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NATIONAL LIBRARY OF MEDICINE
       Bethesda, Maryland
            Gift of
    Worth B. Daniels, Jr., M.D.
      In memory of his father
      Worth B. Daniels, M.D.
 
A TREATISE
YENEEEAL DISEASE
 
/J.&r 
           A TREATISE



                  ON THE





VENEREAL  DISEASE.




                   BY


       JOHN HUNTEE, F.E.S.




    WITH COPIOUS ADDITIONS,


                   BY


         Dr. PHILIP  EICOED,
           SURGEON OF THE HoPITAL DD MIDI, PARIS, ETC.


          TRANSLATED AND EDITED, WITH NOTES,


                   BY

       FREEMAN J. BTJMSTEAD, M.D.,
     LECTURER ON YF.XFREAL AT THE COLLEOE OF PHYSICIANS AND SURGEONS, N. T.;
          ASSISTAST SURGEON TO THE N. Y. EYE INFIRMARY.


           Swnfc  (Btifm, $elris*&,

               CONTAINING A RESUME OF

  RICORD'S RECENT LECTURES ON CHANCRE.
     PHILADELPHIA:

BLAN CHARD  AND  LEA.

           1859. 
14 m2>

        Entered according to the Act of Congress, in the year 1858, by
                    BLANCHARD AND LEA,
in the Office of the Clerk of the District Court of the United States in and for the
               Eastern District of the State of Pennsylvania.
    PHILADELPHIA :

COLLINS, PKINTEK. 
EDITOR'S  PEEEACE.
  In the early part of the present year, M. Fournier, Interne of the
Hopital du Midi, published a volume of notes of the recent lectures
of M. Eicord  on Chancres; enriched, also, by many remarks of M.
Ricord in his clinical instruction at the bedside.1  This volume was
issued with  the approval of M. Ricord, and under his supervision, sp
that it bears all the authority  of the name of this eminent surgeon.
  Though apparently limited in its  subject,  this work, in reality, em-
braces most of the important points connected with Syphilis.  It is
especially worthy of notice, since it contains those modifications of
the views of M. Ricord and others, which recent investigation, excited
by the increased interest in the doctrines of syphilis during the last
few years, has introduced.
  The American Editor of Ricord and Hunter has made a free trans-
lation of those portions of M. Fournier's work which  are new, and
added them in a condensed form, to the notes of the present edition.
He would invite particular attention to the  notes relating to the im-
portant distinction between infecting and non-infecting chancres, their
diagnosis and treatment; the  affections of the lymphatic ganglia cor-
responding  to each;  the laws of  transmission  of these two varieties
of chancre;  the question  of  the  unity or  duality of the syphilitic
virus; the treatment  of constitutional syphilis, and the curative and
prophylactic effect of chlorate of potash on mercurial salivation.
  It is believed by the Editor that the present edition of " Ricord and

  1 Lecons sur le Chancre, professe'es, par le Dr. Ricord, Chirurgien de VHdpital du Midi,
etc.,  ridige'es et publie'es par Alfred  Fournier, Interne  de VHdpital du Midi.  Paris,
1858. 
iv
editor's preface.
 Hunter," contains the fullest exposition of the views of M. Ricord that
 has yet been published.
   Some slight modification of the typographical arrangement has been
 made, in order to render more distinct the authorship of the different
 portions of the work.  All matter added to the original text of Hun-
 ter is inclosed in brackets.  The  notes of  the Editor are  printed in
 smaller type,  and the  additions are, moreover, distinguished by the
 names of "Ricord," "Home," "G-. G. B." (the initials of Mr. Babing-
 ton), or "Editor," as respectively contributed by them.  When these
additions extend over more than one page, the names are placed at
both the beginning  and end, in order  that the reader may readily
trace the authority.
New York, November, 1858. 
PEEEACE  TO THE  EIEST  EDITION.
   The school, of which M. Ricord is the head, has, by its adherence
 to some of the  most important views of the  immortal Hunter, and
 more particularly by its adoption of Hunter's division of constitutional
 syphilis into two periods, and of his belief  in the non-contagiousness
 of secondary symptoms, acquired for itself the name  of Hunterian.
 It is not without reason, therefore, that the names of these two distin-
 guished  authors, though separated  by  more than half a  century,
 appear conjointly on the title-page of this volume.
   M. Ricord's annotations to Hunter's, Treatise  on the Venereal Disease
 were first  published  at  Paris, in 1840, in connection with Dr. Gr.
 Richelot's translation  of the work, including the contributions of Sir
 Everard Home and Mr. Babington.   In a second edition, which has
 recently  appeared, M. Ricord has thoroughly revised his part of the
 work, bringing it up to the knowledge of the  present day, and so
 materially increasing  it that  it now  constitutes full one-third of the
 volume.
  This publication has been received with great favor by the French,
 both because it has placed within their reach an important work of
 Hunter, of  whom one of their most  eminent  living physicians says:
 " Un silcle nous separe bientot  de  la publication  de ses premiers travaux,
 et il a si peu vielli, que, sHl est mal apprecie, c'est moins parceque nous
 Vavons laisse derrilre nous  que parce quHl nous  devance,vi  and also be-
 cause it is the only recent practical work which M. Ricord  has  pub-
 lished, no  edition of his Traite des  Maladies  Veneriennes  having
appeared for the  last fifteen years.

       1 Trousseau, Traite" de The"rapeutique et de Matldre M<fdicale, p. L. 
VI             PREFACE TO  THE FIRST EDITION.
  The present volume is a translation by the Editor  of M. Ricord's
annotations, and a reprint of the edition of Mr. George G. Babington,
which was first  published in 1837.  It is  hoped that  the  notes and
additions  by the Editor will be found either to assist the reader in a
correct understanding of the text, or to contribute additional informa-
tion on some of the important subjects herein treated, and that the
index which has been added will increase the usefulness of the work.

   278 Sixth Avenue, New York, •)
       September 16, 1853.      ) 
ME.  BABINGTON'S  PEEEACE.
  Of all the works of John Hunter, there is none on which he bestowed
more labor, or which he was more solicitous to perfect than his treatise
on the Yenereal Disease.  " I am resolved," said he to a friend, " that
it shall not be a mere bookseller's job, every subsequent edition ren-
dering the former useless.   The truth of the doctrines I have proved
so long as to reduce them to  conviction;  and,  in order to render the
language intelligible, I meet a committee of three gentlemen1 to whose
correction every page is submitted."  It would seem that this correction
of style was adopted in the second edition.   On comparing it with the
first we find numberless verbal alterations, which were evidently in-
tended to render the expressions more lucid and more elegant.   It is
doubtful whether much has been gained by the  change.  The language
is certainly less rugged, but it is also less forcible, and occasionally less
distinct and decided.   However, as the corrections have extended in
some instances to points of more consequence than style, the second
edition must undoubtedly be considered as containing the latest expe-
rience and ultimate conclusions of the author.  The third edition was
published after his death by Sir  Everard  Home, who has in general
followed the text of the first edition, and has introduced some passages
which were certainly never written by John Hunter. For these reasons
the text of  the second edition has been followed as the most genuine:
but, as the alterations of Sir E. Home profess to be derived from mate-
rials left by the author, it has been thought best not to omit them en-
tirely, and consequently such of them as  are more than verbal  have
been added in notes at the bottom of the page.
  It cannot be disputed that the work thus produced bears marks of the
mind that gave it birth.  To form a just estimate of its merits, it is
necessary to compare it with the books on the same subject which had
previously appeared in this country.  These seem, for the most part, to
have been written less with the design of increasing the knowledge of
the disease, than with a view to temporary notoriety, and to the emolu-
ments which such notoriety might bring.  John Hunter always had

  1 The three gentlemen were, Dr. (afterwards Sir Gilbert) Blane, Dr. George Fordyce,
and Dr. David Pitcairn, and with these Mr. Marshall appears to have been associated. 
Vlll
MR.  BABINGTON'S  PREFACE.
 higher objects.  He has labored to apply to  this disease the general
 principles of pathology, and to subject it to the same scrutinizing ana-
 lysis which generally guicjed his philosophical researches.  The facts he
 has selected from his daily experience are valuable, not for their singu-
 larity, but for the inferences to which they lead.   Where the practice
 was previously uncertain and contradictory, he has often established
 systematic principles of treatment; and where the practice was right,
 he has placed it on a sure foundation, by substituting the deductions ot
 reason for the  habits of empiricism.  With respect especially to dis-
 eases of the bladder and  urethra, the observations  contained in this
 work first  threw light on those affections, and formed the basis on
 which our present accurate knowledge of them has been founded.
   Yet at the same time it must be admitted that this  treatise is not
 without defects; and that the reputation of John Hunter rests more on
 his other works than on this.  Many of the remarks are rather theore-
 tical than practical, and some of the  doctrines have not obtained that
 general assent which has crowned most of his other labors.  The causes
 of these imperfections are to be found in the nature of the subject and
 the character of the author.
   A little reflection will show that the venereal disease was less adapted
 than many  other subjects to the peculiar genius of John Hunter.  The
 faculties which chiefly distinguished him from other men of science, and
 which generally insured his success, were an ardor and an energy which
 nothing could damp, and an industry which nothing could tire.  Under
 the influence of these qualities he pushed his investigations with unex-
 ampled activity, and  brought to light a multitude of facts, which the
 less energetic  inquiries of other philosophers had failed  to discover.
 Wherever our previous knowledge was partial and indistinct, the new
 facts which he collected by observation, or discovered by dissection, or
 established  by experiment, illuminated  the whole subject, and substi-
 tuted the clear distinctness of the day for the obscurity and uncertainty
 of twilight.  His view was  always  large and comprehensive; and by
 combining these new discoveries with what was known before he de-
 duced without difficulty laws which had eluded previous research and
 then  verified  his  deductions by a farther observation and a  more
 extended experiment.   It is more to the activity of his inquiries  than
 to the strength of  his  reasoning powers that we  owe his  discoveries.
 Indeed, his powers of reasoning were scarcely on a level with his other
 faculties, but the errors of his logic were perpetually corrected by the
 variety and accuracy of his experiments.
  Now it so happens that in the venereal disease he had little opportu-
nity for the exercise-of his usual means of investigation. Experiments
on animals are impossible in this case, as the disease seems to be con- 
MR. BABINGTON'S PREFACE.               ix
fined to the human species.  Dissections give little information, for the
virus itself altogether eludes our sight;  and such of its effects as are
not obvious are for the most part too minute to be distinguished by the
eye. As most syphilitic symptoms occur in parts which are superficial
and exposed to view, their general form and character have long been
familiar to surgeons; the minuter changes are not discoverable by sim-
ple inspection, nor easily demonstrable to  the  senses.   The  casual
observations of every day were open to John Hunter as to others, but
he was exposed to the same difficulties which had checked the progress
of his  predecessors, and was liable to be misled by the same causes of
error.  In the venereal disease we have abundance of facts, of a certain
kind, on record.  It is not additional experience that we want, but a
more correct discrimination, which would enable us better to understand
our experience, to disentangle its perplexities, and reconcile its apparent
contradictions.  The facts noticed by John Hunter are not sufficiently
novel or important to throw of themselves much additional light on the
pathology of the malady.  He was therefore  reduced to the necessity
of reasoning from the old experience, and of endeavoring, by subjecting
it to a more correct process of induction, to correct the errors and im-
prove on the knowledge of those who had preceded him. Consequently,
it is not surprising that his labors should have been less successful here
than in some other branches of pathology, and that he should  often
have failed in removing the obscurity which envelops this malady. It
may even be doubted whether his natural appetite for generalization
has not sometimes misled him, and whether, in his desire to ascertain a
general law, he has not sometimes abandoned his hold of the acknow-
ledged facts of the disease, and left it even more obscure than before.
  There was one way in which the investigation might have  been con-
ducted which would have promised higher results.  The symptoms of
the venereal disease, though very obvious, are at the same time infinitely
various, and even to this day they have never been  accurately dis-
criminated.  If the author had bent the full  powers of his keen and
penetrating mind to tracing out in the first instance a correct descrip-
tion of each separate symptom; if he had then pursued the research so
as to have ascertained in each case the particular structure affected, and
the particular nature of the morbid alteration, he would have laid a firm
basis for  his reasoning, and could not have failed to elucidate both this
malady and many which resemble it.  It is  probable  that  he would
have so ascertained the laws which regulate the peculiar action of the
venereal  virus, as to have left no room for confounding its effects with
diseases from  other causes.   It is probable that he would  have ex-
plained the apparent contradictions in the effect of remedies, and, by
appropriating each to its  peculiar class of affections, have rendered the 
 X                 MR. BABINGTON'S  PREFACE.

