ulcerated  throat may often depend, like others, upon chronic
inflammation, and on an atonic state of the  system.
    I have lately seen a case,  under Mr. Lawrence, at St. Bartholo-
 mew's hospital, which induces me to ask if scurvy will not produce
 a similar affection of the throat to syphilis, although I am not aware
 that authors who have treated  specially of  scurvy allude to it.   The
 case is  the following :—
    A  boy, eighteen  years of  age, entered  Henry the Eighth ward,
 complaining of his throat; on examining it,  a large ulcer was apparent
 on the back part of the pharynx, of some months' standing.  He was 
OF THE MUCOUS MEMBRANE.
295
in a weak state of health, had lived badly, and dwelt in a low  con-
fined alley.   The peculiar feature of the case was the spongy, fun-
gous state of the gums, and the existence of pelechiae on various parts
of the body, particularly on the abdomen.  Now this patient, some
years before, had a chancre,  probably a phagedenic one, for  on his
entrance we observed on the prepuce a cicatrix, as large as a shilling,
which was much lighter colored  than  the surrounding skin.   The
sore, the patient stated, was healed in about a month after its appear-
ance, and from that time to the present date, October, 1840, no symp-
tom of any kind followed ;  and, with the exception of  the throat, the
gums, and the petechiae, no traces of secondary or tertiary syphilis
existed.
   Was, then, this a scorbutic  affection ?   I leave others  to decide ;
for my own part, my opinion will  be decided by future  experience.
I might mention that the patient  improved under occasional fumiga-
tion, and went out nearly well, after the use of the hydriodate of
potash and a nutritious diet.
   It still remains for me to speak of the diagnosis between the ter-
tiary syphilitic affections, aud  cancer of  the tongue and throat.
   The indurated state  or  tubercles on the tongue have  often been ,
mistaken  for cancer, and the  distinction is not a little difficult even
to those who have had  frequent  opportunities of seeing  both com-
plaints.  The  principal  points of difference  are, however, the  fol-
lowing :—
   The History.—On this sore little  information can  usually  be de-
rived, inasmuch as cancer may come on in persons who have suffer-
ed  from  chancres ; instead, then, of clearing  up the  diagnosis, the
history  of the case would only mislead the  practitioner.  I have
stated  that tertiary symptoms  may appear,  although the  patient be-
lieves and states that he  has never had primary  symptoms.   Hence
too much stress must not be placed on  the history alone.
  Previous  to  ulceration of the tubercles,  I  have  noticed that  the
number and  position of the indurated points are different  in the two
affections.   Thus  in  cancer  there  is  usually but  one,  in syphilis
there are several.   In cancer  the disease is seated  at the  side of the
tongue, close to the teeth, about opposite the first molar.   In syphilis
it is the dorsum of the tongue  which is affected.
  The same rule has been  observed  when  the affection takes on an
ulcerative character ;  then the  characteristic features of the two
complaints become more marked.  In syphilitic affections, the ulce-
ration is  covered with a dirty, foul secretion, and the  glands  in the 
296
SYPHILITIC AFFECTIONS
neck are but slightly swollen.   In cancerous affections the ulcers are
clean,  florid,  looking as  if they were  about  to  throw out healthy
granulations ;  yet weeks and months go on, and no restorative pro-
cess is set up, and the glands in the  neighborhood become of that
stony hardness so peculiar to cancer.
   I  have  been able  to place but little confidence in the general ap-
pearance  of  the  patient,  for in both affections a yellow cadaverous
look is met with.
   The cautious surgeon  will, however, not readily give an opinion
until he has commenced the treatment;  it is the best means of diag-
nosis, for  I need not say that the one can be only palliated.   Hap-
pily  surgery can triumph over the other.
   Prognosis.—This must be  gathered from the preceding pages :
it follows that it must be much modified  by form, stage, complications,
condition of the patient, number of relapses, and the treatment that
has  been  pursued.   The surgeon should always  inform his patient
that  the disease can be checked, but  he must be given to learn, at
the same time,  that no means exist of regenerating bones or mucous
membrane ; otherwise the surgeon will  often be blamed for causing
that  which the  disease has done previous to the time  he was  con-
sulted.
   Treatment.—The indications of treatment  are few, and  must
present  themselves at once to the mind  of the reader from what has
preceded.   In the first place, every exciting cause must be removed
which can in any way aggravate the complaint.   In public practice,
no sooner does the  patient  enter an  hospital than the effects of a
warm bed, nutritious diet, and abstinence from spirituous liquors, at once
suffice to relieve many of  the symptoms.  The surgeon's next object
is  to reduce the local irritation ;  for this purpose a sedative mucilagin-
ous gargle is very useful, together with a few  leeches applied to the
angles of  the jaws,  if the condition of the patient allow  it;  small
doses of morphia will tend greatly to quiet that general irritability
of system  so frequently found combined with ulcerations of the throat;
at the same  time tonics, particularly the vegetable  ones, with good,
nutritious, unstimulating food, will be most efficacious.  As the con-
tact  of  the teeth with the ulcerating surfaces is very prejudicial, a
layer of lead, such  as is used  by grocers, may be employed as a
protective  means ; and  it will  be  often necessary to attend to the
slate of the gums and teeth, for the tartar accumulated  around  them
causes great local irritation.
   When  all  these  preparatory steps  have been  taken, the surgeon 
OF THE MUCOUS MEMBRANE.               297
may then  commence the  employment of that  heroic  remedy, the
hydiodate  of potash;  given in doses of three grains  at  the  com-
mencement, this substance  should be increased in quantity every five
days, and  patients have,  without danger, taken  one hundred and
twenty grains in the twenty-four hours.   Its first effect is to increase
all  the secretions, and the  appetite is not the last to receive an im-
pulse from this salt.   Its principal action, however, is on the ulcera-
tions ;  the secretion is first  checked, then altogether stopped ; healthy
granulations spring up in the centre of what was lately a slough, and
often  require to be repressed by the nitrate of silver.   In some of
the more chronic cases a local stimulant is necessary, a gargle is
often all  that is required, composed of iodine and water, in the pro-
portions  of 3j to fviij., of water, or the edges of the ulcer may be
touched with the  tincture of iodine.   The appearance of the throat
after cicatrization is very  curious; bridles of a thick mucous mem-
brane, of a peculiar mother-of-pearl white, are seen running in differ-
ent directions,  which differ much  from  the  surrounding mucous
membrane ; to the uninitiated these white bridles look like so many
patches of  lymph, and I have  often wished  to remove them with  a
probe, so convinced  was I that a mere layer of lymph was seated
there.
  This is the usual rapid progress of the  cure.  Examples, however,
occur which cause the surgeon  to despair; the local  irritation  does
not diminish, and  no  attempt at cicatrization is observed.  In  such
cases the presence of a portion  of dead bone may be anticipated, and
can usually be detected by  a probe :  as long as this remains, it must
cause mischief; it should be removed with caution as soon as it can
be detached, for however efficacious the hydriodate of potash  may
be, it can not produce absorption of a dead portion  of bone ; it is the
forceps of the surgeon which most quickly gets rid of it, and the case
will go on  prosperously afterward.
  When complete cicatrization  has occurred, the deformity that re-
mains  is often considerable, though not to such an  extent as may
have been  expected; the  speech  of the patient  is not distinct, in
conseauence of those bridles of mucous  membrane above spoken of,
and if a communication exist  between  the  palate  and nose, that
peculiar nasal twang betrays the nature of the accident.  These are
permanent  defects that medicine can not cure, but various mechanical
contrivances, called obturators, may  be employed with considerable
success.
  As regards any operation for  the purpose of bringing  the sides of 
298          SYPHILITIC AFFECTIONS OF THE EYE.

these fissures together, it  should never be sanctioned;  the  tissues
around are not highly organized, and union by the first intention will
not take place ; the knife detects  a lardaceous substance,  which
readily  sloughs; so  that  all  rhinoplastic  operations  are now given
up, more especially as great relief may be obtained from the  obtura-
tors.  It must not be forgotten, however, that as foreign substances
they will produce great irritation, and may require to be left off.
                        SECTION  IV.

            SYPHILITIC AFFECTIONS OF THE EYE.

  The eye, like the skin and throat, may become affected by syphilis
in both its secondary and tertiary forms ; the importance of the organ,
and the rapidity with which the disease can destroy the tissues  com-
posing it, deserve the particular attention of the reader.

                   SECONDARY AFFECTIONS.

  Among  the patients admitted into the  London  hospitals, covered
as they often are with scaly and tubercular eruptions, the surgeon
may frequently  corroborate the statement of  Mr. Lawrence, " that
syphilitic  eruptions frequently appear on the  external surface, and
on the ciliary margins of the lids."   We may often be able to  trace
the  gradual changes between the affections of  the skin and mucous
membranes, corroborating the statements we have made elsewhere,
that  they  are but one  and the same  disease, appearing on tissues
which closely resemble one another.   In some instances the corners
of the eyelid  have that  cracked, scaly appearance, well delineated,
as occurring at the angles of the mouth, in plate V., fig. 4.
  In other cases a distinct papule, one half like psoriasis, the  other
similar to  mucous tubercle, may be witnessed on the ciliary margin ;
more  rarely, we observe a softened condition of the mucous mem-
brane, which is reduced to a sort of pulp,  and at  the same time the
conjunctiva is  very red and flocculent;  one or more small pustules
of the size of pins' heads may appear on this  softened membrane.
  I have not yet seen the bleached excoriated surface on the palpebra
so frequently  seen on the  mouth and tongue, though analogy would
expect us  to meet with it.  Usually, the symptoms above  described 
SYPHILITIC AFFECTIONS OF THE  EYE.           299
do not occur alone.  There is more or less redness of the tunics of the
eye;  there may be oedema or  inflammation of the lids, and usually
the body bears marks of other  syphilitic eruptions, particularly the
scaly or tubercular form, and the secondary symptoms as they occur
on the throat,  head, anus, &c.
  On the subject of Prognosis, Diagnosis, and  Treatment,  I have
nothing  to add ;  it must be guided  by the same indications that have
been already so  fully alluded to elsewhere.
  The conjunctiva is not the only component part of the eye  which
may become affected.   The iris may simultaneously or consecutively
show signs of disease, and  this leads me  to  speak at length of this
affection.

                         SYPHILITIC  IRITIS.