 system of treatment no longer dubious and  empirical, but clear and
 intelligible.  It is certain that he would have opened the way for sub-
 sequent discoveries to an extent which cannot be calculated, and that,
 not only in the disease under consideration, but also in other maladies
 which have hitherto been little studied by pathologists, especially in
 eruptions and other diseases of the skin.
  That such a task as this was well adapted to  the powers of John
 Hunter cannot be questioned.   The descriptions  he has given  in the
 work before us are sufficient of themselves to establish his reputation.
 In accuracy and distinctness they have never been surpassed, and they
 remain at the end of half a century the standard  definitions to which
 all subsequent writers have referred.   But the plan here sketched out
 would have been  toilsome and long.  It would have required the labor
 of a life.  The fruit which it promised was remote and uncertain.   It
 might never  have been gathered by the  author, but might have re-
 mained to be the  spoil of a future generation.  He followed his natural
 inclination.  He preferred the more delusive, apparently the more direct
 road which has seduced so many philosophers. He sought to arrive  at
 the general laws of nature at once by conjecture; rather  than, by a
 close and detailed study of her inferior operations, to ascend, step by
 step, through a slow and gradual induction to those laws which govern
 her general procedure.   " Altera (via) a sensu  et particularibus advolat
 ad axiomata maxime generalia, atque ex iis principiis eorumque immota
 veritate judicat et invenit axiomata media; altera a sensu et particu-
 laribus excitat axiomata,  ascendendo  continenter  et  gradatim  ut
 ultimo loco perveniatur ad maxime generalia."1
  But though this treatise is tainted more than any other of the works
 of John  Hunter with the vice of a too hasty generalization yet it  is
 full of practical observations of the  highest  value, and must always
 form  an  essential part  of the  study of  every surgeon  who wishes to
 make himself acquainted with the disease of  which it treats. In the
present edition it  has been attempted to render it raore generally useful
by engrafting on  it the labors of other surgeons.   The opinions of the
 author have  been treated with the respect which is due to his  hie-h
 reputation; but where important facts have been  brought to light b
 others, either in confirmation or in correction of his principles  th
 have been presented to  the reader, in order that  he may have befor
 him in one view the present state of the science, and that, by comparing
 the reasoning of others with that of the author, he may be enabled to
 form a just opinion of the truth or the error of his conclusions.
                                          G. G. BABINGTON.
  London, June 13,1835.
                        1 Bacon, Aphorism, six. 
CONTENTS.
Editor's Preface
Preface to the First Edition
Mr. Babington's Preface
Introduction
    1. Of sympathy
    2. Of morbid actions being incompatible with each other
    3. Of the comparative powers of different parts of the body—from situa
           tion—from structure
    4. Of parts susceptible of particular diseases
       M. Ricord's addition
       Editor's addition ....
    5. Of inflammation .
    6. Of mortification ....
generation
in chancre
-Action
                                 PART  I.

Chapter I.—Of the Venereal Poison  .
    1. Of the first origin of the poison .
    2. It began in the human race, and in the parts of
    3. Of the nature of the poison
       Mr. Babington's addition
       M. Ricord's addition
    4. Of the greater or less acrimony of the poison
    5. Of the poison being the same in gonorrhoea and
       Mr. Babington's addition
       M. Ricord's addition
       Editor's addition
    6. Of the causes of the poisonous quality—Fermentation

Chapter II.—The Mode of Venereal Infection
       M. Ricord's addition     ...

Chapter III.—Of the Different Forms of the Disease
    1. Varieties in different constitutions

Chapter IV.—Of the Lues Venerea being the Cause of other Diseases

                                 PART II.

Chapter I.—Of Gonorrhoea     ...-••
       M. Ricord's addition     ....-•
       Editor's addition        ......
    1. Of the time between the application of the poison and effect .
       M. Ricord's addition     ......
    2. Of the difficulty of distinguishing the virulent from the simple gonor
           rhcea ....••••
       M. Ricord's addition     ....-•
67
68
69
16.
70

71
72 
Ill
CONTENTS.
 9.
10.

11.

12.
13.
3. Of the common  final  intention of suppuration  not  answering in  the
      present disease     ....
   M. Ricord's addition    ....
4. Of the venereal gonorrhcea
5. Of the seat of the disease in both sexes
6. Of the most common symptoms and the order of their appearance
7. Of the discharge  .
   M. Ricord's addition    ....
8. Of the chordee   .....
   Of the manner in which the inflammation attacks the urethra
   Of the swelled testicle   ....
   M. Ricord's addition    ....
   Of the swellings  of the glands from sympathy .
   M. Ricord's addition    ....
   Of the diseases of the lymphatics in a gonorrhcea
   Short recapitulation of the varieties ia the symptoms
Chapter II.—Of the Gonorrhcea in Women
    1. Of the proofs of a woman having this disease
       M. Ricord's addition
Chapter III.-
-Of the Effects of the Gonorrhcea on the Constitution in both
  Sexes   ........
Chapter IV.—Of the Cure of the Gonorrhcea .....
    1. Of the different modes of practice—Evacuants—Astringents  .
    2. Of local applications—Different kinds of injections;  irritating, seda-
          tive, emollient, astringent  ......

Chapter V.—Of the Cure of Gonorrhcea in Women   ....

Chapter VI.—Of the  Treatment of the  Constitution  in the  Cure of the
              Gonorrhcea     .......
       Mr. Babington's addition      ......
       M. Ricord's addition     ••.....
       Editor's addition        ....
Chapter VII.—Of the Treatment of Occasional Symptoms of the Gonorrhcea
    1. Of the bleeding from the urethra      ....
    2. Of preventing painful erections .....
    3. Of the treatment of the chordee
    4. Of the treatment of the suppuration of the glands of the urethra
    5. Of the treatment of the affection of the bladder from gonorrhcea
    6. Of the treatment of the swelled testicle
       M. Ricord's addition   •••...
       Editor's addition       .....
    7. Of the decline and termination of the symptoms of gonorrhoea
       M. Ricord's addition    ....
1.
Chapter VIII.—Observations on the Symptoms which often remain after the
              Disease is subdued     .
       Of the remains of the disagreeable sensations excited by the'original
          disease      •••...
       M. Ricord's addition    .....
       Editor's addition       .....
       Of a gleet       ......
       Mr. Babington's addition       ....
       Of the cure of gleets—Constitutionally—Locally
       M. Ricord's addition    .....
       Of the remaining chordee      ....
       Of the continuance of the irritation of the bladder
       Of the remaining hardness of the epididymis  .
       M. Ricord's addition    .      .       . 
CONTENTS.
xiii
                               PART  III.
                                                                          PAGE
Chapter I.—Of  Diseases supposed to arise in Consequence of Venereal In-
              flammation in the Urethra of Men   .      .      .       .161
       M. Ricord's addition    .......     162
    1. Of strictures     ........     165
       M. Ricord's addition     .       .      .      .      .      .       .166

Chapter II.—Of the Permanent Stricture    .      .      .      .       .167
       Mr. Babington's addition       .      .      .      .      .       .170
       M. Ricord's addition     .       .      .      .      .      .       .171
    1. Of the bougie    ........     172
    2. Of the treatment of the permanent stricture   .      .      .       .173
       M. Ricord's addition     .       .      .      .       .      .       .177
    3. Of the cure of stricture by ulceration  . .     .      .      .       .     179
       M. Ricord's addition     ..".....     182
    4. Of the application of caustic to  strictures     ....     ib.
       Mr. Babington's addition       ......     186
       M. Ricord's addition     .       .      .      .      .             .     188

Chapter III.—Of Strictures in  Women       .      .      .      .       .191
       M. Ricord's addition     .       .      .      .      .      .       .195
    1. Of the cure of strictures in women    .....     ib.
        M. Ricord's addition   .......     ib.
    2. Of the gleet in consequence of stricture       ....     ib.