  History.—If the  reader believes that any particular symptom  of
syphilis  began to exist only about the period  that we first meet  with
descriptions of it, he must conclude that syphilitic iritis first appeared
about  the  year  1801, when Schmidt of Vienna*  wrote an essay  on
the subject.f   Since this period few  authors  on affections of the eye,
or venereal diseases, have neglected to notice the complaint,  con-
sidering it more  or  less  confidently  as a  syphilitic  symptom.   I
should not dwell upon this fact, did it not serve to explain differences
of opinion  on  the history of venereal diseases, and show how easily
so important a symptom as iritis was overlooked  by them, and  by

  * Since  writing the above, I have obtained possession of a very rare book, written in
1773, entitled, " Exposition Anatomique des Maux Veneriens sur les Parties de l'Homme
et de la Femme," par M. Gautier Dagoty Pere.  Paris, fol., plates.
  He says, page 9 : " It happens that persons become blind, not by an obstruction of
the optic nerves, as in cases of the Goutte sereine, bat by a thickening of the vitreous
and crystalline humors, which lose their transparency, preventing the rays of light
from falling upon the retina.  The salt and acid nature of the virus is very fit to pro-
duce this  effect upon the humor which it coagulates.  We observe an infinity of con-
cretions of the aqueous humors, which seem to form cataracts, which moving about
in this humor cause objects to appear as if pierced, like a spider's web,  or as little flies;
this is  occasioned by a relaxation of the glands, which allows these lymptiatic concre-
tions, thickened by the virus, to pass into the" body of the humor, thus confirming my
hypothesis. It seldom happens that a person recovers from these affections by means
of the sovereign remedies (les grands reme'des).*   However, patients are met with
who do recover sufficiently well to find their way  about, read and write, which they
can not, however, previous to submitting to these sovereign remedies.
  t Nachstaar und Iritis Nachstaar Operationen, 4to.
  * Grands  remedes meant, in 1773, to employ frictions until a patient spat one or two pints
of saliva in twenty-four hours, and  the salivation was to be kept up eighteen or twenty
days.  I quote the words of the author at page 15. 
300         SYPHILITIC AFFECTIONS OF THE EYE.
authors of the present  day.  If, then, modern, authors, previous  to
1801, have  failed  to  describe iritis, or connect it with syphilis, can
we be surprised that  those who wrote previous  to 1496 should not
have accurately described primary symptoms, or connected them,  as
we do now,  with general infection and various affections of the skin
which we call secondary symptoms 1
   On looking into the  most modern treatises,  I  find that Mr.  Law-
rence describes a distinct syphilitic affection of the  eye.   Mr.
Tyrrell  speaks simply of iritis, although he admits  "  that a  specific
taint, by its  influence upon the  system, no doubt, in many cases,
modifies the local disease."
   Mr. Bacot seems to have no doubt that syphilitic iritis  is a con-
sequence  of general  contamination  of  the  system.    Sir Astley
Cooper states, however, at page 299 of his lectures, " I have, I must
say, considerable doubt on the subject, for I  have never met with a
person laboring at the same time under any  other secondary symp-
toms of syphilis, with  eruptions or nodes on the bones."
   M. Ricord speaks of syphilitic iritis, and gives a brief description
of it in his Notes on Hunter.
   Mr. Carmichael  likewise admits a venereal  iritis, although he says
it  is difficult to distinguish it from  the  other forms,  except by the
presence of some other venereal symptoms.
   My own opinion has been greatly modified  within this last twelve-
month.   During the period I carried on my investigations on venereal
diseases  in  Paris,  although my opportunities  of seeing disease were
immense, I  witnessed so few cases of iritis, compared to the great
number of syphilitic complaints, that I was induced to deny any re-
lation between them.  At  one period of my studies  I would have
corroborated the statement of Sir A.  Cooper,  and I believed that the
few cases which I  witnessed were mere coincidences, so slight were
the secondary symptoms  which attended  the  complaints; and it was
my intention to exclude syphilitic iritis from this treatise, so unsatis-
factory were its diagnostic signs.   I  even could not go so  far as Mr.
Tyrrell,  and believe  that " a specific taint,  by  its influence on the
system, no doubt,in many cases, modifies the local disease."  When,
however, on my return to London, I wished to corroborate  my views,
my confidence became shaken, and  I  had not long  witnessed the
severe  cases to be met with weekly in St. Bartholomew's  and  other
London  hospitals,  before I began to see the  correctness of Mr.
Lawrence's  description, as given in his valuable work  on " Venereal
Diseases of the Eye," without, however,  being able to diagnose the 
SYPHILITIC AFFECTIONS OF THE EYE.         301
affection always from that which  is the consequence of rheumatism
or gout, by the symptoms which, as I shall  presently show, are not
always to be met with.
   Symptoms of Syphilitic Iritis.—Were this  treatise one which
professed to treat on affections of the eye, I  might be  induced to
dwell at great  length on the various  symptoms of iritis, but I  must
here refer such of my readers as would require a knowledge of them
to Mr.  Lawrence's  admirable  description.  For my  object, a  very
cursory enumeration will be sufficient.
   The syphilitic affection  of the iris is usually ushered in by con-
siderable constitutional disturbance, headache,  inability to sleep  from
constant pain over the brow, which is aggravated toward  evening;
but, as Mr. Lawrence observes, even in acute  cases such  symptoms
exist only in a slight degree, or are entirely wanting.
   Mr. Tyrrell lays  great stress, and I think deservedly, on the  state
of the  general health and constitution ;  in  nearly  all  the  case that
have come under my notice, the powers of the system were depressed
by bad treatment, insufficient food, exposure to all the inclemencies
of the weather, frequent attacks  of syphilis, excesses  of  all kinds,
and, lastly, severe  depletory measures ; even  in cases where  these
circumstances have not been so very apparent, the result has shown
that the  power .of the  pulse was usually deceptive, and the disease
rarely accompanied with evident inflammation ; when blood is drawn
from the arm, it does not present a firm coagulum, but is  sizy, dark-
colored, and contains more  than its average quantity of serum.   The
skin is dusky or cadaverous, and  often covered with eruptions, as I
shall have again occasion to allude to.
   When the eye is  viewed under a strong light, intolerance of that
agent is very marked, or it may be little affected ;  usually, there is
more or less external redness of the  eye, in the form of a  red band
round the cornea.
   " The iris," says  Mr. Lawrence,  " becomes changed in color ; a
light-colored iris assumes a yellowish or greenish tint; occasionally
it is distinctly yellow ;  and  if the eye be blue, a bright green is some-
times seen.  Generally, however, the tint, whether yellow or green,
is of a dull, muddy cast, and darker than in the sound state."  When
the iris  is naturally dark-colored, it presents, when inflamed, a red-
dish tinge.  Its  natural brilliancy disappears, and its beautiful fibrous
arrangement is lost, absorbing the rays of light instead of  reflecting
them, as  Mr. Tyrrell  observes.  The color of the iris is not  only
thus altered in  consequence of the effusion of lymph into its  inter- 
302          SYPHILITIC AFFECTIONS OF THE EYE.
 stices, but it becomes thickened and fringed.  Coagulable lymph is
 likewise effused in distinct  globules or masses, usually presenting a
 reddish color on the surface or margin of  the iris, which appearance
 has been compared by Beer to condylomata.  There is, at the same
 time, partial closure of the pupil, or adhesions of the iris may occur,
 and the pupil be drawn in a variety of directions; but none of these
 changes are peculiar to syphilitic iritis.  Vision is of course impaired
 in various degrees.
   Syphilitic iritis  may occur at any  period of life ;  Mr. Lawrence
 mentions  two cases  in  children:  in one  the  child was eighteen
 months old.
   But the disease is most frequently seen during the middle period
 of life, as persons are most  liable to syphilis at this age.
   In analyzing the cases which Mr. Lawrence  has reported, I find
 that one man out of the seventeen had arrived at the age of fifty-three
 years.  Among the thirteen cases of females, two are stated  to have
 been  thirty-five years of age,  and one to  have  arrived  at forty-five.
 Now, if any deduction can  be drawn from  statistics of thirty cases
 of syphilitic affections of the  eye, I might state that  in this  number
 seventeen occurred among men, and thirteen in women ;  this propor-
tion of females is large, if compared  with the number of males and
females, who are  laboring under secondary symptoms, for ten men
 apply  at hospitals  for one  female.  This  greater frequency in  the
female I must attribute to her greater exposure to the exciting causes
—a subject I shall presently allude to.
  It is remarkable, likewise, in these cases, that we find so  great a
proportion of syphilitic iritis  among persons of advanced life.   Syphi-
litic affections  are  rare at this period compared with the earlier ones,
 and yet no less than four  cases exist in  thirty.   This corroborates
 an observation I have myself made, that, ceteris paribus, iritis is more
frequent at the later periods of life, and advanced stages  of secondary
 symptoms.  Mr. Lawrence's thirty cases further prove that syphilitic
iritis occurred twelve times in  persons of  good or moderate constitu-
tion, and five times in cases of an opposite nature.   In the  thirteen
other instances, no notice is taken of the condition of the patient, but
 it  may be inferred  from statements made  in the  course  of treatment,
 that the constitution was greatly impaired.   This, again, agrees with
 an opinion I  have above advanced, which I find coincides with  the
 statements of Mr. Tyrrell.
   Causes.—In the preceding  paragraphs  I have traced the cause to
 constitutional infection, in common  with syphilitic secondary symp- 
SYPHILITIC AFFECTIONS OF THE EYE.          303
toms, therefore it is not my object here to allude again to this cause ;
but as every case of secondary symptoms is not accompanied with
iritis, it is necessary for us to study the exciting causes, as they may
lead to the prevention of the  complaint.
   On consulting authors, however, I have been able to gain but little
information on this point; I must, therefore, depend upon my own obser-
vations.   I have already mentioned  that the  disease is rarely met
with in Paris, compared  to  London; of this  fact I have no doubt;
but of its explanation I am not so certain.  I believe it  to depend
upon  the  following  circumstances : the French prostitute, from the
strict vigilance of the police,  rarely suffers under any severe form of
secondary symptoms ; because the primary ones are instantly attend-
ed to, and should secondary affections supervene, measures  are  at
once taken to  check their progress ; hence this, then, sufficiently ac-
counts for the  fewer number of cases among this class of women.
  Why iritis is rarely met with  among  the  male population,  I was
some time in  discovering, but my investigations have led me to the
following conclusion : those patients, or at least the majority I have
seen  in London, belong to one  or other of the following  classes :
some appertain to  the  poor,  half-starved,  emaciated  Spitalfields
weavers, who have no  creature comforts, are ill fed, badly clothed,
and worse lodged ;  disease has a greater hold upon them than the
well-fed mechanic.
  Other  patients in London, who suffer under iritis, belong to the
class  addicted to drinking large quantities of porter or gin ;  they are
bloated and unhealthy,  and furnish a large number  of those afflicted
with severe syphilitic affections.
  In  Paris these two  classes barely exist.   Where will a surgeon
see a being that he can compare to the sickly mechanic of London,
who has but work three days  in the week, and spends his earnings in
gin ?   Neither gin nor  porter is indulged in at Paris by the  lower
classes, and hence, in  that capital, we do not witness those deplor-
able  pictures of penury,  gin-drinking, and  dissipated habits, to  be
met with at each step in our London hospitals.
  I am inclined, then, to attribute the exciting causes of iritis  to ex-
posure, when the system is depressed or over-excited by want, cold,
damp, dram-drinking—for it is  in such  cases that we witness the
most formidable instances of iritis.  I have clearly traced more than
one case of iritis to cold caught from the patient's bed being exposed
to a draught of air.  In most cases there exists an assignable cause
for the affection of the iris, independent of the syphilitic infection. 
304          SYPHILITIC AFFECTIONS OF THE EYE.
   The  Prognosis  may, generally speaking, be favorable, but  must
always  depend upon a  variety, of circumstances.  When seen in the
early stages, and the constitution is good, a favorable result may be
always  anticipated ; but when the disease has  been left unchecked
by treatment, or  has become chronic in  consequence of ill-directed
treatment, or the lymph  effused has become organized, or the con-
stitution very much reduced, the surgeon should not too favorably
judge of the case.   Even here much may be done, although too  often
the patient escapes with an impaired organ and feeble  vision.  I
should here state that relapses are not unfrequent.
   Diagnosis.—It is not my intention in this section to enumerate all
the diseases with which iritis may be confounded, or to  speak of the
various  means which we must employ to distinguish the syphilitic from
the other forms ;  I shall only allude to those which will  most materi-
ally assist the student,  as the greater number of those that have been
vaunted are now found to be useless.
   The  History  of  the case is a circumstance which may either
assist or mislead the surgeon, when taken alone;  yet  it is the  diag-
nostic sign that I mostly rely upon.
   When a patient has had syphilis, it does not follow, as some would
believe, that iritis depends upon it, for, I  have had  previously occa-
sion to  observe,  a certain period must have  elapsed, and this  will
often be modified by the treatment which has been had recourse to.
Usually, when mercury  has not been employed,  the  patient who
labors under syphilitic  iritis will tell you that three months after a
primary indurated  sore, eruptions appeared on various  parts of the
body, which continued, and some weeks later iritis followed.  When
mercury has been used, the secondary symptoms occur later, and so
does the iritis j but  even here a twelvemonth seldom passes  between
the chancre which has preceded, and the iritis which is a consequence
of it.
   Under  the  head  of history  I may mention  the  other  coexistent
symptoms.  Thinking  that  statistics may, in a case  like this, be use-
ful, I have analyzed  Mr.  Lawrence's thirty cases.   I  find that in
nineteen male patients iritis was  accompanied—four times by a papular
eruption ; once  by  sore-throat; seven times  by a scaly  tubercular
eruption; by no symptoms  in three  cases ;  no notice is  taken of an
eruption in one case ; in three  cases, eruptions not specified are said
to have occurred.
   In the eleven females the iritis was complicated—twice  with the
papular eruption ; twice with  sore-throat; three times with a  scaly 
SYPHILITIC AFFECTIONS OF  THE EYE.         305
eruption ;  with the pustular once ; condylomata were present in three
cases ; one case presented no other secondary symptom ; the perios-
teum was affected in one case; the remaining one had a primary sore.
  In  forming a diagnosis, then, these thirty cases lead to the con-
clusion that great stress should be placed upon the coexistent second-
ary symptoms, and my own experience leads me to infer, that on them
alone our diagnosis  can be founded, for  all other supposed syphilitic
characters may  be  wanting.   Ophthalmologists are now convinced
that the color of the lymph, the direction of the adhesion of the pupil,
&c, are signs common to all forms of iritis.  When then iritis  de-
pends upon syphilis, it rarely occurs as a sole  symptom; in fact, so
rarely, that it becomes a question  if it be truly syphilitic iritis.
  The above statistics prove,  most conclusively, that  iritis  occurs
with a peculiar train of secondary symptoms, usually with the scaly,
tubercular, or papular eruptions.  Mr.  Lawrence mentions  having
met with one  case accompanied by a pustular disease,  resembling
scabies purulenta; but at page 231 he mentions that there exist like-
wise copper-colored scaly blotches.  It is curious that ulceration of
the throat was so rarely met with by him.  In almost every case of
syphilitic iritis I  have witnessed, it has been attended with a super-
ficial  excoriation.   There  is but  one solitary case  in  which  the
periosteum was affected.   This agrees with my view of the subject;
hence I have with reason placed  it among the secondary symptoms
of syphilis.
  The preceding cases likewise prove that primary symptoms may
not have disappeared when the iritis commences, as happened in  five
instances.
  Treatment.—The consideration of the causes will often  enable
a surgeon to prevent the occurrence or  recurrence of  the affection,
and I shall not again refer to them, or state how these exciting causes
should be avoided.
  When the disease is at its  commencement, and the general symp-
toms run high, it may be necessary to deplete generally and locally ;
but  this treatment should not  be too long continued.   Mr. Tyrrell
has related several interesting cases to show the inefficacy of  an-
tiphlogistic measures when carried to  excess.
  The preceding pages, moreover, show that the affection is not  one
of those complaints which would probably be benefited by bloodlet-
ting ;  and  experience confirms this view of the  subject.   The  indica-
tions are, to relieve pain, which is said to depend upon inflammation
of the unyielding sclerotic coat; to check that inflammation, prevent
                               20 
306          SYPHILITIC AFFECTIONS OF THE EYE.
the effusion of more lymph, and cause the absorption of that which
is already poured out;  destroy any adhesions the iris may have con-
tracted, and, by dilating it, allow more light to enter the pupil.
   These indications are  best fulfilled by  mercury ; not, however,
given in the manner that has been previously recommended.   The
importance of the organ, and the rapidity with which  mischief may
occur, demand a more liberal use of the mineral.  The opponents of
mercury are here unanimous in favor of  its utility; it is the neutral
ground  upon which we  all meet.   The preparation  that  modern
surgeons prefer, is calomel and opium, in the proportion of two grains
of the former to  a quarter of a grain  of the latter, given every six 01
eight hours : and as the disease yields,  the frequency of the  doses
may be diminished.
   There are some  observations on the administration of mercury in
Mr.  Tyrrell's work, which will  amply  repay  the  attention of my
readers.  As that gentleman  so  justly observes, mercury is  of in-
valuable service  even in the worst cases and most depressed states
of constitution, provided we at the same  time support  the system by
generous diet and a small quantity of stimulus. From a non-observance
of this plan, mercury has fallen into discredit in some people's hands.
   In very weak  and feeble constitutions, it may even be necessary to
renovate, by tonics and stimulants, the powers of the system previous
to commencing with mercury, which  may be then employed as above
described.
   When mercury  gives rise  to unfavorable symptoms, it  should,
however, not be  persevered in ; its disagreeing with the patient will,
however, usually depend upon inattention on the part of the uatient to
diet, or  to some other cause.
   The  other indications  are fulfilled by  drawing blood from the
temples, rubbing the brow with belladonna, and by attending  to the
state of the  digestive  organs ; these, and the indications  we have
given, will usually bring the case to a favorable termination.

                     TERTIARY SYMPTOMS
Generally  appear on the eyelids  in the  form of ulcerations, for
the  first description of which we are chiefly  indebted to Mr. Law-
rence.  I have  lately witnessed several cases which that gentleman
has  had under his care, and they correspond in every respect  to the
account given in his treatise.   Syphilitic ulcerations may commence
on the papular secondary eruption  which occurs on the  eyelid, and
which has been neglected or irritated; more frequently, however, as 
SYPHILITIC AFFECTIONS OF THE EYE.          307
Mr.  Lawrence observes, " the  ulcer  commencing  on  the  ciliary
margin, where  it is generally described as  beginning with a small
hardness supposed  to be a sty, may occupy the whole thickness  of
the lid, involving all its tissues."
  The surface is usually grayish, with bloody points, the surrounding
edges sloughy, and  considerable inflammation may supervene.
  This form of ulceration I have not yet seen occurring without other
tertiary symptoms.   Mr. Lawrence, however,  cites two or three such
instances, but admits that they occur most frequently with other affec-
tions.  There are  foul  sores on  various parts  of the  body,  rupia,
exostosis, periostitis, nodes, &c.   The  cases  we have met with have
not been in young people, but those advanced in life,  and who  have
been reduced by excesses, or who  are naturally of bad constitutions ;
and,  in all the cases we have witnessed, these  ulcerations have occur-
red at a very advanced period of syphilitic affections, generally eight
or ten months after primary symptoms.
  Treatment.—Nearly all  the cases I  have  witnessed of these
affections have been  treated by mercury, and,  as  Mr.  Lawrence
states, " I have found the free use of mercury to  be the quickest and
most effectual mode of arresting and curing the  disease.  As soon as its
influence on the system was produced,  the sores lost  their syphilitic
character, and then quickly healed."
  Notwithstanding  this opinion, coming from such high authority, I
wduld pause before prescribing  the mineral.   Modern surgeons find
so much benefit following other means employed in tertiary symptoms,
that I may perhaps be excused for  recommending a milder treatment,
and I believe that the cases I have seen treated and arrested by mer-
cury would have yielded nearly as rapidly under other means.
  From what  I have witnessed then, I should recommend the sur-
geon to lose sight of the  specific disease, and treat the case on gene-
ral principles.  A warm bed, good  and  generous  diet, will alone often
tend to  put a  stop to this species of  ulceration ; local and general
pain may be relieved  by the  internal use of  morphia, the saturated
solution of opium and warm  poultices  should be prescribed to the
ulcers, and the hydriodate of potash, in doses above alluded to, may
be combined with tonics.  I  have  not yet seen this treatment fail in
arresting ulceration ;  but I  must likewise state that  my experience
has been limited.  Did I, in spite of these means, observe the ulcera-
tion  increasing, I would without scruple immediately resort to mer-
cury, to prevent the loss of substance which  would occur in the lid,
if the disease were allowed to go on uncontrolled.      - 
308       SYPHILITIC AFFECTIONS OF THE TESTICLE.
                        SECTION  VI.

          SYPHILITIC AFFECTIONS OF THE TESTICLE.

  Occasionally we meet with an affection of the testicle coming on
at a late  stage of secondary  symptoms, which  has been variously
termed by different  writers.  Sir A. Cooper has a chapter  on the
" Venereal  Inflammation  of the  Testicle."  M. Ricord entitles
the affection Sarcocele Syphilitique.
  Symptoms.—Some months after the  occurrence of primary symp-
toms, the  patient will complain of vague pains in one or both testi-
cles, particularly felt toward night, and which shoot upward  toward
the loins.   In other instances  no pain is felt, and the patient is  sur-
prised  at  finding one  or  both testicles gradually enlarging, and he
consults the surgeon merely on  account of  their additional  weight.
On examination by  the finger, the  organ will  be  found enlarged,
heavier than usual, but without discoloration of  the skin.  The  sur-
face of the testicle will be more or less regular; its elastic feel will,
however,  be lost; the  epididymis often participates in the  enlarge-
ment as well as the spermatic  chord, and some fluid may be present
in the tunica vaginalis.  The functions of the organ will be generally
impaired,  but secretion of sperm still  takes  place,  and in nocturnal
emissions no blood will be observed mixed with  the seminal fluid.
   Pathology.—Sir Astley Cooper,  at page 104 of his work on the
testes, says : " When the venereal poison affects the testicle, it prob-
ably attacks the tendinous structure—for example, the tunica albuginea,
and thence extends into its interior fibres, and not  its tubular part;
but this I allow to be hypothetical, and am led  to that opinion  from
the  structure  of that  part most resembling the periosteum in its
tendinous  composition, and from the very ready and complete recovery
of the  organ ;  but I wish the reader to understand that I have had no
opportunity of dissecting this disease."
   Causes.—The predisposing causes are similar to those we men-
tioned when speaking of epididymitis ; we, therefore, shall not  again
allude to  them.  The exciting cause is constitutional infection, which
seems in  particular constitutions to give rise to the  affection.
   The Diagnosis must generally be founded on the history and co-
 existing secondary symptoms, as well as on the  absence of the symp-
 toms peculiar to other affections of the testicle, which it is not our
 intention  here to allude to. 
TERTIARY SYMPTOMS.
309
  The Prognosis is usually  favorable : under  judicious treatment
we may expect to see the affection  rapidly disappear, and the func-
tion of the organ will be recovered when the disease is not of very
old  standing;  under opposite circumstances, atrophy of the  testicle,
or a scrofulous or scirrhous degeneration may supervene.
  Treatment.—We have had occasion to speak several times, in
the course of this work, of the wonderful action of mercury ; it is no
less beneficial  and rapid in its effects when given in syphilitic affec-
tions of the testis ; in fact, little else but mercury need be prescribed ;
the chronic course of the complaint calls generally for no other treat-
ment, unless it be to support the organ ; we have occasionally seen
resolution of the complaint expedited by compression, with strips of
mercurial plaster, as recommended at page  88.
                        CHAPTER III.