Chapter IV.—Of Stricture attended with Spasmodic Affection     .       .     196
Chapter V.—Of some Circumstances attending the Use of Bougies—Their
               Figure and Composition        .      .       .       .      .    197
       M. Ricord's addition    .       .       .  •            .       .      .    200
     1. Of a new passage formed by bougies   .....    202
       M. Ricord's addition    .......    205

Chapter VI.—Of Diseases in Consequence of a Permanent  Stricture in the
               Urethra       .......    209
     1. Of the enlargement of the urethra     .      .        .      .            ib.
       M. Ricord's addition    .......     ib.
     2. Of the formation of a new passage for the urine        .      .      .210
     3. Of inflammation of the parts surrounding the urethra  .      .      .    215
     4. Of the treatment of the inflammation in the surrounding parts      .    217
       M. Ricord's addition    .      .       .      .        .      .      .218
       Editor's addition       .......    219
     5. Of the effects of inflammation in the surrounding parts upon the con-
          stitution     .       .      .       .      .        .      .      .220
     6. Of fistulae in perinseo    .      .       .      .       .      .           221
     7. Of the operation for fistula? in perinseo  .      .       .      .      .     ib.
       Mr. Babington's addition      ......     224
       M. Ricord's addition    .......    225

Chapter VII.—Of some other Affections of the Urethra    .      .      .    229
     1. Of the spasmodic affections of the urethra     .       .      .      .      ib.
       M. Ricord's addition    .......     230
     2. Of the cure of the spasmodic affection of the urethra  .      .       .      ib.
     3. Of the paralysis of  the urethra ......     232
     4. Cure of the paralysis of the urethra     .      .       .      .       .      ib.
     5. Of caruncles or excrescences in the urethra    ....      ib.
     6. Of the cure of the excrescence or caruncle    ....     233

Chapter VIII.—Of the Swelled Prostate Gland     ....      ib.
       M. Ricord's addition   .......     237
    1. Of the treatment of the swelled prostate gland ....     238
       Mr. Babington's addition       ......     239
       M. Ricord's addition   .......     ib. 
XIV
CONTENTS.
 Chapter IX.—Of the  Diseases of the Bladder, particularly from the be
               fore-mentioned Obstructions to the Urine
     1.  Of the treatment where the actions  of the urethra and bladder do not
          exactly alternate   ......
     2.  Of the paralysis of the bladder from obstructions to the passage of the
          urine .      .      .      .
     3.  Of the cure of the paralysis of the bladder from obstruction arising from
          pressure or spasm   ......
        M. Ricord's addition   ......
 Chapter X.—Of a Suppression of Urine and Operation for .the Cure of it
        Mr. Babington's addition       .....
     1. Of allowing a catheter to remain in the urethra and bladder  .
     2. Of the increased strength of the bladder
     3.  Of the distension of the ureters .....
     4. Of irritability in the bladder independent of obstructions to the passage
          of the urine .......
     5. Of the cure of simple irritability of the bladder
     6. Of a paralysis of the acceleratores urinse

Chapter XI.—Of the Discharge of the Natural Mucus of the Glands of the
              Urethra       ......
     1. Of the discharge of the secretions of the prostate gland and vesiculse
          seminales    .......
       M. Ricord's addition   ......

Chapter XII.—Of Impotence   ......
     1. Of impotence  depending on the mind   ....
     2. Of impotence from a want of proper correspondence between the actions
          of  the different organs      .....

Chapter XIII.—Of the Decay of the Testicle ....
       M. Ricord's addition    ••....

Chapter XIV.—Gonorrhceal Ophthalmia, by M. Ricord

Chapter XV.—Gonorrhceal Rheumatism, by M. Ricord
page

 240

 242

  ib.

 245
  tb.

 246
 251
 252
 253
 254

  ib.
 255
  ib.


 256

  ib.
 257

 258
 260

 262
 265
 268
 ib.

 275
                               PART  IY.

Chapter I.—Of Chancre  «    .
       Mr.  Babington's addition       ....
       M. Ricord's addition    ....
       Editor's addition       .
    1.  Of the phimosis and paraphimosis
       M. Ricord's addition           ,

Chapter II.—Of Chancres in Women   ....
       M. Ricord's addition    .

Chapter III.—General Observations on the Treatment of Chancre
       Mr.  Babington's addition       .
       M. Ricord's addition    .....
    1.  Of the destruction of a chancre .
       Mr.  Babington's addition       ....
       M. Ricord's addition    .....
       Editor's addition       .....
    2.  Of the cure of chancres—Local application
       M. Ricord's addition    ....
    3.  Of the  treatment of phimosis in consequence of, or attended with
         chancre     .....
    4.  Of the common operation for the phimosis produced by chancres
    5.  Of the constitutional treatment of phimosis
       Mr.  Babington's addition
       M. Ricord's addition    .....
       Editor's addition       ....
283
287
291
299
308
311

313
314

315
316
317
318
319
320
322
 16.
323

331
334
335
336
 ib.
338 
CONTENTS.
XV
    6.  Of the treatment of the paraphimosis from chancre
       M. Ricord's addition    ....
    7.  Of the cure of chancres by mercury given internally
       M. Ricord's addition    ....
       Editor's addition       ....

Chapter IV.—Of the Cure of Chancres in Women
       M. Ricord's addition    ....

Chapter V.__Of some of the Consequences of Chancres and the Treatment
              OF THEM  ..••••
    1. Of dispositions to new diseases during the cure of chancres
       Mr.  Babington's addition on phagedenic ulcers
       M. Ricord's addition
    2. Of ulceration resembling chancres
       M. Ricord's addition
    3. Of a thickening and hardening of the parts
       M. Ricord's addition
    4. Of warts .
       M. Ricord's addition
    5. Of excoriations of the glans and prepuce
page
 338
 339
 340
 342
 344

 346
  ib.
347
 ib.
349
352
353
354
 ib.
355
 ib.
356
359
                                PART  Y.

Chapter I.—Of Bubo   ....••••

Chapter II.—Of Buboes in Women     ...•••
       Editor's addition       ...••••

Chapter III.—Of the Inflammation of Buboes, and the Marks that distin-
               guish them from other Swellings of the Glands

Chapter IV.—General Reflections on the Cure of Buboes
    1. Of resolution of the inflammation of the absorbents on the penis
    2. Of the resolution of buboes in the groin       .
    3. Of the resolution of buboes in women  .
    4. Of buboes in other parts       .      •      •       •      •
    5. Of the quantity of mercury necessary for the resolution of a bubo
    6. Of the treatment of buboes when they suppurate

Chapter V.—Of some of the Consequences of Buboes .
       M. Ricord's addition on the treatment of buboes
361

368
369
373

377
379
380
 ib.
381
 ib.
382

383
387
                               PART  VI.

Chapter I.—Of the Lues Venerea     .
       M. Ricord's addition    .       •       •      *•,",'
    1.  Of the nature of  the sores or ulcers proceeding from the lues venerea
       M. Ricord's addition    .       •       •      •       •       •
    2.  Of the matter from sores in the lues venerea compared with that from
          chancres and buboes       .
       M. Ricord's addition    .       •       •      *.,"■,    "...  ,
    3.  Of the local effects arising from the constitution considered as critical
          Symptomatic fever  .      •       •      •           .  ■     .
    4.  Of the local and  constitutional forms of the disease never interfering
          with one another   .      •       •      •      •      •
    5.  Of the supposed termination of the lues venerea in other diseases
    6*.  Of the specific distance of the venereal inflammation .
    7*  Of the  parts most  susceptible of the  lues venerea—Of the time and
          manner in which they are  affected—What is meant by contamina-
          tion, disposition and action—Summary of the doctrine

Chapter II.—Of the Symptoms of the Lues Venerea .
       M. Ricord's addition    ...••••
393
394
397
399

400
405

406

408
409
 ib.
410

418
420 
XVI                             CONTENTS.
     1.  Of the symptoms of the first stage of the lues venerea
        Mr. Babington's addition on syphilitic eruptions
        Mr. Babington's addition on syphilitic affections of the throat
        Mr. Babington's addition on syphilitic iritis
     2.  Experiments made to ascertain the progress and effects  of the venereal
           poison      ......
     3.  Of the symptomg of the second stage of the lues venerea
        Mr. Babington's addition on syphilitic affections of the bones
     4.  Of the effects of the poison on the constitution
        M. Ricord's addition on the secondary and tertiary symptoms of syphilis
        Editor's addition       ......

Chapter III.—General Observations on the Cure of the Lues Venerea
     1.  Of the use of mercury in the cure of the lues venerea
        M. Ricord's addition    ....
        Mr. Babington's addition
     2.  Of the quantity of mercury necessary to be given
     3.  Of the sensible effects of mercury upon parts  .
     4.  Of the action of mercury
     5.  Of the different methods of giving mercury—Externally—Internally
     6.  Of the cure of the disease in the second or third stage
     7. Of local treatment       ......
     8.  Of abscesses—Exfoliation      .....
     9.  Of nodes or tendons, ligaments and fasciae
   10.  Of correcting some of the effects of mercury
   11. Of the form of the different preparations of mercury when in the cir
           culation      .......
   12. Of the operation of mercury on the poison
   13. Of gum guaiacum and radix sarsaparillse in the venereal disease
       M. Ricord's addition on the treatment of  constitutional syphilis
       Editor's addition       ......

Chapter IV.—Of the Effects remaining after the Disease is  cured, and of
              the Diseases sometimes produced by the  Cure .
    1. General observations on the medicines usually given for the cure
    2. Of the continuance of the spitting     ....

Chapter V.—Of preventing the Venereal Disease
       M. Ricord's addition on the prophylaxis of  syphilis
page
 421
 423
 429
 431

 432
 434
 435
 436
 437
 462

 465
 467
 472
 473
 474
 475
 476
 478
 483
 485
 486
 ib.
 487

 490
 491
 493
 494
 497
508
510
513

514
 ib.
                               PART  VII.

Chapter I.—Of Diseases resembling the Lues Venerea which have been mis-
              taken for it
       Mr. Babington's addition      ....
       Mr. Babington's addition      ....
       M. Ricord's addition    .....
    1. Of diseases supposed to be venereal produced by transplanted teeth  '.

Explanation of the Plates      ....
Index
519
520
528
530
536

543
549 
A   TREATISE
                          on the

YENEREAL    DISEASE.
                    INTRODUCTION.

   Two motives have induced me to publish the following treatise.  In
the first place, I am not without hope that several new observations
contained in it will be deemed worthy of the public attention; in the
next  place, I am  desirous to have  an opportunity of showing from
whom some opinions that have made their way into the medical world
originated.
   But as much of the theory which will often be referred to in the
course of this work is peculiar to myself, it seems necessary to give
an introductory explanation of some  parts of it, in order that the terms
used may be the more intelligible to the reader.

                       § 1. Of Sympathy.

   I divide sympathy into two parts,  universal and partial.
   Universal sympathy is an  affection wherein the whole constitution
sympathizes with some sensation  or action.  Partial sympathy is  an
affection wherein one or more distinct parts sympathize with some local
sensation or action.
   The universal sympathies  are different in  different diseases; but
those that occur in the venereal disease are principally two, the symp-
tomatic fever and  the hectic fever.   The symptomatic fever is  an
immediate effect of some local injury, and seldom  takes place  in the
venereal disease in any great degree under any of its forms, except
in the case of a swelled testicle, which is itself an instance of a par-
tial sympathy;  the symptomatic fever here, therefore, is a  universal
sympathy arising from a partial one.   The hectic fever is a universal
sympathy with a local disease, which the constitution is not able to
overcome.  This takes place  oftener and in a greater degree in the
lues venerea than in any other form  of the disease.
       3 
34
INTRODUCTION.
  I divide partial sympathy into three kinds; the remote, the contiguous,
and the continuous.  The remote, is where there appears to be no visible
connection of parts from  whence we can account for such effects, as
in the case of pain of the shoulder in an inflammation  of the liver.
The contiguous, is  that which appears to have no other connection
than what arises from vicinity or contact of separate parts, an instance
of which we have In the stomach and  intestines  sympathizing with
the integuments of  the  abdomen.   The  continuous, is where there is
no interruption of  parts,  and the sympathy runs along from the irri-
tating point, as from a  centre, which is the most common of all sym-
pathies. We have an example of this in the spreading of inflammation.

       %2. Of Morbid Actions being incompatible with each other.