                     TERTIARY SYMPTOMS.

  Definition.—By the term tertiary symptoms, we mean those con-
stitutional  syphilitic  affections  usually included  under the name of
nodes, inflammation of the periosteum, exostosis, caries, and tubercles
of the subcutaneous and  submucous cellular tissue;  like secondary
symptoms, they are not inoculable, but are incapable of transmitting,
hereditarily, constitutional syphilis.
  History.—Previous to Hunter, these symptoms were confounded
under the term secondary effects of syphilis, or constitutional syphilis.
That original observer, without placing them in a division quite apart
from the rest, thought it, however, necessary to distinguish  them in
some measure from secondary symptoms, properly so called ;  hence
we find them placed together, and classed under  Paragraph III.,
in his work, which is thus headed :  " Symptoms of the Second Period
of Constitutional Syphilis."
   M. Ricord, in his  classification,  preferred separating them from
secondary  symptoms, and making a distinct division, which he has
called tertiary symptoms.  In the following description it will be seen
that they differ from secondary symptoms in various points, and to  a •
sufficient extent to authorize us in  placing them in another division. 
310
TERTIARY SYMPTOMS.
Though they depend upon chancre, they follow it after a much longer
interval; they are seated  in  other  and deeper tissues, can  not be
transmitted from mother to child, but are capable directly of produ-
cing in the offspring a scrofulous diathesis.
  Causes.—Those who have seen  syphilis  of late years treated by
simple means, without the aid of any mercury, must, like ourselves
have been able to observe the natural history of the disease uncom-
plicated with those effects which  we admit mercury may produce.
In such  cases we have been  able  to trace tertiary symptoms to the
effects of  the syphilitic virus, at first committing local ravages, next
infecting the constitution, and, lastly, giving rise to such lesions as
we are about to speak of.   In consequence,  then, of these symptoms
appearing when no mercury or any other  treatment  has been  had
recourse  to, from  their occurrence usually  after  a certain  period,
from the primary introduction into the economy of the syphilitic virus,
surgeons are  agreed to attribute them to constitutional syphilis.
  It would be wrong to suppose, however, that syphilis, when left
to itself, universally produced these  effects.   Experience has shown
that in the majority of cases, fortunately for  humanity,  such does not
happen ;  this, then, brings us to the consideration of the
  Predisposing Causes.—It is not so easy  to discover the predispo-
sing causes of tertiary, as it was of secondary symptoms ;  however,
it is to the constitution that we may generally ascribe them, and to
the treatment which has been null or injudicious ;  still, tertiary symp-
toms will  occasionally occur,  in spite of all our endeavors.  Such
cases are, however, of very rare occurrence.
  The constitution,  as  a predisposing cause,  has  a considerable
effect.   Observation shows that it  is in persons of lymphatic  tem-
perament  that syphilis commits the greatest ravages;  this we have
seen throughout  the whole history of the disease, and is more espe-
cially true of this stage ;  for, as we shall presently see, scrofula and
tertiary symptoms have many points in common.   Let it not be  sup-
posed, however, that it is only in the pale and the emaciated that we
see  such  effects, for syphilis often appears in very severe forms in
stout and  plethoric  individuals.  The previous habits of the patient
will act as  a powerful  predisposing  cause :  thus,  a constitution
naturally  good,  but depressed by  dissipation, poverty, insufficient
clothing, exposure  to damp or unwholesome air—in  fact, all those
causes which induce secondary symptoms, have a great tendency to
produce likewise the tertiary form.
  Previous disease  will naturally have a great influence ; in the first 
TERTIARY SYMPTOMS.
311
place, we may mention the existence of secondary symptoms.   It is
a fact which can not be denied, that where syphilis has produced
secondary symptoms, with or without  treatment of the primary sore,
the probability, is,  that the tertiary form will sooner or later make
its appearance,  showing a tendency in the constitution, which, if not
controlled, will  produce the worst effects.   The severity of the form
of secondary symptoms, the  late period  at which they have been
treated, the obstinacy with which they have resisted, and the length
of time the syphilitic temperament has existed, are so many predis-
posing causes, and will furnish the surgeon with so many indications
which may induce him to judge of the probability of their occurrence.
  The Treatment  of the Primary  and  Secondary forms may act as a
very powerful predisposing cause.  We shall not  here  repeat what
we  said, when  speaking of primary sores, under  the head  Predis-
posing Cause of Secondary Symptoms ; the same observations apply
equally  to tertiary  symptoms.  With respect to  the treatment of
secondary symptoms, daily observations prove that if they be treated
without mercury, tertiary symptoms will frequently occur ; that even
when mercury  be employed at an early period of their (secondary
symptoms) occurrence, the appearance of  tertiary symptoms can not
be prevented ;  that in such cases, provided  the mineral  has  been
used judiciously, they will, however, be slight; lastly, that  if mer-
cury have been  indiscriminately  used, or if the precautions  spoken
of under the chapter on the employment of mercury, be not attended
to, tertiary symptoms will not only occur in  spite of,  but  become
complicated  with,  those  effects  which depend upon the mineral;
thus, the constitution will be depressed, and the two diseases carried
to an extent that now fortunately  is rarely witnessed.
  Course.—This stage of syphilis has a  peculiarly chronic charac-
ter.  In the majority of  cases, and under the circumstances above
described, the secondary  form passes insensibly into the tertiary, for
we should be guilty of a great fault, did we lead our readers to sup-
pose that the  limit between the two  stages is always  distinct; in
the natural course  of syphilis, this transition  is insensible,  without
any accession of general symptoms, the tertiary form appearing  fre-
quently during the existence of the secondary, in the same way that
the latter  may come on during that of the primary.  Under  other
circumstances,  from treatment, care, &c, the secondary symptoms
have successively disappeared and returned ; and, lastly, assume  the
tertiary form.
  Finally—and these are by far the rarest cases after the treatment 
312                TERTIARY SYMPTOMS.

of a primary  indurated sore by mercury—a considerable lapse of
time may pass away, and secondary symptoms do not follow ; when,
after exposure to cold, from disease or  some  exciting cause, tertiary
symptoms all at once declare themselves, at first under a slight form,
but successively  increasing  in severity.   Such cases, though rare,
we have met with ;  and they further prove the protective power of
mercury, though they militate against the idea of its specific powers.
   The  Complications are various ; inflammation, gangrene, scor-
butic diseases, scrofula, may  occur, masking altogether the disease,
which gradually loses its specific  appearance, and degenerates into
a general disease of the economy.  Of course, as one or other of
these complications  occur, so will the course of the tertiary symptoms
be altered, and the termination be different.
   The Prognosis is always grave ; it  shows that syphilis has made
deep inroads on the constitution, and that  its cure will require time,
and a treatment which demands patience on the part of the surgeon
and the patient;  the latter, however, should be made aware of the
precautions  necessary  to be taken, and the  consequences of their
non-observance; although we may often triumph over  the disease5
we are liable to see it return ;  and  there are cases  in which  our
treatment can be only palliative, or the  patient, having consulted us
too late, is obliged  to bear  the deformities which nature is unable to
remove, although art may frequently alleviate them.
   Diagnosis.—The reader will doubtless  have remarked, that as we
receded from the point of primary  infection, the diagnosis  became
less certain ; that during the ulcerative period of  chancre, a positive
diagnosis could be arrived at  though inoculation, but when cicatriza-
tion had once taken place, we were obliged to confine ourselves to  a
rational diagnosis.   This  became more  evident as  we spoke of
secondary symptoms ; however, we showed  that there were certain
features which are peculiar to secondary symptoms, as, for instance,
mucous tubercles, seen in the frontispiece.
   In the form  we are describing,  however,  our  diagnosis must be
founded on  rational principles alone,  for we have no  certain test.
The history, the antecedents, the course, concomitant circumstances,
the treatment,  the character of the affections, will, if taken together,
indicate the nature of the complaint, and  enable us to form a diag-
nosis, but this should be always done  with caution.  The treatment
must still be  such, that if  our diagnosis be incorrect, the remedies
made use of can not be injurious.  This is a rule that our readers
will shortly  be enabled to appreciate. 
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TERTIARY SYMPTOMS.
313
   Particular description of Tertiary Symptoms.—This stage
 of syphilis, as stited in our definition, seems to attack the submucous
 and cellular tissue, and the osseous system, in preference to any others ;
 to the description of each of these we shall now direct  the attention
 of our readers.
   Lesions  of the Subcutaneous Cellular Tissue.—At a late period
 aftet the  first occurrence of secondary symptoms,  and in  persons
 whose  constitutions are deeply affected by  constitutional syphilis,
 small tumors may be observed, either isolated or occurring on various
 parts of the body.   At  first  the patients pay little attention to them,
 as they are not accompanied by much pain, and produce no uneasi-
 ness ; the first notice taken  of  them'is often some months after their
 first appearance ; they may  be  hard, and unattached  to  the adjacent
 structures. -When  after several months they have attained the size
 of a hazel-nut, a distinct fluctuation  may be perceived  through  the
 hard shell which  surrounds them,  and which is firmly  impacted in
 the cellular tissue.   The skin over them  may become discolored,
 thin, and ultimately ulceration of the surface follow ;  thus the  small
 tumor may make its way to the surface, and by one or more openings
 a  serous  or ichorous  discharge take  place.  Fistulous openings
 result,  and may  extend by ulceration, or in consequence of inflam-
 mation  coming on in the surrounding tissues, and it is kept up by the
 irritation of the cyst,  which  does not usually become wholly separa-
 ted.  When, however, this  happens,  cicatrization   slowly  follows,
 leaving a considerable depression at  the point affected.  No sooner,
 however, is one  tumor removed, than another appears on some other
 part of the surface, or several may run through this  course at once,
 during a period of  several months.   These tumors may be observed
 on every part of the  body, we have frequently noticed  them on the
 tongue,  where, from shackling the movements of that organ, they give
 rise to  great inconvenience,  and it is from their  rupture that those
 rents or deep crevices are occasionally seen in  the substance of the
 tongue.   Among others, we have lately witnessed a very severe case
 in the person of a medical man at  Bordeaux, which, however, ter-
 minated in a favorable manner.
  These tumors may be the only symptoms  present,  as  in  the case
just mentioned ; but more frequently they co-exist with  affections of
 the bones or mucous membranes.
   The  tumors may exist in  the submucous  cellular  tissue;  at least
 we have  observed in  the throat, on the palate and  pharynx, the
 chronic swellings which eventually are converted into  the most in- 
314
TERTIARY SYMPTOMS.
tractable ulcers ; and  as  the bones at first do not seem diseased,
though they subsequently become so, we are justified in concluding
that these tumors have their origin in the submucous cellular tissue.
   Tertiary Symptoms, as they occur  in the Osseous System.—The
earliest notice of constitutional syphilis attacking the bones consists
in pain at first of a vague or intermittent kind, like that of rheumatism ;
sooner or later, however, it becomes fixed to particular bones or por-
tions of bone, and is more  severe at night; these nocturnal pains
are, however, not peculiar to syphilis ; they occur in other diseases,
and depend upon the resistance  made by the  periosteum  to any
swelling of the   bone  itself;  thus, then, the pain is often the  first
symptom of inflammation of the bone; it  is, however, at the  com-
mencement, very difficult to distinguish  from rheumatism, though the
latter, as M. Ricord observes, usually appears at  a different period,
is not generally fixed, is more superficial, and attacks  by preference
the joints, or those portions of bone around them.
   Periostitis, says M. Ricord, is a disease less frequently  met with
than is generally imagined ;  and  the  effects attributed to it depend
more  frequently upon a superficial ostitis y he, however,  describes
three varieties.
   They have the following characters in common : they  consist of
small tumors, more  or less circumscribed, situated most  frequently
on the superficial bones,  as the clavicle, tibia, ulna, radius ; on the
bones of the cranium, sternum, metacarpus, and particularly on those
points  of  these  bones nearest the surface.  They  are  sometimes
indolent;  more  frequently, however, painful on being touched, and
the finger may detect a sort of doughy feel, or  fluctuation may be
more  or less  apparent.   The skin which covers  them may remain
moveable and unchanged.   Periostitis, though  susceptible  of resolu-
tion, may terminate in suppuration or abscess.
   The first variety, which is often indolent in its course, is capable
of resolution.   When the  diseased structure is  divided,  we  find  a
tumor  containing a serous  liquid, such as may  be witnessed  in
scrofulous patients;  in other cases the fluid resembles synovia.
   In  the  second variety,  the  affection  may be an acute or subacute
inflammatory  one,  and free suppuration  may follow; but in such
cases we rarely fine the surrounding bone sound ; whether this has
taken place previously or subsequently,  it is difficult to decide.
   The  third variety is more slow in its  progress, at the  same time
that it is more painful (sua, sponte), as M. Ricord terms it; that is to
say, when no pressure is made upon it.  On examining such tumors, 
TERTIARY SYMPTOMS.
315
 they will be found  to consist of organizable lymph, which raises up
 the periosteum, and is capable of producing one form of exostosis.
   Ostitis shows the  same  preference  as periostitis for particular
 regions.  Circumscribed in  some  cases, in others diffused,  it may
 attack the superficial parts, or the parenchymatous structure of the
 bones.   Although chronic in its course,  it may assume  a subacute
 form ;  and  after having existed a considerable time without giving
 other indications of  its presence than pain, the swelling it ultimately
 gives rise to betrays itself externally.  This tumor, which ultimately
 succeeds inflammation of the bone, sometimes depends on a deposi-
 tion of osseous secretion similar to  the callus around fractured bones,
 or resembles that we have described  as seen  in  the third variety of
 periostitis, and constitutes an epigenic exostosis, differing in form and
 volume, having a large or pedunculated base, and a smooth or irregu-
 lar surface.   In other cases  the swelling may depend  upon general
 hypertrophy of the  whole thickness  of  the bone, giving rise to the
parenchymatous exostosis, or hyperostose.
   Ostitis may terminate in  resolution, in suppuration  or caries, in
 necrosis, or in induration like ivory; this constitutes the  eburnee of
 French writers.
   The termination by resolution easily takes place when the swelling
 depends on a  cellular  layer  of bone, or on a deposition of  plastic
lymph.   When the disease is seated  in  a spongy bone, those of the
face for example, and particularly in the maxillary bones, suppuration
readily and frequently occurs.   Necrosis, although  frequently caused
by the  violence of the inflammation, in proportion to the vitality of
the osseous  system, still more frequently occurs in consequence of
depositions taking  place suddenly in the tissue, or  from  the  bone
being laid bare, or the destruction  of the soft parts which surround
the bones, thus depriving them of their sources of nutrition.
   Necrosis  may occur  previous  to  the appearance  of caries,  or
simultaneously with or subsequently to it; most frequently, however,
 as may  be often observed in diseases of the bones of the  face, what
has been considered as  a necrosis  is nothing less than  the result  of
caries, by which the whole  organic  tissue has  been destroyed  by
means of ulceration and suppuration peculiar to bones,  leaving noth-
ing more than the calcareous portions, which thus form  a sequestrum
very different  from necrosis properly so called, and in which we may
find the anatomical elements of the bone.
   Lastly, the  termination by induration, or the conversion  of bone into
 ivory, takes place in consequence of a deposition  of the saline in- 
316
TERTIARY SYMPTOMS.
organic matter which enters into the  composition of bones, together
with a more or less complete disappearance of the cellular tissue.
   Treatment.—The preventive and  prophylactic treatment  of ter-
tiary  symptoms  will  consist, in a great measure, in the employment
of the same means spoken of  in the preceding chapter, and in atten-
tion to the rules  there laid down.   We think it, therefore, unnecessa-
ry to return to that subject here.   The same remark applies to causes
both predisposing and exciting.  The  knowledge of any predisposing
cause being attained, the surgeon will necessarily remove  it if it
already exist, or prevent  its  development  by all the means in his
power; this can not always be obtained, however much  it may be
desired, or the patient demands our advice too late ;  it then behooves
the surgeon to remove, in as short a  time  as possible,  the  effects
produced ;  and this brings us then to a consideration of the
   Curative Means.—In M. Ricord's work on the treatment  of ter-
tiary symptoms, which, before  proceeding further, we beg permission
to quote, we find the following paragraph :—
   " Although we recognise the syphilitic virus as the regular  cause
of tertiary symptoms, we must allow that it undergoes a modification
in secondary  symptoms, in consequence  of which it is  no  longer
inoculable.  In  tertiary  symptoms this  modification is  still more
striking.  If it were not  hazardous to form an hypothesis in order to
explain facts, the proximate cause of  which it is difficult to fix upons
it might be said, that in the secondary  symptom, which is kept up by
its presence, the virulent cause still exists; that in the tertiary symp-
tom it is completely transformed."
   The important consideration of this last phrase  we  can not too
strongly impress on our readers;  it forms one of the best indications
for the treatment which, whatever may  be  said on  the  subject of
secondary symptoms, ought not and can not be specific  here.   Ter-
tiary  symptoms  must be treated  on  general  principles; the same
means should be employed as if the diseases we are called upon to
treat depended upon any other than a specific cause now completely
transformed.
   Our first care  should be to  remove  all inflammation  or irritation
which can aggravate the  local  disorder; this point gained, we may
next turn our attention  to  the  constitution.  The  employment of
tonics, nutritious  diet, proper clothing, &c, will often have the best
effects.   Among other preparations,  we have observed  those con-
taining the principles of  opium to be followed by the best effects in
allaying local and  constitutional  irritation.  Mercury, in  its various 
TERTIARY SYMPTOMS.
317
forms, is, generally speaking, as prejudicial at this stage as it was
beneficial in secondary symptoms ; and although in those symptoms
of transition between the secondary and tertiary, as in deep tubercles
of the skin, attended with callous ulcerations, it may still be advan-
tageously employed, it is nevertheless true that the further we retire
from the  early stage of secondary symptoms, the less efficacious it
becomes,  until  it ends in being highly prejudicial; and  when  used
even in the former cases, it  should be combined with iodine in the
form of proto-ioduret;  of the dose, quantity, &c, we  shall not here
speak.
   If mercury then be, generally speaking, prejudicial, surgeons have
the satisfaction of knowing that modern practitioners have the credit
of discovering  this,  and rating  the effect of the  mineral  at its just
value, while their observations  have enabled  them to replace it by a
preparation which daily experience in various parts  of the  world
promises to establish as one of  the  most efficacious in the  Pharma-
copoeia—we mean iodide of potassium.
   Iodide of Potassium.—Those who have, like ourselves, witnessed
the effects of this preparation given in all the stages of syphilis, will
allow that its good effects seem pretty nearly confined to the cure of
tertiary symptoms ;  it has been much vaunted, but as we  think in-
judiciously, in the other forms,  although the  cases in  which it has
produced  relief are not sufficiently detailed, and in the successful
cases the disease had arrived at  what we term the tertiary  form.
We shall, however, in the following pages, state the results that may
be expected from it, and the best means of producing them, the more
especially as, when  employed  in the cases now under consideration,
it is a treatment new to English practitioners.
   We prefer giving M.  Ricord's  description : in speaking of the
treatment of tertiary symptoms, he thus expresses himself:—
   " We may commence by a  dose of ten  grains  taken  daily in a
mixture, for which I give the following formula :—
                    Distilled  water, |iij.
                    Iodide of Potassium, gr. x.
                     Syrup of Poppies, fj.
This mixture  should be taken in the course of  the  day,  in  three
glasses of decoction of sarsaparilla, or some bitter infusion.  The
doses may then be augmented by ten grains every five  days, until the
dose of a hundred grains may be taken daily : this dose I have rarely
exceeded.
   In addition  to  the curative  effects, the iodide of potassium may 
318
TERTIARY SYMPTOMS.
have an action on different  parts  of  the economy, which  it may be
well to mention.
   The digestive organs usually bear  it well;  but  in  some cases the
patients complain of pain or an uncomfortable feel at the  stomach ;
this  pain has some  analogy with that met with  in pleurodynia, but
differs from it in being deeper seated.  In certain cases the thirst is
augmented, although usually the  appetite alone becomes  increased,
and nutrition so much exaggerated that patients grow quite fat.  I have
seldom had  occasion to observe diarrhoea or vomiting.   The skin
may become the seat of certain eruptions  analogous  to acne, or ech-
thyma, with small  pustules.  The urinary system may be  consider-
ably affected, and the quantity of  water voided may be considerable.
   The circulation  has not appeared  to me  particularly affected, at
least  in  the majority  of cases.  In  respect to the nervous system,
some patients have experienced what is called iodic intoxication,
characterized by a  slight  uncertainty in the voluntary movements,
some  subsultus tendinum, heaviness in the head, a species of intellec-
tual idleness, and  sometimes slight delirium.   In all cases, even at
the extreme dose to which  I carried  this remedy, all the  symptoms
have been  very trivial.   Their  appearance, however, and  especially
any tendency to become  aggravated,  has  always  been  an  indication
for me to stop the dose, whatever that  may have  been ; in the same
way that each time a symptom got better, I  have continued  at that
dose  which produced the  amelioration, not  wishing to increase it
until a stationary condition  supervened.  It seldom happens that the
affection we are called upon to  combat does  not  show  marks  of
amelioration during the second week of the administration of the
iodide, or  sometimes later.  The tubercles  become absorbed, the
ulcerations grow cleaner, suppuration diminishes, the pains in the
bones cease; and the osseous tumors, provided they  have not reach-
ed the indurative state, which resembles ivory, speedily become dis-
sipated.
   Treatment of particular or individual forms of Tertiary Symptoms.
—If the above  treatment be beneficial in relieving and curing the
diathesis, or state of constitution in which we  have found the patient,
we must nevertheless not neglect the  local treatment;  for here, as
elsewhere, although the local depends upon and is kept up by the gene-
ral diathesis, it in its turn reacts on the general health, and maintains
it in an unfavorable state for recovery.
  Local Treatment of Tumors seated  in the Subcutaneous  Tissue.—
It  is  unnecessary here again to remind the reader that any  vnflam- 
                      TERTIARY SYMPTOMS.                  319