  The venereal disease is not only suspected to be present in  many
cases where the nature of the disorder  is not well marked, but it is
supposed that it can be combined with other diseases, such as the itch
and the scurvy.  Thus, we hear of  pocky itch and  of scurvy and the
venereal disease combined; but this supposition appears to me to be
founded in error. I have  never seen any such cases, nor do they seem
to be consistent with the principles  of morbid action in the animal
economy.   It appears to me, beyond a doubt,  that no two actions can
take place in the same constitution, or in the same part, at one and the
same time.  No two different fevers can exist in  the same constitution,
nor two local diseases in the same part, at the same time;  yet as the
venereal disease, when it attacks the skin, bears a resemblance to those
symptoms which are vulgarly called scorbutic, they are often supposed
to be mixed, and to exist  in the same part.
  What has been  called  a scorbutic constitution  is no  more than a
constitution very susceptible of an action producing  eruptions on the
skin whenever an immediate cause takes place;  and there are  some
parts of the body more susceptible of this than others, in which, there-
fore, a slighter immediate cause is sufficient to  excite the action; but
the easy susceptibility with respect to one disease is not a reason why
a constitution should not likewise be susceptible of other  diseases.  A
man may  have the  pox and the smallpox  at the same time; that is,
parts of his body may have been contaminated by the venereal poison,
and the smallpox may take place, and both diseases may appear together,
but not in the same parts.   If both were consequences of fever, and
each followed the fever nearly about the same time, it would be im-
possible for each to  have its respective eruption, even in different parts,
at the same  time;  two fevers, antecedent to  these different  diseases,
cannot be coexistent.1

  1 Ricord.—Hunter does not believe it possible for two distinct morbid actions to take
place in the same part at the same time.  Hunter's doctrine taken literally, would be
a very serious error.  Our daily practice presents individuals affected at the same time
with scabies, and primary or constitutional syphilis ; also with scurvy or scrofula, and
syphilitic symptoms. These are cases in which there is, strictly speaking, no " pocky
itch," nor syphilitic scurvy or scrofula, but a complication of two concomitant affections,
which singly or together assume an acute form.  Moreover, we meet with numerous
cases in which scrofula, an herpetic or dartrous diathesis, or scurvy, impresses upon 
MORBID  ACTIONS ARE  INCOMPATIBLE.          35
   From this principle, I think I may fairly put the following queries.
Does not the failure of inoculation, and the power of resisting many
infections, sometimes  arise from the person's having at the same time
some  other disease, and  therefore being incapable  of a new action ?
Does not the great difference in the time, from the application of the
cause  to the appearance of the effect, in many cases,  depend upon the
same principle ?  It has been sometimes observed that the puncture in
the arm has shown no sign of inflammation in fourteen days after the
application of the variolous poison. Has there not been another disease
in the constitution at  the time of inoculation ?  Does not the cure of
some  diseases depend upon the same principle ?  The suspension or
cure of a gonorrhcea by a fever may be an instance of this.
   Let me  illustrate this principle still farther, by one of many cases
which have come under my own observation.   On  Thursday, March
16,1775,1 inoculated a gentleman's child, in whose arms it was observed
I  made large punctures.   On the Sunday following, he appeared to
have received the infection, a small inflammation or redness appearing
round each puncture,  and a small  tumor above the surface of the skin
having been observed.  On the 20th and 21st, the child was feverish,
but I declared that the fever was not variolous, as the inflammation had
not all advanced since the 19tb.  On the 22d, a considerable eruption
appeared, which was evidently the measles; upon this, the sores on the
arms  appeared to go  back, becoming  less inflamed.  On the 23d, he
was very full of the measles, the punctures  on the arms being in the
same  state  as on the preceding day.   On the 25th, the measles began
to  disappear.   On  the 26th and  27th, the  punctures began to look a
little red.   On the 29th, the inflammation increased, and there was a
little  matter formed.   On  the 30th, he was seized with fever.  The
smallpox appeared at  the regular time, went through its usual course,
and terminated favorably.1  In like manner, it may  be observed that

the syphilitic symptoms a  peculiar stamp, in which we are forced to recognize a com-
bination of these morbid causes, acting together on the same region and  on the same
tissues.
  If Hunter's doctrine can be sustained with regard to acute and especially febrile
affections, where, by the laws of revulsion, the stronger disease may moderate or sus-
pend the feebler for the time being, it is often untrue of diseases analogous to syphilis.
There is no disease which is an absolute protection against contracting syphilis ; and
the latter, in turn, cannot, while it lasts, protect against any other, if it be not against
a new constitutional syphilis.—Ricord.
  1 Editor.—The following case is added in the French edition of this work.  It was
reported in the Zeitschrift fiir die gesammte Medicin, for November, 1836, and was also
inserted by Dr. Glehn, in  the Transactions of the Medical Society  of St. Petersburg,
under the head of " Struggle between Scarlatina and Smallpox."                «
  On the 25th of November, 1834, at a time when epidemics of scarlatina and small-
pox were prevailing, a  young  naval officer was seized with vomiting, without any
apparent cause. He was better on the 26th; but on the 27th he experienced headache,
vertigo, and extreme prostration; his pulse was frequent, his tongue coated, and his
eyes injected.  Chills alternated with flushes of heat.  These symptoms became very
violent  on the 28th; and on the 29th an eruption of scarlatina, in patches of a dark-
red color, appeared on his face, neck, chest, and upper extremities. At the same time,
isolated pustules were observed on the forehead and face.  The velum palati and uvula
were inflamed, and deglutition was  very difficult.   The next day,  the eruption of
scarlatina faded and disappeared, whilst the pustules, on the contrary, became  more
numerous and clearly defined, and were at once recognized as belonging to that form
of smallpox which is called varioloid.  The variolous eruption afterwards extended 
86
INTRODUCTION.
the venereal disease makes its appearance at different periods after in-
fection.  Is not this explicable on the same principle?

§  3.  Of the Comparative Powers of different  Parts of the Body—from
                      Situation—from Structure.
   We shall have occasion to observe, that  the parts affected assume
the morbid action more readily and continue it more rapidly when near
to the source of the circulation  than when far from it;  for  the heart
exerts its influence upon the different parts of the body in proportion
to their vicinity to it; and the more  distant that  the  parts are, the
weaker are their powers.
   This is perhaps better illustrated by disease than by any actions  in
health; for in health we have no comparative trials, as no two parts of
the machine, at unequal distances from the heart,  can be thrown into
equal action, and therefore no conclusions can be  drawn.  It may be
observed that all the vital parts are near the heart.
   In  diseases, we see mortification  arising from  debility, in the ex-
tremities oftener than  in other parts,  more  especially if the  person  is
tall, the heart not propelling the blood to these distant parts with equal
force.  In such a state of constitution,  those who labor under a hemi-
plegia are often found  to die at last from a mortification in the extremi-
ties of the paralytic side.   In some  of these cases, the arteries give
way, and allow of an extravasation of the blood, and therefore we may
reasonably suppose that they are proportionally weak in health.  We
also find that such extravasation commonly begins in the extremities.
This principle is not  only evident in  these  two diseases, but also in
every disease that can  affect an animal body.   It appears in the readi-
ness with which diseases come on and proceed in parts distant from
the source of the circulation, and also in  the steps towards a cure.
   Parts differ not only in their powers, in proportion as they are nearer
or farther from the heart, but likewise according to their peculiar struc-
ture, whereby they vary as much in the progress of morbid actions as
in the operations of health.
   An animal body is composed of a  variety of substances; as muscle,
tendon, cellular membrane, ligament, bone, nerve, &c.  We have, there-
fore, an opportunity of observing the comparative progress of diseases
in them, and their comparative powers of performing a cure; and we
find that they differ very much from one  another in those respects.
How far these differences take place in  all diseases, I have  not been
able to  determine; but should  suppose that in specific diseases as
scrofula  and cancer, there is  in  general  no difference in the mode of
action in any of the  structures,1 these diseases producing  the same

over the whole body.  All the alarming symptoms  disappeared with the scarlatina
and the varioloid run its course very mildly.                                '
  Hufeland relates a similar fact in his Observations on Smallpox and Vaccination  at
Weimar, in 1798.  In this case, also, the smallpox held the ascendency.  For several
other cases of coexisting variola and scarlatina, see the Archives Gtn. de M>'d  for
Jan., 1848; also Valleix, Guide du Midecin Practicien, vol. v. p. 412.__Ed.     '
  1 Here it is to be understood that we do not include those parts which have a greater
tendency to specific diseases than what many others  have ; as the lymphatics to the
scrofula, the breast to the cancer. 
        PARTS SUSCEPTIBLE  OF  PARTICULAR  DISEASES.      37

 specific effects in all the parts that are capable  of being affected  by
 them;  but in diseases arising from  accident, a great difference in the
 degrees of action takes place, the parts from such a cause being allowed
 to act according to their natures ; which  observation holds good also
 in the venereal disease.  This  difference appears to be chiefly in the
 degrees of strength and weakness  in  resisting  morbid  action.  The
 less the  natural  powers  of action  are in any particular structure of
 parts, the less they are able to resist disease; therefore bone, tendon,
 ligament, and cellular membrane  go  through their morbid actions
 more  slowly than muscle or skin;  and this principle is applicable to
 the venereal disease.1

            § 4. Of parts susceptible of particular Diseases.

   There  are some parts much more  susceptible of specific diseases than
 others.   Poisons  take their different seats in the  body as if allotted  for
 them.  Thus we  have the skin attacked with what are vulgarly called
 scorbutic eruptions, and many other diseases;  it is also the seat of the
 smallpox and the  measles; the throat  is the seat of the hydrophobia
 and the  hooping-cough.  The  scrofula attacks the absorbent system,
 especially the glands. The breasts, testicles, and the conglomerate
 glands, are the seat of cancer.   The skin, throat, and nose, are more
 readily affected by the lues venerea than the bones and periosteum;
 which, on the other hand, suffer sooner than many other parts, particu-
 larly the vital parts, which, perhaps, are  not at  all susceptible of the
 disease.
   [Ricord.—I exhibited to the Academy of Medicine some syphilitic
 tubercles of the brain, which coexisted with tubercles of the cellular
 tissue, in a patient with tertiary syphilis.   My colleague, M. Cullerier,
 presented another case of the same affection to this learned Society, a
 short time after.]