matory symptoms should be  combated  by antiphlogistic measures
adapted to the condition of the patient;  when all such  have ceased,
the tumor, if at its commencement, or even when fluctuation is per-
ceptible  (provided the skin has not become discolored), should be
covered with a blister, and the  denuded  skin  may then  be dressed
with a solution of iodine ; this acts as a local irritant, and is far pref-
erable to the solution of  corrosive  sublimate, as it may produce
beneficial effects both locally and generally.  Usually, after the first
blister, the tumor will be  sensibly  diminished ; in such cases let  a
second or third, be made use of, until complete  resolution  is effected.
We  have seen no  cases resist  this  method when they have been
treated sufficiently  early, and when the constitution  has been, sup-
ported by the general means spoken of above, for we repeat  this form
of the affection principally occurs at a late stage, and in very unfavor-
able  subjects.   When, together with distinct fluctuation, there is dis-
coloration of the skin over the tumor, it is useless to attempt this plan
of resolution: the pus may be allowed to escape by puncture, and
should the hard shell mentioned as surrounding the cyst  be present,
the cure  will be often expedited by its excision.  When called upon
to treat those cases which assume, at a later period, a fistulous char-
acter, and are surrounded  with an  indurated margin, their  local ap-
pearance may be  benefited by covering the surface with the following
application :—
              Honey     .     .     .     .12 parts.
              Proto-ioduret of mercury    .    1 part.
  The same  effects will be  obtained if the margin of the  ulcer be
touched with the solution of iodine, which is thus composed :—
                       Tincture of iodine, 3ii.
                       Distilled water, ^viii.
The  latter preparation is particularly useful in cases where no indura-
tion  exists ; these chronic ulcerations will slowly cicatrize,  and their
edges rise to the level of the  surrounding skin.  This may be often
hastened  by  applications of strips of plaster composed of vigo cum
mercurio.   An alternate treatment with sedatives and stimulants may,
likewise, often be employed with advantage.
  These  observations equally apply  to those  cases of submucous
cellular tumors, which admit  of  this treatment from their  position,
when placed beneath the mucous membrane of the mouth and. pharynx.
On  the  first symptoms of the appearance of suppuration, the cysts
should be at once opened, and treated by emollient gargles ;  the parts
may then be touched with the watery solution  of iodine,  or a gargle 
*
320                TERTIARY SYMPTOMS.

may be employed, which, containing 3i. of iodine to eight ounces of
water, and gradually  augmented in  strength,  will speedily bring a
healthy action of the  affected  parts ; but  this  local treatment alone
will  not suffice.  The general one of the iodide of potassium com-
bined with mercury, in proper proportions,  when any induration exists
around the edges of the ulcerations, must likewise be put in practice,
and its success will surpass the most sanguine expectations.
  Local Treatment of Affections of the Osseous System.—Pains in
the Bones should be treated, at  first, by  repeated applications of a
few  leeches,  followed by poultices; or  the parts may be covered
with  lint dipped in a warm decoction of poppies,  or  water  and
laudanum; this  treatment, together with  a general one  compatible
with the state of the patient's constitution, will usually suffice, when
the pain does not depend upon deep inflammation of the bones.  How-
ever, there are forms of this affection which resist, and, although we
are unable to detect either periostitis or ostitis, yet only  cease on
employing the treatment adapted to them.
  The Treatment of Periostitis should  consist, at first, in attempting
to allay all irritation by leeches and poultices; when the first and
third varieties exist, such a practice will often suffice ; in other cases
we must have recourse to a treatment which acts like a charm on the
disease.   Let a  blister be applied on the painful portion of the bone ;
when it has  risen, the serum may be allowed to escape,  but  the
epidermis need not be removed, as the  pain will be less ;  lint spread
with the ceratum opii may be laid over it, and the whole covered
with  warm  poultices, which  should be  constantly renewed.  The
severity of the disease, or  its return, may require  a repetition of the
blisters, which should be treated on the same plan.  When the tissues
have not undergone much organic change, the relief felt is immediate
and lasting ; we have frequently seen patients  fall into a calm sleep
even during the  drawing of the blister, and this in the case of persons
who have been kept  awake by violent  pain for weeks ; if swelling
be present, it may be  often removed by  the employment of blue oint-
ment, applications of tincture of iodine  and water, as by the formula
given above, or  the suppuration may be  kept  up  by means  of  the
solution of corrosive  sublimate.   The  pain attending  this last  sub-
stance  will,  however, generally preclude its  employment.  In  the
second variety of periostitis, this treatment is less efficacious ;  it  may
be necessary in  such  cases to make incisions  and  let out the pus, as
by such means we may prevent a further separation of the periosteum
from  the bone, an object always to be desired. 
SYPHILIS IN CHILDREN.                 321
   Local Treatment of Ostitis.—The treatment recommended in the
 two former affections, viz., pain in the bones and periostitis, is equally
 applicable and judicious in the early stages of ostitis, accompanied
 with a deposition of callus forming the epigenic exostosis,- but it may
 be necessary to employ the treatment more actively, and for a longer
 time, particularly in the parenchymatous exostosis.  When called upon
 to treat a patient for diseased bone which has been converted into a
 species of ivory, all treatment will be unavailing, and it will  become
 a question whether or no we might  be justified in removing, by  a
 surgical operation, this form of exostose.
  In cases of caries or necrosis, particularly of the bones of the face,
 no  time should be lost; they must be removed as soon as that is
 possible.  M. Ricord observes, that the surgeon should be fully aware
 that  caries produces caries ; that a bone, the organic matter of which
 has been destroyed by suppuration, or which  is dead,  can  never be
 regenerated by any treatment, general or local;  and that  it should
never be left  to be eliminated by Nature's  efforts,  except in those
cases where the surgeon is unable to reach it.  Bone of this descrip-
tion is truly a foreign body, keeping up and maintaining the disease,
which, by means  of the suppuration it  gives rise to, may gain still
deeper parts, and thus occasion death.   The  means adopted to  re-
move these portions of necrosed bones need not be mentioned here.
                        CHAPTER IV.

                     SYPHILIS IN CHILDREN.

  This subject has been already treated of in various parts of this
work, but it has been suggested to me that, in a " Complete Practi-
cal  Treatise on Venereal Diseases," a chapter ought to be devoted to
syphilis as it occurs in infancy.   I therefore shall, in  the following
pages, speak of such peculiarities as may be met with in early life.
  Primary Symptoms.—On the  subject of contagion in children, I
may mention that the same laws  exist as in the  adult, with this dif-
ference alone, that the tissues being very delicate, inoculation would
be more liable to occur, provided children were as frequently exposed
to the effects of the  virus.   This, however, is not the case;  and I
have met with no instances of primary symptoms, nor  can I  find in
                                21 
322
SYPHILIS IN CHILDREN.
 authors any cases where distinct chancres  have existed.  In  early
 life, however,  ulcerations of the genitals are not unfrequently met
 with.  I have lately seen in St. Bartholomew's Hospital two instances
 of  children (both females) with some ten or twelve ulcers  on  the
 thighs and labia, attended with discharges  from the vagina, and a
 considerable excoriation of the surrounding parts.   Such appearances
 I could attribute alone to dirt and want of cleanliness on the part of
 the parents, together with pustular itch  which had ulcerated; but as
 inoculation was not employed, it was impossible to speak more pre-
 cisely of their nature.  Cleanliness alone speedily produced a per-
 fect cure.
  In the  children's hospital at Paris, I have not unfrequently met with
 ulcerations about  the  anus,  mouth, and  throat, depending  upon a
 disease called Muguet or Thrush.   A very able article on the subject
 has been lately written by my friend M. Roget,  which may be seen
 in the French Medical Dictionary, in twenty-five volumes.   Such
 appearances have been often  attributed to syphilis, but, I believe, on
 insufficient grounds.   Without,  then,  in  any manner denying  the
 occurrence of primary symptoms in children, I  think they must be
 very rare.   Should they occur,  the  treatment would  be  necessarily
 simple, and guided by the same indications  spoken of in the  chapter
 on Chancres in the Adult.
  Secondary  Symptoms in  children are, as far as  my own experi-
 ence  goes, much less common  than is generally  supposed;  such,
 however, is not the opinion of those who have written upon the sub-
ject ; but  when the difficulty which surrounds the whole question is
 considered, when the little attention that has been paid to the diseases
 of infants  (until  within  the  last few years) is considered, this sup-
 posed  frequency of syphilis is not so surprising.  The opportunities
 I have possessed of studying infantile  disease in special hospitals,
 and of seeing the children of prostitutes, lead me to urge the correct-
 ness of my opinion.  The result of my  own observations I  shall,
 therefore, now describe.
  Infection of the foetus  in ulero is  stated  to occur, and is now sup-
 ported by so many facts, that it would be superfluous  for me to  insist
 upon it.   Authors, however, are not agreed upon  the manner in
 which this takes place.  The physiological school would attribute it
 to sympathy ; my own opinion is, that as the foetus partakes of  the
 existence, and  lives on the mother, so does it participate in many of
 her diseases, although, as we  are in ignorance of the exact connexion
 between the foetal and maternal placenta, how this is affected  must 
                     SYPHILIS IN CHILDREN.                 323