   [Editor.—The early writers on syphilis assigned it as a frequent cause of
 disease  of the internal organs, and particularly of the lungs.   Subsequently,
 the opinion which Hunter expresses prevailed :  that the vital organs are not
 susceptible of this disease; but within the last few years,  the subject has again
 excited  attention, and sufficient facts have  been brought forward to warrant
 the belief  that these parts are not exempt from syphilitic manifestations.
  Dr. Schutzenberger, in the  Strasbourg Medical Gazette, for March, 1850,
 details several cases of severe cerebral symptoms which depended on consti-
 tutional syphilis.  They consisted of vertigo,  tremor, epilepsy, and muscular
 debility, in one or more extremities.   In  two of these  cases,  the symptoms
 disappeared under the use of iodide of potassium.
  Sandras, in his excellent work on nervous diseases, relates a case of epi-
lepsy which resisted treatment for years, when the physician of the patient
accidentally discovered symptoms of secondary syphilis.  He  subjected him

  1 Some exceptions should, however, be made with regard to venereal diseases. Next
to the mucous membranes and the skin, the cellular tissue is doubtless most subject to
the morbid action of syphilis; and, of all the tissues, the serous resists it most.—Ricord. 
o8
INTRODUCTION".
to antisyphilitic treatment, and the epilepsy disappeared, never to return.
Sandras concludes  that the epilepsy in this case was  dependent  on some
syphilitic tumor of the brain, which was removed by the treatment.
  Syphilitic  affections of the lungs, heart, and liver, will also be described"
in the latter part of this work, when we come to consider tertiary syphilis.
  In the preseut state of science, we may conclude :—
  1. That the existence of  syphilitic  lesions  of the viscera is  proved by
analogy, by certain cases in pathological anatomy, and  by cures effected by
antisyphilitics, after other means have failed, in serious affections of the vis-
cera, coexisting with undoubted specific symptoms.
  2. That these lesions cannot  be recognized, at present, by any pathogno-
monic sign, aside from the history of the case and the coexisting symptoms;
but that the possibility of their existence should always be borne in mind,
and an appropriate treatment be employed, whenever a syphilitic  cause  is
suspected.—Editor.]

                       § 5. Of Inflammation.
  I consider common  inflammation  to be  an increased action of the
smaller vessels of a part, joined  with a peculiar mode of action, by
which they are enabled to produce the following effects; to unite parts
of the body to each other, to form  pus, and  to  remove parts of the
solids.  These effects are not  produced by a simple increase of action
or enlargement of the vessels, but by a peculiar action, which is at
present, perhaps, not understood.
  These  three effects of inflammation I have called distinct species of
inflammation.  That which unites parts, I have called the adhesive
inflammation; that  which forms  pus, the suppurative inflammation;
and that which removes parts, the ulcerative inflammation.
  In  the adhesive inflammation, the arteries throw out coagulable
lymph, which becomes the bond of union.  This,  however, is not sim-
ply extravasated, but has undergone some- change before it leaves the
arteries, since in inflamed veins it is found  lying  coagulated upon the
internal surface of the vessel, which could not have happened if simply
extravasated. In  the suppurative inflammation, a still greater change
is produced upon the blood  before it is thrown out by the  arteries
whereby it  is formed into pus: which change is probably similar to
secretion.  In the ulcerative  inflammation, the action of the  arteries
does  not  remove the parts; that office is performed by the absorbent
vessels which are brought into action.
  In  the first two species of inflammation, there  must be a change in
the disposition and  mode  of  action of the arteries; for the suppura-
tive species  cannot be  considered as  simply an increase of action of the
adhesive, as  its effects are totally different; but, in the third species
there is probably no change of action in the arteries from that of the
second;  the action only of the absorbents being superadded, by which
solid  parts, and of course the arteries themselves,  are removed. 
MORTIFICATION.
39
                       § 6.  Of Mortification.

  Mortifications are of two kinds, one preceded by inflammation, the
other not.  But as the cases of mortifications which will be mentioned
in this work are all of the first kind, I shall confine my observations
to that species.
  I consider inflammation as an increased action of that power which
a part is naturally in possession of.  This increased action, in healthy
inflammations at least, is probably attended with an increase of power;
but  in  inflammations which terminate in mortification there is  no
increase of power.  On the contrary, there is  a diminution of power,
which, joined  to an increased action, becomes the cause of mortifica-
tion, by destroying the balance which ought  to subsist between the
power  and action of every part.
  If this account of mortifications be just, we shall find it no difficult
matter to establish a  rational practice.   But, before we attempt this,
let us just take a view of the  treatment hitherto recommended, and
see how far it agrees with our theory.
  It is plain, from the common practice, that the weakness has been
attended to, but it is as plain that the increased action has been over-
looked, and, therefore, the whole aim has been to  increase the action,
with a view to remove  the weakness.  The Peruvian  bark, confectio
cardiaca, serpentaria, &c, have been given in as large quantities as the
case appeared  to require, or the constitution could bear; by  which
means an artificial or temporary appearance of strength has been pro-
duced, while it was only an increased action.  The cordials and wine,
upon the principle on which  they have been given, are rationally
administered;  but there  are strong  reasons  for  not  recommending
them, arising from the general effect which all cordials have of increas-
ing  the action without giving real strength;  and the powers  of the
body are afterwards sunk proportionally as they have been raised;  by
which nothing can be gained, but a great deal may be  lost; for, in all
cases, if the powers are allowed to sink below a certain point, they are
irrecoverable.
  The local treatment has been as absurd as the constitutional.  Scari-
fications have been made quite to the living parts, that stimulating and
antiseptic medicines might be applied to them, such as turpentines, the
warmer balsams, and sometimes the essential oils.  Warm fomenta-
tions have been also applied as congenial to life; but warmth always
increases action, and  stimulants are improper where the actions are
already too violent.
  Upon the principles  here  laid down, the bark is the only medicine
that can be depended upon, as it increases the powers and lessens the
action.   Upon many occasions, opium will be of singular service  by
lessening the  action, although  it does not give real strength.  I have
seen good effects from it, both when given internally, in large doses,
and  when applied  to the part.  To  keep the parts cool  is proper; and
all  the applications should  be  cold.   The above mentioned practice
is to be kept in view in mortifications that happen in the venereal dis-
ease. 
 
PART   I.
                        CHAPTER I.

                    OF THE VENEREAL POISON.

  The venereal disease arises from a poison, which, as it is produced
by disease, and is capable  of again producing a similar disease, I call
a morbid poison, to distinguish it from the other poisons, animal, vege-
table, and mineral.
  The  morbid poisons are many, and they have different powers  of
contamination.  Those which infect the body either locally or consti-
tutionally, but not in both ways, I call simple. Those which are capable
of affecting • the body both locally  and constitutionally, I  call com-
pound.  The venereal poison, when applied to the human body, possesses
a power of propagating or multiplying itself; and, as it is  also capable
of acting both locally and constitutionally, it  is  a compound morbid
poison.   Like  all such poisons, it may be communicated to others  in
all  the various ways in which it can be received, producing  the  same
disease in some one of its forms.

                 § 1. Of the first Origin of the Poison.

  Though the first appearance  of this poison  is certainly within the
period of modern history,1 yet the precise time and manner of its origin
has hitherto escaped our investigation, and we are still in doubt whether
it arose in Europe or was imported from America. I shall not attempt
to discuss this question; and those who wish to examine at length the
facts, authorities, and arguments brought in favor of the latter opinion,
may consult Astruc; and,  for the former, a short  treatise2 published in

  1 This is not proved.—Ricord.
  8 Entitled A Dissertation on the Origin of the Venereal Disease ; proving that it was
not brought from America, but began in Europe from an epidemical distemper.  Trans-
lated from the  original manuscript of an eminent physician.   London, printed  for
Robert Griffiths, 1751.
  [The author's name is Antonio Nunes Ribeiro Sanchez.  He was born at Pogna-Ma-
coen, Portugal, in 1699, and died at Paris, October 14, 1783.   His work was published
in French, and entitled Dissertation on the Origin of the Venereal Disease, proving that
it was not brought from America, and that it commenced in Europe by an Epidemic.  Paris,
1753.  He  afterwards published An Historical Investigation on the Appearance of  the
Venereal Disease in Europe.  Lisbon, 1774.  Finally, still another work by Sanchez was
published after his death, entitled Observations on Venereal Diseases. Paris, 1785.—Ed.] 
42                  THE VENEREAL POISON.

1751, without  a name.   The  author of this treatise appears  to  have
considered the subject very fully, and, as far as reasoning goes on a
subject of this kind, proves that the disease was not brought from the
West Indies.   Not  contented with this, he goes on to account for its
first rise in Europe; but in this he is not equally successful.  The sub-
ject is a difficult one, and the want of a sufficient number of facts leaves
too much room for conjecture.
   We shall  not, therefore, enter farther into this question; nor is it
material to know at what period, and in what country,  this disease
arose; but we  may in general affirm that, as animals are not naturally
formed with disease, or so as to run spontaneously into morbid actions,
but with a susceptibility of such impressions as produce such actions,
diseases must always arise from impressions made upon the body; and
as man is probably susceptible  of  more impressions that become the
immediate cause of  disease than any other animal, and is besides the
only animal which can be said to form artificial impressions upon him-
self, he is subject to the greatest variety of diseases. In one of those
self-formed  situations, therefore,  the impression  most  probably was
given which produced the venereal disease.

    § 2. It began in the Human Race, and in the Parts of  Generation.

   In whatever  manner it arose, it certainly began in the human  race,
as we know no other animal that is capable of being infected with this
poison.1  It is probable,  too, that  the parts of generation were the first
affected;  for if it had taken  place in any other part of the body, it
might probably never have gone farther than the person in whom it
first arose, and therefore never have been known; but being seated in
the parts  of generation, where the only natural  connection takes  place.
between one human being and another,2 except that between the mother
and child, it was in the most favorable situation for being propagated;
and as we shall find hereafter, in the history of the disease itself, that
no constitutional effect of this poison  can be communicated to others,
we are led of necessity to conclude that its first effects were local.3

                  § 3. Of the Nature of the Poison.

   We know nothing of the poison itself, but  only its effects on the
human body.   It is commonly in the form of pus, or united with pus,

  1 Hunter's opinion appears to be correct.   I have taken  syphilitic  pus in every pos-
sible condition, and attempted to inoculate with it dogs, cats, rabbits, guinea-pigs, and
pigeons, which, it has been asserted, are soon killed by the absorption of the virus. In
no case, in spite of the variety of my experiments, has it been possible to communicate
the disease. Some persons have lately succeeded, after numerous failures in  inocu-
lating primary symptoms (non-indurated chancres) upon  various animals,' monkeys
cats, &c, and then inoculating man from these animals ;  but without the production
of buboes or constitutional symptoms.   But this is not syphilis !
  We must not, as the physiological school has done in later times, confound simple
ulcerations and catarrhal affections, to which animals are subject as well as man with
true syphilis; nor primary with secondary symptoms.—Ricord.
  2 This is not absolutely true.—Ricord.
  8 This proposition is true.—Ricord. 
ITS  NATURE.                         43
or some such secretion, and produces a similar matter in others, which
shows that it is most generally, although not necessarily, a consequence
of inflammation.  It produces  or excites, therefore, in most cases, an
inflammation in the parts contaminated;  besides which inflammation,
the parts so contaminated have a peculiar mode of action superadded,
different from all other actions  attending inflammation;  and it is this
specific  mode of action which produces  the specific quality in the
matter.  It is not  necessary that inflammation should be present to
keep up this peculiar mode of action, because the poison continues to
be formed long after all signs of inflammation have ceased.   This ap-
pears from  the following facts: men having only what is called a gleet,
or healing chancre, give the disease to sound  women; and many vene-
real gonorrhoeas happen without any visible signs of inflammation.1
  In women, the inflammation is frequently very slight, and often there
is not the  least sign of it, for they have been known to infect men,
though they themselves have had no symptoms of inflammation, or of
the disease in any form.2 Therefore, the inflammation and suppuration,
when present, are only attendants on the  peculiar mode of action, the
degree in which they take place depending more on the nature of the
constitution than on that of the poison.
  The formation of matter, also,  though a very general,  is not a con-
stant attendant  on this disease;  for we sometimes find inflammation
produced by the venereal poison which does not terminate in suppura-
tion; such inflammation I suspect to be of the erysipelatous kind.  It
is the matter produced,  with or without inflammation,  which alone
contains the  poison; for without the formation of matter no venereal
poison  can exist.   Therefore, a person having the venereal irritation
in  any form,  not attended with a discharge, cannot  communicate the
disease to another.   To communicate the disease, therefore, it is neces-
sary that the  venereal action should first take  place, that matter should
be formed  in  consequence  of that action, and that the matter should
be applied  to a sound person or part.3

  1  By the word inflammation, in this place, Hunter evidently means acute inflamma-
tion ; for, otherwise, he would be inconsistent with his own doctrine that  pus is a
product of inflammation, and a necessary vehicle of syphilitic virus.
  Chancres, which are absolutely undergoing the healing process, become simple ulcers,
and cease to be contagious.  My experimental inoculations place this truth beyond a
doubt. Where the contrary is apparently the case, the reparative stage is incomplete,
and some part of the ulcer remains in the period of specific ulceration.—Ricord.
  2  If this were true, Hunter would  again be  at  complete variance with  himself.
Women can communicate syphilis only during the time that they are themselves in-
fected.  When they apparently communicate the disease, without offering any trace
of it themselves, it is because their symptoms are deep-seated and concealed from
view, and not discovered for want of a speculum-examination; or, else, having had
previous connection with infected men, they harbor virulent pus for a time in  their
organs, and then communicate it to others, without becoming diseased themselves.—
Ricord.
  8 Hunter's proposition is  entirely correct;  no syphilitic virus is produced without
suppuration, and no contagion nor transfer of the virus is possible without virulent
pus.  The exception which Hunter seems to make to this law is only an apparent one ;
and is due to  the fact that he does not recognize the two distinct properties of virulent
pus, which may act as a simple agent, like other kinds  of pus, such as the erysipela-
tous ; but which, when it acts primarily  in virtue of its specific character, inevitably
produces ulcers and suppuration.—Ricord. 
44
THE VENEREAL  POISON.
   That the venereal disease is to be propagated only by  matter, is
proved every day by a thousand instances.  Married men contract the
disease, and, not suspecting  that they have  caught it, cohabit with
their wives, even for weeks.   Upon discovering symptoms of the dis-
ease, they, of course, desist; yet in all my practice I never once found
that the complaint was communicated under such circumstances, except
where they had not been very attentive to the symptoms, and there-
fore continued the  connection after  the discharge  had appeared.  I
have gone so far as to allow husbands, while infected, but before the
appearance of discharge, to cohabit with their wives in order to save
appearances, and always with safety.  I could carry this still  farther,
and even allow a man who has a gonorrhcea  to have connection with
a sound woman, provided that great care be taken to clear all the parts
of any matter, by first  syringing the urethra, making water, and wash-
ing the glans.1
   The matter which is impregnated with  this poison, when it comes
in contact with  a living part, irritates that part, and  inflammation is
the  common consequence.  It must be applied either in a fluid state,
or rendered fluid by the juices of the part to which it is applied. There
is no instance where it has given the infection in the form  of vapor,
as is the case in many other poisons.9
   [G. Gr. B.—The omission of the last sentence of the last paragraph
but one, in Sir Everard Home's edition, is not without reason,  since
the truth of the doctrine is, to say the least, very questionable, and
the practice which is deduced from it is undoubtedly most mischievous
and reprehensible.
   The author's doctrine is, that the virus resides in pus, or some such
secretion, and hence he draws two practical conclusions:—
   1. That  when there is no pus, or puriform secretion, the  disease
cannot be communicated.  So that before the appearance of a gonor-
rhoea, or after the healing of a chancre, there is no possibility of in-
fection.
   2. That  even when pus  actually exists, yet if particular care be
taken to remove it in the first instance,  by very careful ablution, the
individual may have connection with a sound woman without  danger
of infecting her.
   The second conclusion cannot be too strongly reprobated.  It is op-
posed to every day's experience; and from  the omission of the passage
in Sir E. Home's edition, it may be supposed that farther observation
had led the author himself to change his opinion before the termination
of his life.
   The former position, also, is by no means free from  danger, as will
be seen by the following instances, which are far from singular:—3

  1 The last sentence omitted.—Home.
  * Hunter's  remark is very just;  virulent pus, in  order to  act, must be in a liquid
form.  The scabs which form on chancres, and dry there, preserve their virulent pro-
perty ; and, after being  kept a long time, they may be  inoculated, like smallpox or
vaccine scabs, when diluted with water.—Ricord.
  8 Hunter's first conclusion cannot be called in question ;  but Mr. Babington's cases
are open to criticism in every point of view.—Ricoao. 
ITS NATURE.
45
   A married woman was seized with the usual symptoms of gonorrhcea,
which greatly surprised her, as her husband was free from complaint.
On questioning, however, the husband, he confessed that he had had
connection with a  common girl  about a week before his wife  com-
plained ; but he  positively asserted  that he had had no discharge  or
uneasiness whatever, and certainly then  showed no signs of disease.
In about four  days afterwards, that  is to say, nearly a fortnight after
the impure connection, and a week after he must have communicated
the disease to his wife, a gonorrhceal discharge appeared on him.
   A gentleman, when absent from home, exposed himself to the hazard
of infection.  At the end of three days he returned home, and in about
four days afterwards  his wife had a gonorrhcea.  On the tenth day
after  the connection, the gentleman  first perceived  a discharge, and
the other symptoms of gonorrhcea.
   But it may be said that, though such cases show that the conclusion
at which the author has arrived is practically unsafe, they by no means
disprove the  truth of  the general principle on which it  was founded.
It may be said that in these cases it  is an error to suppose that there
is no  purulent secretion; that in the  very early stage of  a gonorrhoea
it is probable that the pus is too small in  quantity to flow from the
urethra; that it lodges in the lacunas, and is washed out  by the urine,
and is  thus concealed from observation; but that  it not less really
exists; and that the position, therefore, remains untouched—that where
there is no matter there can be no infection.
   However, there is another class of cases which go still farther  to
throw doubts on the truth of this doctrine.
   A gentleman was exposed to infection when in London.  A day  or
two afterwards, he set off for Ireland, where his family resided.  He
made some stay at Cheltenham, and while there, there appeared on the
inner prepuce two or three small indurations or tubercles.  He showed
them to a surgeon, who convinced himself that there was no ulceration,
and did not believe the affection to be venereal.   After a short inter-
val, he returned to Ireland, these indurations still existing, and infected
his wife, who suffered from primary sores.
   A gentleman had an induration on the penis, which remained after
the healing of a chancre.   He  suffered repeatedly from secondary
symptoms, which were as often  removed by appropriate treatment;
but the induration always remained.   At length, when a considerable
interval had passed without a relapse, and he believed  himself to be
finally cured, he  married, though the induration was not removed.
His wife was infected.
   Cases of this kind might be multiplied without difficulty, and almost
necessarily lead to the inference that infection may take place from the
contact of a simple chancrous  thickening, although no ulceration
whatever is present.  A misconception of this truth has often led  to
consequences which are most  lamentable.  In  a considerable  propor-
tion of those cases in which  a wife has been infected in consequence
of marriage with a man laboring under syphilis, the communication
seems to have taken place from the cicatrix of a sore which has been
healed.—G. G. B.] 
46
THE VENEREAL POISON*.
    [RlCORD.—In the present state of science, it is impossible to accept
  the cases by which Mr. Babington attempts to refute Hunter's- propo-
  sitions.
    With the uniform results of experimental inoculation as my proof,
  I assert that no surface which  is not smeared with virulent  pus, and
  which secretes  none during coitus, however prolonged,  can ever com-
  municate syphilis.
    But, following out this  doctrine, we cannot, as Hunter did, allow
  intercourse to a patient, with the use of lotions as the sole guarantee
  against infection; for the morbid secretion is incessant, and  becomes
  more active during the increased vitality which takes place in sexual
  intercourse.  But before all suppuration, and without its development
  during the sexual  act, can the disease be communicated?   Doubtless
  no.  There must be virulent  pus; the quantity  may be very  small,
  and may pass unseen  by the  patient in the early stage;  but no effect
  can be produced without it.  To be convinced  of the truth  of these
  assertions, follow the  results  of artificial inoculation.   Often on the
  second day the  budding pustule already furnishes contagious pus, but
  in quantities so minute  that,  if it were concealed in the  urethra or
  vagina, the most careful  observation of the patient's linen, or of the
 external parts of the affected organs, would discover nothing.  Again,
 it is well known how little of this pus on the point of a lancet is suffi-
 cient to communicate the disease.
   In opposition to these incontestable facts, is it possible to offset Mr.
 Babington's two cases of gonorrhoea, whose whole value is based on
 the morality of  the  patients alone ?   Without discussing in this place
 the nature and diagnosis of gonorrhoea, who does not  see, from the
 order in which  the symptoms in these two cases were  developed  in
 the husbands, that  the disease was really communicated to them by
 their wives;  either because the parties overindulged in coitus after
 long abstinence, and produced the affection by mechanical irritation,
 or because the two women had previous disease of the parts, of which
 they were ignorant, or which they were interested in concealing until
 a convenient time for confession.  These cases are so common in prac-
 tice, that they do not need farther comment.
   Does an induration without  suppuration;  does  the perfect cicatrix
 of a chancre, allow the communication of syphilis, as Mr. Babimrton
 asserts !  Here again his observations are founded on female morality
 and on the supposition, in every case, that the disease could have been
 communicated to the wives only through their husbands
   The following are the results that facts, looked at in a different light
 have taught me:—                                           °   '
   Chancres may be developed  in a follicle, in the cellular tissue,  or in
 the superficial lymphatic  vessels, and be accompanied by  surrounding
 induration, which incloses them in a kind of shell or cyst   Unde?
 these circumstances, they may appear to be simple indurations without
 suppuration; whilst, during sexual intercourse, the walls of the abscess
gape, the pus escapes and  communicates the disease, which  is wronT
luly attributed to a consecutive ulceration.  These cases are commorf
and I have shown a large number of them at my clinique   But  in 
THE ACRIMONY  OF  THE POISON.
47
every  case where the  induration has been complete, and free  from
primary pus  shut up within, if, from any cause, ulcerations or mecha-
nical lesions  ensued upon the induration without  new  infection, the
pus then furnished has  never been inoculable.
  However, in any case, in which there remain any suspicious symp-
toms, and if  there be any uncertainty as to the cicatrix being perfect,
or any possibility of any hidden points of suppuration, it is necessary
to abstain from sexual intercourse, and especially from marriage.—
Ricord.]