still be unknown, and I could but amuse my readers with a more or
less probable conjecture.  We must, therefore, be content with the
knowledge of the possibility of  infection,  in the  present state of
physiology.
  Some modern authors believe that syphilis is communicated to the
child by means of the milk of the nurse, the parents being perfectly
free from disease, as well as the child  previous  to  suckling a nurse
who labors under secondary symptoms.   This opinion, as far as I
can collect from the cases which I have read, seems to require further
corroboration ; without  denying the possibility,  I  should  believe  it
very improbable.  I have never met with a case, and those recorded
in books are liable to  so many objections, that on this score I  would
give no opinion of my own.
  It is a very prevalent opinion that  the father  who labors  under
secondary symptoms will beget offspring who show visible marks of .
constitutional syphilis, and  such  cases are scattered up and down
medical writings  and books on  midwifery.   This opinion, like the
last, however, seems very problematical; the chances  of  error are
so great that I can hardly credit them ; and  the  fact,  if true,  is so
contrary to direct experiments, that I am inclined to  be skeptical.
My incredulity is based on the following reasons :  The  father may
have chancre in the urethra, and  the semen, acting as the vehicle to
the  virus,  will thus infect  the mother, and  secondarily  the  child.
(See case in note to page 202.)   The  father  or mother may have
gone astray and contracted chancres, of the existence of which they
are  ignorant, or wish  to conceal.   The mother may have contracted
chancres in other parts  of the body, by the virus coming in contact
with a sore or abraded surface.  There are, in fact, a thousand chances
of contagion, as modern investigations  have proved, and which have
been alluded to in various parts of this  work.
  Mr. Colles and Mr.  Carmichael,  if I  mistake  not, believe  that
secondary  syphilis may be communicated to the   child by the dry-
nurse ;  how this could occur I am unable to understand;  and I must
believe that parties have conspired to deceive these eminent surgeons,
who have such claims to public confidence, as correct observers  and
faithful delineators of symptoms.
  In the  commencement of my studies I was taught  to believe  that
the death of the foetus, and abortion about the seventh month, was
due to constitutional  syphilis in  the female, and to its effects on the
foetus as characterized  by a discoloration  and  peeling of the skin of
the  expelled embryo.   Modern treatises on midwifery and  diseases 
324
SYPHILIS IN CHILDREN.
of children still repeat these opinions, and support them with what is
supposed to  be corroborative  evidence, namely, that if mercury be
given, these  abortions cease, and  living children are born  at  the
full period
   When I was attached  to  the Venereal  hospital in  Paris, a great
many pregnant prostitutes passed under my notice, who were labor-
ing under secondary symptoms, but I did not remark  that abortions
were more frequent at the seventh month than at any other period.
If the reader will refer to the valuable work of Parent Duchatelet, he
will find that abortions frequently take place, but syphilis is not  the
cause :  unnatural means, excesses of all  kinds, abuse of  the  sexual
organs, are there stated  as  the  exciting  causes, and  the  period  at
which it occurs varies from the fifth week to the ninth month, and no
mention is made of the peeling off of  the skin, or  other  marks of
secondary  symptoms.  I am  inclined,  then, to  believe  that  these
statements, once started by eminent accoucheurs, have been admitted
and believed  on too slight grounds, and that they have not yet passed
through the crucible of modern analysts  of facts.
   The children that I  have seen laboring under secondary syphilis,
have usually  at birth presented no morbid appearance, although  the
mothers  were  severely   affected  with  well-marked  constitutional
symptoms.  Such children  may have a  healthy  appearance, or be
puny and  weak ; a few weeks pass over, and spots are  seen about
the anus or scrotum.  A  child was  lately brought to Mr. Wormald,
the assistant-surgeon at  St. Bartholomew's  hospital, with very dis-
tinct condylomata encircling the anus, which, the mother stated, ap-
peared  three  weeks after birth.  Frequently these spots resemble
those seen in plate VIII., are raised, of a livid color,  and have a very
unpleasant odor.  They  may disappear, and a papular  eruption
cover the  little patient, the stains having that coppery-colored hue
which is so very characteristic, and lasting  lqng  after the papules
have disappeared.   The  general healthy color of the skin  is lost, the
eye is dull, and the corners of the mouth and tongue present  those
white pearly  patches so characteristic, and which  have been alluded
to elsewhere. Mr. Carmichael, in No. lxxvi., of the Dublin Medical
Press, says, that the eruption in children is always  found to be scaly ;
such an opinion does not accord with my investigations.
   Prognosis.—As far as  my own observations go, the prognosis is
favorable, provided the mothers can  and will take proper care  of the
children; in  a few weeks the disease  can be cured, and  the  child
will rapidly  gain its strength.   I can not  help here  calling attention 
SYPHILIS IN CHILDREN.
325
to a statement of Mr. Tait, in  his  book lately published, entitled
Magdalenism.  According to his account, the mortality among chil-
dren born of mothers laboring under secondary symptoms is dreadful.
In the Lock hospital of Edinburgh, he states, out of twelve children
seen during a period of three years, only one lived to the age of twelve
months.   Now I would appeal to any surgeon if this has  ever  been
equalled  in any other city in Europe.   I  answer no ; and I  am al-
most afraid that professional  readers must admit, either that the treat-
ment in the Lock hospital does not  keep pace with the progress of
knowledge elsewhere, or that Mr. Tait has been led away in draw-
ing a too unfavorable picture of the severity of syphilis, not only  in
this case, but  in others where he has deigned  to enlighten us  with
the few medical passages which  can interest the surgeon.
  Treatment.—Had I not dwelt, elsewhere, at considerable length
on the treatment of secondary syphilis, I might devote several pages
to it; but, as far as my experience goes, I should say that the same
indications must be followed in the treatment of infants as in adults,
the doses being diminished, and the mildest preparations being em-
ployed.   For this purpose we refer the hydrargyrus cum creta,  in
doses of two  or three grains twice a day, and continued until the
entire disappearance of the eruption.  Other means have been recom-
mended, but we have not found them so successful.  It may here be
mentioned that salivation  is not liable to occur  in the child, and that
under the use  of a mild preparation the recovery of the infant  may
be expected:  it then rapidly gains flesh and recovers, but is liable
to relapses, although, as Drs. Evanson and Murphy state, each will
be slighter than the last.
  The mother at the same time should undergo a course of mercury for
the cure of her complaints; and the child should not be allowed to take
her breast, but may be fed on spoon food.  Provided, however, it has
no affection of the mouth, we can see no reason why it may  not be
suckled by a healthy nurse ;  we have not seen any disease produced
on the nipple of its wet-nurse, or the occurrence of secondary symp-
toms follow, although instances  are stated to have occurred in pre-
viously healthy young women who have nursed syphilitic children.
  We have, however, met with a few instances where a  child  with
aphthae on its mouth has produced sores on the nipples of  its  nurse,
who affirmed  that she had never had syphilis.  We believe that  such
cases may be  classed under two categories.  In the one, the sores
have no  specific character ; they are the result of irritation and the
contact of the diseased secretion of the child's mouth  on an irritable 
326
SYPHILIS IN CHILDREN.
nipple.   Such instances are not followed by secondary symptoms.
The second category includes those cases where the nurse has suf-
fered under syphilis, although she may have reasons  for denying  it,
or motives for concealing it, wishing to attribute it  to a sickly child
she has taken in to nurse ; such cases are very frequently  followed
by  secondary symptoms, and may give rise  to the supposition that
the child was the  cause.  An interesting example will  be  found at
page 508 of  M. Ricord's valuable  treatise :  notwithstanding all his
endeavors, the sores on  the nipples (stated  by the female  to have
resulted from suckling a diseased child),  tested by inoculation, failed
to produce  the  characteristic pustule ;  only  slight irritation of the
inoculated point followed, and passed away in a few days. 
EXPLANATION  OF   THE  PLATES.
PLATE  I.
FIG. i._EXCORIATION.
  The subject of this drawing had suffered many months  from a
greenish purulent discharge.  She was a married woman, and attrib-
uted it to  a disease which her husband  had contracted about the
same  period.  The introduction of the instrument was not  attended
with much pain.   The characters of the excoriated condition of the
epithelium, and the color of the secretion, show the analogy which
it bears to balanitis in the male.

                FIG. 2.—GRANULAR CONDITION.

  This granular appearance of the  os  uteri and vagina is a very
marked instance of what is often to be met with in the hospitals of
Paris and London ; though generally in a less degree.   The subject
of it was  a  short stout  female servant; she stated that a discharge
from the vagina had appeared eight months previously, and had con-
tinued to  increase.  The introduction of the instrument was very
painful   The secretion was purulent, of a green color of the con-
sistence of  cream, and so abundant that it ran out of  the speculum.
 The  analogy between this disease, and the granular condition of the
 con]unctiva in chronic affections of that membrane, can not escape
 the notice of the surgeon. 
328
EXPLANATION OF THE PLATES.
PLATE  II.
                     FIG. 1.—ULCERATIONS.

  This view was taken from a  female,  the wife  of a  shoe-
maker at  Tours; she came  to Paris in consequence of a discharge
which had existed twenty  months.  This  patient attributed  it to
abortion which occurred about that period ;  her husband, she stated,
had suffered from several successive venereal complaints.  Inocula-
tion  was  tried on several and separate  occasions, by M. Vidal de
Cassis and myself, but the  inoculated point healed in twenty-four
hours, and as we always failed in producing the characteristic pustule,
we concluded that these ulcers were not specific.
                       FIG. 2.—CATARRH.

  This affection occurred in a young girl, a Belgian by birth, seven-
teen years of age, who presented a lymphatic temperament.   She
had been placed as servant to  wait upon an old lady in Paris, and
entered the  hospital for  a discharge.   She stated, that previous to
her arrival in Paris she had used  much exercise in the open air, but
during the last few months had hardly ever left the house, and lived
in a very  crowded and damp  situation.   The  condition of the  os
tincae  in young females is well shown, but the  mucous membrane is
paler  than usual.   The  artist  has very correctly represented  the
glairy white of egg like discharge proceeding out  of  the os uteri, in
which we occasionally meet with  globules of pus, a  secretion very
different from those witnessed in the other forms of blennorrhagia. 
EXPLANATION OF THE PLATES.
329
PLATE  III.
                        FIG. 1.—BALANITIS.

   The character of balanitis may, with advantage, be studied in this
 plate.   It  was impossible to say if sexual  intercourse or a want of
 cleanliness was the  cause.  The general erysipelatous redness of the
 glans is well seen, and the excoriated appearance so often to  be met
 with in this affection.

                      FIG. 2.—VEGETATIONS.

   The subject of this  complaint was a young man twenty-four years
 of age.  States he  never has  had  either  gonorrhcea  or chancres.
 The characters of the complaint are well seen;  the  clusters  of the
 granules are very florid, each  granule presenting a conical appear-
 ance, though collected into masses.

                         FIG. 3.—ECZEMA.

  The appearances  as seen in this  plate are very characteristic of
 the affection ; namely, the exudation of a serous fluid forming little
 scales, and the crevices  are distinctly seen running  between these
 little lamellae, resulting from the drying of the exuded fluid.  The
 history of the case was obscure ; the patient advanced in life.

                 FIG, 4.—HERPES PRAEPUTIALIS.

  Herpes  in its various stages is delineated in this plate; commencing
 as a vesicular disease, its vesicles may ulcerate, and assume all the
physical characters of chancre.  The five or six vesicles will be seen
on distinct  patches of inflamed skin, differing in this respect from all
 other vesicular eruptions. 
330
EXPLANATION OF THE PLATES.
                       PLATE  IV.