          §  4. Of the greater or less Acrimony of the Poison.

   Venereal matter  must in  all cases be the same; one  quantity of
matter cannot have a greater degree of poisonous quality  than another;
and, if there is any difference, it is only in its being more or less diluted,
which produces no difference in its effects.  One  can conceive,  how-
ever,  that it may be so far diluted as not to have the power of irrita-
tion.   Thus, any fluid  taken  into the mouth, capable of stimulating
the nerves to taste, may be so diluted as not to be tasted.  But if the
poison can  irritate  the part to which it is applied to action, it  is all
that is required; the action will be the same, whether from a large or
small  quantity, from a  strong or a weak solution.1
   We find from experience that there is no  difference in the kind of
matter; and' no variation can  arise in the disease from the  matter's
being of different degrees of strength, for it appears that the  same
matter affects very differently different people. Two men having been
connected with one woman, and both catching the disease, one of them
shall have a violent gonorrhoea, or chancre, while the other shall have
merely a slight gonorrhoea.   I have known one man give the disease
to different women, and some of the women have had it very severely,
while in  others  it has been very slight.   The same reasoning  holds
good  with regard to chancres.  The variations of the  symptoms in
different persons depend upon the constitution  and  habit of the  pa-
tient at the time.  What happens in  the inoculation of the smallpox
strengthens this opinion.  Let the symptoms of the patient from whom
the matter is taken be  good or bad; let it be from one who has  had a
great  many pustules, or from one who has  had but few;  let it be from
the confluent or distinct kind, applied in  a large quantity or a  small
one, it produces  always the same effect.   This  could only be known
by the great numbers that have been  inoculated under all these differ-
ent circumstances.2

   1 These words added:  " Since those men who have taken great pains in washing
the parts immediately after connection  have caught the  disease, and the symptoms
have been equally severe as in others who used no such precaution."—Home.
   2 Sir E. Home has here added a note, in which he calls in question the truth of this
doctrine, as far as regards smallpox.  He says that  he has in many instances diluted
the variolous matter, and always found that the disease produced from such  matter
was milder than when employed for inoculation in an  undiluted state.  However, in
the venereal disease, it must be acknowledged that there are no facts which prove the
existence of a similar difference  in the virulence of the contagion, or would  justify
the conclusion  that the variations in the symptoms depend on any other cause than
the constitution and habits of the recipient.—G. G. B. 
48                  THE  VENEREAL POISON.
    § 5.  Of the Poison being the same in Gonorrhoza and in Chancre.

  It has been supposed by many that the gonorrhoea and the chancre
arise from two distinct poisons; and their opinion seems to have some
foundation, when we consider only the  different appearances of the
two symptoms, and the different methods of cure; which, with respect
to the nature of many diseases, is too often all we  have to lead  our
judgment.  Yet, if we take up this  question upon other grounds,  and
also have recourse to experiments,  the result of which we can abso-
lutely depend upon, we shall find this notion to be erroneous.
  If we attend to the manner in which the venereal poison was com-
municated  to the  inhabitants of the islands of the  South Seas, there
are many circumstances which tend to throw light  upon the present
question. It has been supposed, as no mention is made of a gonorrhoea
at Otaheite, that it must have been the chancre that was first introduced
into that island, and that of course nothing but a  chancre  could be
propagated there; for, as no gonorrhcea  had been communicated, no
such disease could take place.   But if we were to reason upon all the
probable circumstances attending the voyages to that part of the world,
we  should conclude the contrary; for it was almost impossible to carry
a chancre so long a voyage without  its destroying the penis; while we
know from experience that a gonorrhcea may continue for a great
length of time.  It is mentioned in Cook's Voyage, that the people of
Otaheite, who had this disease, went into the country, and were cured;
but when it became a pox it was then incurable.  This shows that the
disease which they had must  have  been a  gonorrhoea, for we know
that it is only a gonorrhcea that can be  cured by simple means;  and
farther, if it had been a chancre, and they had  been acquainted with
the means of curing it, they could also have cured the lues venerea.1
  Wallis left Plymouth in August,  1766, and arrived at Otaheite in
July,  1767, eleven months after his embarkation; and, if none of his
men had the disease when he sailed, there was hardly a possibility of
their contracting it anywhere afterwards in the voyage.  This appears
to be  too long for a gonorrhoea to last.  But let us suppose even that
Wallis  carried  it -thither in his ship, one or two of his crew having
the disease; as he stayed there five weeks, it was very possible, even
very probable, that such  person or persons might have communicated
it so  quickly as to have become the cause  of contamination of the
whole crew of his ship.  But as this did not happen, it is a presump-
tive proof that Wallis  did not carry it thither.
  Bougainville left France in December,  1766; but he touched at
several  places where some of his people might have  got the disease,
the last of which places was Rio de la Plata, which he left in November
1767, and arrived at Otaheite in April, 1768, five months after. This
interval of time agrees better with  the usual continuance of the  dis-
ease than the length of Wallis's voyage; and, therefore,  from this

  1  Hunter, it appears, did not know that chancres may last several months, or even
several years, and continue inoculable. He was  also ignorant of a fact, which every
day's experience teaches, that a chancre may get well of itself, or by the use of simple
remedies, and never give rise to constitutional syphilis.—Ricord. 
          THE SAME IN  GONORRHCEA  AND CHANCRE?       49

circumstance, it becomes more probable that Bougainville carried it
thither.   Besides,  it is likely that  he could guard his  people  less
against the disease than Wallis; for Wallis could have his choice of
men at his first setting out, which was all that was  necessary to pre-
vent his carrying the disease with him; for he ran no risk  of contract-
ing it afterwards; but although Bougainville had the same advantage
at first, yet he had it not afterwards, for his  men were in  the way of
infection in  several  places,  and he  had no  opportunity of changing
them, and probably no great chance of having them cured.  The cir-
cumstance of the disease being found by Bougainville at Otaheite soon
after his arrival is  a kind of proof that he carried it thither himself;
for I observed before, that if Wallis had  carried it by  one man only,
this man could in a very few days have so far propagated it as to have
spread  it through the whole ship's crew;  and as Bougainville  arrived
at the island ten months after Wallis, there was a sufficient time for
the inhabitants of the whole  island to have been  infected,  and the
ravages of the disease  must have been evident to them immediately
upon their arrival.  Bougainville remained only nine days at the island
of Otaheite, and observed nothing of the  disease till some  weeks after
his departure, when it was found that several of the crew were infected,
which most probably must have happened in consequence of the poison
being carried there by some of his own people.  It is also mentioned
by Cook that the Otaheiteans ascribed the introduction of the disease
to Bougainville;  and we  can hardly suppose that they would be  so
complaisant to our countrymen as to accuse  Bougainville, when they
must have known  whether the disease was imported by Wallis or not,
especially as they had no reason to be partial in  favor of the people
who accompanied the latter.  But as we find in Cook's  last voyage
 that the disease in  every form is new there, and as we have  no  new
 intelligence of a gonorrhoea being since introduced, we must suppose
 that every form of the disease has  been  propagated  from one root,
 which most probably was a gonorrhoea.1
   If any doubt still remain with respect  to the two  diseases being of
the same nature, it will be  removed by  considering that  the matter
produced in both  is of the same kind, and has the same  properties;
the  proofs of which are, that the matter of a gonorrhcea will produce
either a gonorrhcea, a chancre, or the  lues venerea; and the matter of
a chancre will also produce either a gonorrhoea, a chancre, or  the lues'
venerea.3
   The following case is an instance  of a gonorrhoea  producing a lues

   1 Hunter's charges against Bougainville are without foundation.  In the first  place,
it does not follow from the fact that Wallis's sailors were not diseased at the time of
setting out, that the disease may not have appeared a few days later.  And, in  the
next place, since Bougainville discovered that his men were infected a few days after
leaving Otaheite, why should he not have discovered it as easily, if they had first con-
tracted the disease in another port ?—Ricord.
   2 The following paragraph is here inserted :—
   " That chancre is sometimes the consequence of gonorrhoea is rendered probable by
the following case :  A. B. had a gonorrhoea about the beginning of  January, 1788 ;
the inflammation went off, the discharge continued ;  about a month after, a chancre
appeared on the glans penis, for which he took mercury, and  it got well in about a
month."—Home.
        4 
50                  THE VENEREAL  POISON.
venerea: A gentleman twice contracted a gonorrhcea, of which  he
was cured both times without mercury. About two months after each,
he had symptoms of the lues venerea.  Those in consequence of the
first infection were ulcers in  the throat, which were removed by the
external application of mercury; the symptoms in consequence of the
second were blotches on the skin, for which also he used the mercurial
ointment, and was cured.  With regard to the  lues venerea proceeding
from chancres, instances occur so frequently to every one's observation
as to require no farther proof here.
  Since, then,  it appears  that the gonorrhoea and  chancre are the
effects of the same poison, it may  be worthy of inquiry to what cir-
cumstances two such different forms of the disease are owing.
  To account for these two very different effects of the same poison,
it is only necessary to observe the difference in the mode of action of
the parts  affected when irritated,  let  the irritation  be what it  may.
The  gonorrhcea always proceeds  from a secreting surface,1 and the
chancre is formed on a non-secreting surface;  and in this last the part
to which the poison is applied must become a  secreting surface before
matter can be produced.   All  secreting surfaces in the body being
probably similar, one mode of application only is  necessary to produce
this  disease in  them all, which is by the  poisonous matter simply
coming in contact with them. But to produce the chancre, the  vene-
real matter may be applied in three different ways: the first and most
certain is  by a wound, into which it  may be  introduced; the second
is by applying the matter to a surface with a  cuticle, and the thinner
that is, it allows the matter to come more readily to the cutis; and
the third is by applying the matter to a common sore already formed.
   The poison, then, being  the same in both  cases, why  do they not
always happen together in  the same person ?   For one would naturally
suppose that the gonorrhcea, when it has appeared, cannot fail to be-
come the cause of a chancre; and that this, when  it happens first, must
produce a gonorrhcea.   Although it does not often happen  so,  yet it
sometimes does; at least, there is  great reason to believe so.  I  have
seen cases where a gonorrhcea came on; and  in a few days  after in
some, in others in as many weeks, a chancre has appeared; and I have
also seen cases where a chancre has come first; and in the course of its
cure, a running and pain in making water have succeeded.  It may be
supposed  that the two diseases arose from the original infection, and
only  appeared at different  times;  and their not  occurring oftener  to-
gether would almost induce us to  believe it was so, since the matter is
the same in both, and therefore capable of producing either the one or
the other.
   I suspect that the presence of one  irritation in these parts becomes