   FIG. 1.—INOCULATION—SIMPLE  UNCOMPLICATED CHANCRE.

  The original drawing was taken at the Venereal  hospital,  Paris.
from a patient forty years of age.   Connexion  had taken place six
weeks previously.  The patient had continued his usual occupation
of a blacksmith until two days prior to entering the hospital.   The
characters of simple chancre are well seen,  more or less circular in
shape, with loss of substance ; the edges of the sore neither elevated
nor indurated,  only  slightly oedematous,  with a  red  areola.   The
bottom as well  as the sides of the  sore  are  covered with tenacious
yellow lymph.
  The letters a, b, c, d, e, f, g, point to  the progress  of the artificial
chancre produced by inoculation on the thigh with the secretion of
fig. 1 ; a represents the inoculated point six hours after the operation,
the other letters at intervals of twenty-four hours.   Letter h  is the
chancre on the  thigh about the tenth day.

                FIG. 2.—FOLLICULAR  CHANCRES.

  Represents a  case similar to that of  Mr. H., detailed at page 188.
The drawing was taken two days  after the  appearance of the  af-
fection, and ten days after  connexion.   We observe the  co-existence
of gonorrhoea; the  pus is seen  issuing from the  urethra.   The
principal object,  however, is the development of the  virus  in the
follicles  on  the  glans,  resembling the appearance  seen in  figure,
marked a, b. 
EXPLANATION OF THE PLATES.
331
                        PLATE  V.

         FIG. 1.—DIPHTHERITIC PHAGEDENIC CHANCRE.

  This drawing was taken from a patient under the care of M. Ricord.
A mason by trade ;  twenty-nine years of age.  On entering the hos-
pital this patient's constitution appeared broken down by the combined
effect of dissolute  habits and poverty.   A thin ichorous discharge
flows from under the prepuce, from which a piece of  lint, soaked in
opium, is seen projecting.  A distinct chord was felt, extending up-
ward, in the direction of the ganglionic bubo, which commenced as a
pimple.   It was impossible  to collect dates from this person.   On un-
covering the glans it presented  the appearance figured in fig. 1, the
phagedena is seen extending rather in breadth than in depth;  no in-
duration  accompanies it; but we  observe some oedema around the
ulceration.   I should wish  to call attention to the analogy of ulcera-
tions in the same individual.
         FIG. 2.—INDURATED  PHAGEDENIC CHANCRE.

  This patient, a  tailor by  trade, twenty-three  years of age, of a
beautiful transparent complexion, stated  that six weeks previously
he had contracted chancres ; they healed under simple treatment, and
the  cicatrix became indurated, and then red; and lastly a sore began
in the centre, which has  since been extending;  a similar sore exist-
ed on the other side of the glands.  The molecular gangrene is very
marked, and the transparent indurated circle around it, elevated and
distinct  from the surrounding skin, is well seen.

                FIG. 3.—GANGRENOUS CHANCRE.

  This affection occurred in a young man twenty years of  age, a
bargeman on the Seine ;  who drank freely.   He stated that  eighteen
days previous to his admission,  he had had connexion with  a prosti-
tute at Rouen; fourteen days after a black spot showed itself on the
upper part of the prepuce,  which had become swollen and red, and
had increased to the extent seen in the drawing.  The  whole  of the
prepuce was destroyed in the succeeding thirty-six hours.

  Fig. 4, shows the mouth of  a person affected with mucous tubercles
in different  parts of the body and the white bleached mucous mem-
brane is well shown. 
332            EXPLANATION OF THE PLATES.
PLATE  VI.
  SYPHILITIC AFFECTIONS OF  THE MOUTH AND
                          THROAT.

                     FIG. 1.—SECONDARY

  This patient entered St. Bartholomew's hospital, in February last,
under the care of Mr. Stanley.   He stated that in the previous Sep-
tember he contracted chancres, which he cured with some aperient
medicine.   About Christmas he first  perceived  eruptions on  the
scalp, and his throat soon after became sore.   I would direct atten-
tion to the analogy between the affections on the skin and the mucous
membrane ; they are seen to pass insensibly one into the other.   In
fact, the white  and bleached superficial excoriation  of the throat
answers to  the syphilitic lepra  seen on  the body.  The speculum
oris allowed us to gain a good view of the back part of the throat.


                      FIG. 2.—TERTIARY.

  The subject of this complaint was a young girl who had led a very
dissipated life.  About fifteen months previous to the time the draw-
ing was  made,  she  had had  primary symptoms, and  had  been in
various hospitals, but I could not learn that she had ever taken mer-
cury.   The principal features of the disease are  well  seen.  The
absence of papilla on the  tongue, where ulceration had previously
existed, excavated ulcers covered with a pulpy secretion, and sur-
rounded with  a red areola, bespeak at  once  the tertiary symptoms ;
this is made  more evident by the occurrence of  rupia, which  was
present on various parts of her body. 
EXPLANATION OF THE PLATES
333
                      PLATE  VII.

                      (see frontispiece.)

  This plate (the frontispiece) represents different phases in the ev-
olution of tubercles.   In  the middle of the cheek are maculae ; on
the upper lip and the external and lower palpebral region, are several
small and separate tubercles ; on the left side of the nose are con-
fluent tubercles, which are thicker at the back part of the ala, and
there form a large tubercle.  On the  cheek also are two pustules of
ecthyma with tubercular base  and  surrounded by a dark red areola.
On the lower pustule the crust appears. 
334            EXPLANATION OF THE PLATES.
                     PLATE  VIII.

  This  plate  represents  those abnormal vegetations which some-
times occur in syphilitic patients and are seen around the anus, and
sometimes even on the penis. 
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to recommend the work.                       « EDWARD DELAFIELD, M.D.,
                                     Professor of Obstetrics and Diseases of Women and
                                        Children, University of State of New York."
  " I am of opinion that the translation of M. Maygrier's Midwifery, as prepared by Dr. Doane,
will be a most valuable acquisition to Students and Practitioners of Medicine.
                                            " ALEXANDER F. STEVENS, M.D."
                     WILLIAM  BTJCHAN,  M.D.

               A   TREATISE   ON    THE

 PREVENTION   AND   CURE   OF    DISEASES,
                BY REGIMEN AND SIMPLE MEDICINES.

              REVISED AND ENLARGED WITH  THE  ADDITION  OP

          A  VEGETABLE   MATERIA  MEDICA,
Poiatjag out the virtues, preparations, and doeea, of our most valuable native
                      medicinal plants, and an outline of
                   ANATOMY  AND  PHYSIOLOGY.
                         BY  J.  G. NORWOOD, M.D.
                     In one volume, 8vo.  Price  Four Dollars.
  "As health is the most precious of all things, and is the foundation of all happiness, the
science of protecting life is the  noblest of all, and most worthy the attention of all man
kind."—Hoffman.

         ----------------------------------£
 
                   BOOKS PUBLISHED BY J. S. REDFIELD.

          -S-Ch€—--------------------------------------<**&■

                              J.  G.  A.  LUGOL,
                  PHYSICIAN TO THE HOSPITAL ST. LOUIS, &C,  &C.
       RESEARCHES   AND   OBSERVATIONS  ON

                SCROFULOUS   DISEASES;
                             Translated from the French,
                      BY A. SIDNEY DOANE, A.M., M.D.
                         One vol.  12mo.   Price One Dollar.
  " This is a work of great value to the members of the medical profession, and to the great
number of sufferers by an insidious and most widely-extended disease."—N. Y. Tribune.
  " It is the most complete work we know of on Scrofulous diseases."—Morning- News.
  " M. Lugol has presented us an admirable treatise on Scrofulous Diseases, adapted to the
comprehension of all reflecting persons. Not only will enlightened parents derive, from
it much useful instruction, but the  medical  professon will  assent  to the statement that
Lugol's Researches contain a very luminous exhibition of the subject to which it  relates."—
Christian Intelligencer.
  " It is a very satisfactory and necessary book for all who would understand how to avoid
the various ills of Scrofula."—Evening Mirror.
  " Dr. Lugol has shed  great light upon a subject of peculiar interest, both to parents and
their children."—N. Y. Evening Post.
  " Dr. Doane has wisely selected this volume for transfer into our language.  The insidious
character of  Scrofula, the multiplied  phases that it assumes, its diversified causes and exhi-
bitions, according to the state of the subject whom it  affects, and its wide-spread evils, ren-
der a luminous and skilful development of this malady a public benefit."—Am. Republican.
                          P.  H.  RICORD, M.L).,

 SURGEON OP THE VENEREAL HOSPITAL  OF PARIS, CLINICAL PROFESSOR OP SPECIAL
                                  PATHOLOGY, &C.

                      PRACTICAL   TREATISE

         ON   VENEREAL    DISEASES;

      OR CRITICAL AND EXPERIMENTAL RESEARCHES ON INOCULATION
            APPLIED TO  THE STUDY OS1  THESE  AFFECTIONS, WITH  A
       THERAPEUTICAL  SUMMARY  AND  SPECIAL  FORMULARY.
                             Translated from the French,
                      BY A. SIDNEY DOANE, A.M., M.D.

                         In one volume, 8vo.  Price $1 50.
  " The subscriber is personally acquainted with Dr. Ricord, and has seen much of his practice,
not only in his Hospital, but In private, and can bear testimony to his merits as a Practitioner,
and also  to the value of his " Practical Treatise on Venereal Diseases," now about to be
translated for the general use of the Profession in this country.  The present translation is
offered to subscribers at less cost than the French edition at Paris.
                                  " VALENTINE MOTT, M.D., Professor of Surgery."
  " The work of Ricord is one of the very best which have been published on Venereal Dis-
eases, and I think that a good English translation will  prove of great service to the Profes-
sion.                                              " J. KEARNEY RODGERS, M.D."
  " I have seen Dr. Ricord in his Hospital, and have been very much interested in watching
his experiments and his practice.  I regard the result of his labors of more importance than
anything which has appeared since the days  of Hunter, and it gives me great pleasure to
know that so valuable a work as  his " Practical Treatise on Venereal  Diseases" is to be
presented to the Profession in the English language.
                                                " WILLARD PARKER, M.D.,
                                         " Professor of Surgery and Surgical Anatomy."
  " M. Ricord's •' Practical Treatise  on Venereal Diseases" is a substantial  addition to our
stock of  sound professional knowledge.  The reprint of his book in this country will do vast
good, and none need doubt that the task will be ably performed by his American editor.
                                                 " JOHN W.  FRANCIS, M.D.,
                                                  " Late Professor of Obstetrics in the
                                                  College of Physicians and Surgeons."
  "M. Ricord's Treatise on Venereal Diseases is generally acknowledged, to be one of the
most valuable on the subject which has ever appeared.  I doubt not that every subscriber
will be fully repaid  for the  small expense he will incur, by the  large amount of original
and useful information which he will receive.             "ALFRED C. POST, M.D.,
                                                             " Professor of Surgery."
-8»o 
 
 
 
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