  1 By secreting surfaces, I mean all the passages for  extraneous matter, including
also the ducts of glands, such as the mouth, nose, eyes, anus, and urethra; and by
non-secreting surfaces, the external skin in general.   To which I may add a third
kind of surface, leading from the one to  the other, as the  glans penis, prolabium of
the mouth, the inside of the lips, the pudendum; which surfaces, partaking  of the
properties of each, but in a less  degree, are capable of  being  affected in  both ways,
sometimes by being excited to secretion, and at other times to ulceration. 
          THE  SAME IN GONORRHCEA AND  CHANCRE?       51

in general a preventive of the other.  I have already observed, that
the two  parts sympathize in their diseases; and it is  possible that
that very sympathy may prevent the appearance of the real disease ;
for if an action has already taken  place which is not  venereal, it is
impossible that another should take place till that  ceases; and it is
probable that this sympathy will not cease while the cause exciting it
exists; and therefore when both happen in the same person at the
same time, I suspect that either the urethra never had sympathized
with  the chancre, or if  it did at first, that the  sympathy had ceased,
and then the venereal matter might stimulate the parts to action.
   [G. G. B.—There is yet a  stronger argument than any which is here
given.  The author inoculated himself with the matter of gonorrhoea,
and the consequence was the production of chancres, followed by bubo,
and by secondary symptoms.   The experiment is related at length in
Part  VI., Chap. IL, Sect. 2,  of  the present work.
   But, nevertheless, the identity of the poison of gonorrhcea with that
of chancre has been disputed, and that on no slight grounds.
   In reply to the argument drawn from the transfer of the  venereal
disease to the  islands in the South Seas, it has been denied that the
disease exists there at all.   Mr. Wilson, surgeon to His Majesty's ship
Porpoise, visited Otaheite in 1801, and, after a careful investigation,
came to  the conclusion  that  the venereal disease was then unknown  in
that island.
   It  may also be alleged that even if the disease actually prevails
there, as has been reported by others, it by no means follows that it
must have been originally carried thither in the form of gonorrhoea.
The  facts stated  by John  Hunter do  not bear out his conclusion.
Bougainville left the Rio de la Plata  in November, 1767, and arrived
at Otaheite in April, 1768.   It is very possible that a chancre might
 have existed during the five  months which  intervened.  Cases fre-
 quently occur in which primary sores  continue  for a much longer
 period, without occasioning any remarkable destruction, and  certainly
 without at all rendering the subject incapable of sexual intercourse.
   The author affirms that cases occur in which true chancres are pro-
duced in those parts which are steeped in the discharge of a gonorrhoea.
At the  same  time, he acknowledges that such  a circumstance  is
extremely rare.  Yet nothing  is more common than that excoriations
 should arise on the surface of the glans, or on the inside of the pre-
puce, from the contact of gonorrhceal matter.   These excoriations, if
neglected, will last for an indefinite period; but if the irritating matter
 is carefully removed by very frequent ablution, they will heal in two
 or three days, without the least necessity for the exhibition of mercury.
 Why do  they not  assume the characters of  chancres, or infect the
system ?  Surely their  innocence affords a negative proof of the diver-
sity of the virus, more strong than the very rare occurrence of true
chancres can be supposed to give of its identity.  For it must not  be
forgotten that, in these cases, the chancre may be. attributed to another
cause.   It may be that the  patient  has again exposed himself to infec-
tion, and that the chancre has arisen from this  second exposure.  The
patient,  under such circumstances,  is naturally disposed to conceal his 
52
THE VENEREAL POISON.
misconduct.  Still, he may often  be induced to confess it, on a strict
examination; and in those cases where no such avowal can be elicited,
it is, perhaps, most  reasonable to suspect that it is only prevented by
shame.
  It cannot be denied that there  are cases in which secondary symp-
toms appear to be the consequence of gonorrhcea; but these are so rare
that they must rather be considered as anomalies which we cannot, as
yet, account for, than be admitted in contradiction to the general cur-
rent of experience.  The secondary symptoms, in such instances, are
rarely of an indubitable character.  It  may be doubted whether dis-
tinct copper tubercles  ever followed simple gonorrhcea.  We have
generally a mottled state of the skin, or  the lighter and more fugitive
forms of lichen, or slight excoriation of  the surface of the tonsil.
  It has been asserted  that women who are affected with gonorrhcea
alone, will frequently produce chancres in those men that are connected
with them.  Without venturing to give  a positive denial to this state-
ment, it may be suggested that its truth has seldom, if ever, been satis-
factorily ascertained.  The  investigation of the surgeon has evidently
been confined  to the external parts.  The interior of the vagina has
not been  examined, yet it is certain that  chancres  do, occur here,
though more rarely, so as to be discovered only by the use of a specu-
lum.  When to  this consideration is added all the deception which is
constantly practised in regard to sexual intercourse, it must be allowed
that these  statements are deserving of very little confidence.
  There still remains the experiment of John Hunter; and if such
experiments were multiplied, it cannot be denied that they would be
decisive.  That in his case the system was infected with the venereal
virus  can  scarcely  be questioned; but it may be doubted whether the
virus might not have been derived from some other source than inocula-
tion with the matter of gonorrhcea.  The chances of falling into error
are so numerous, that such experiments should be frequently repeated.
As it is, the case stands  alone, opposed to the general course of expe-
rience, and opposed to a series of other experiments, which rest on the
authority of Mr. Benjamin Bell.  The subjects were medical  students,
who instituted  the  experiments expressly with  the view of deciding
this question.  They are thus related by Mr. Bell (Bell On  Venereal
Disease, vol. i. p. 439):—
  " 'Matter,' says one of these individuals, 'was taken upon the point
of a probe, from a chancre on the glans  penis, before any application
was made to it, and completely introduced into the urethra, expecting
thereby to produce gonorrhoea.  For the  first eight days, I felt no kind
of uneasiness, but about this period, I was attacked with pain in pass-
ing water.  On dilating the urethra as  much as possible, nearly the
whole of a large chancre was discovered, and in a few days thereafter
a bubo was formed  in each groin.  No discharge  took place from the
urethra during  the  whole course of the  disease;  but another chancre
was soon  perceived in  the opposite side of  the urethra, and red pre-
cipitate was applied to it, as well as to the other, by means of a probe
previously moistened for the purpose.  Mercurial ointment was at the
same  time rubbed  on the  outside of each thigh, by which a profuse 
          THE  SAME IN  GONORRHCEA  AND CHANCRE?       53

salivation was excited.   The buboes, which till then had continued to
increase, became stationary,  and at last disappeared  entirely;  the
chancres became clean, and by a due continuance of mercury, a com-
plete cure at last was obtained.'
  " The  next experiment was  made with the  matter of gonorrhoea, a
portion of which was introduced between the prepuce and glans, and
allowed to remain there without being disturbed. In the course of the
second day, a slight degree of inflammation was produced, succeeded
by a discharge  of matter,  which, in the course of two or three days,
disappeared.
  " The same experiment was, by the same gentleman, repeated once
again,  after rendering the  parts tender to which the matter of gonor-
rhoea was applied ; but no chancre ever ensued from it.
  " Two young gentlemen, while prosecuting the study of medicine,
became anxious to ascertain the  point in question; with which view
they resolved on making  the  following experiments, at a time when
neither of them had ever labored under either gonorrhoea or syphilis;
and  both in  these and in the preceding  experiments, the matter of
infection was taken from patients who had never made use of mercury.
  " A  small dossil of lint soaked in the matter of gonorrhoea was by
each of them inserted between the prepuce and glans, and allowed to
remain on the  same spot for  the space of twenty-four hours.   From
this they expected that chancres would be produced; but, in  the one a
very severe degree of inflammation ensued over the whole glans and
preputium, giving all the appearances of what is usually termed gonor-
rhoea spuria; a considerable quantity of fetid matter was discharged
from the surface of the inflamed parts; and for several  days  he had
reason to fear that an operation would be necessary for the removal of
a paraphimosis. By the use of saturnine poultices, however, laxatives,
and low diet, the inflammation abated, the discharge ceased, no chan-
cres took place, and he soon got entirely well.
  " The other gentleman was not so fortunate.  The external inflam-
mation, indeed, was slight, but by the matter finding  access to  the
urethra, he, on  the second day, was attacked with a severe degree of
gonorrhcea, which continued for a considerable time to give him a great
deal of distress; nor did he for  upwards of a year get entirely free
from it.
  "By this he was convinced of the imprudence and hazard of all such
experiments; nor could he be prevailed on to carry them farther,
although they were keenly prosecuted by his friend, who, soon after
the inflammation arising from his  first experiment was  removed, in-
serted  the matter of gonorrhoea on the  point of a lancet beneath  the
skin of the pr'eputium, and likewise into  the substance of the glans;
but although this was repeated three different times, no chancres ensued.
A slight degree of inflammation was excited, but it soon disappeared,
without anything being done for it.  His last experiment was attended
with more serious consequences.  The matter of a chancre was inserted
on the  point of a probe to  the depth of a quarter of an inch, or more,
in the urethra.  No symptoms of gonorrhcea ensued; but in the course
of five  or six days a painful inflammatory chancre was  perceived on 
54
THE VENEREAL  POISON.
the spot to which the matter was applied.  To this succeeded a bubo,
which ended in suppuration, notwithstanding the immediate application
of mercury; and the sore arising from this proved both painful and
tedious.  Ulcers were at last perceived in the throat;  nor was a cure
obtained till a very large quantity of mercury was given, under a state
of close confinement, for a period of thirteen weeks."
  These experiments, which strictly accord with the general results of
experience, must be admitted to disprove altogether the argument
derived from the difference between a  secreting and  a non-secreting
surface, and to afford a Very strong presumption that, at least in the
great majority of cases, the poison of gonorrhoea is not identical with
that of chancre.—G. G. B.]
   [Ricord.—The question  has been long discussed,  and is still dis-
cussed at the present day, whether gonorrhoea is identical with syphilis
in its cause and constitutional  effects, and whether it differs from it
only in its primary form, owing to the peculiar locality and the ana-
tomical and physiological nature of the tissues which it affects.
  It must be confessed, that,  in spite of the numerous works which
have been written  to solve this interesting problem, at the head of
which, since the time of Tode,11 rank the remarkable work of Her-
nandez, which in 1810 received the  prize from the Socie'te'  M&licale
de Besancon,  no solution  which has satisfied every  mind has  been
attained.  Facts calculated to elucidate this question, and  experiments
capable of solving it, have not, however, been wanting;  but the sys-
tematic spirit, which  has ruled the observations  of  some men, and
falsely  guided others, has  of necessity conducted, in most cases, to
erroneous conclusions. Authors have found it often necessary to evade
a contradictory case, to suspect the good faith of an opponent, or even
to expressly deny a fact; the  work of Hernandez, the most  complete
on this  subject, is an example.
  For my part, I find the  most weighty arguments  in the absolute
agreement of all these writers, and in admitting, without exception, the
materials which  they have furnished; for a fact is a material thing that
cannot  be destroyed by another fact,  but a good explanation may
destroy false explanations.
  Hunter inoculated gonorrhceal pus and produced a chancre, followed
by its characteristic constitutional symptoms.   Harisson conveyed pus
from a chancre,  by means of a sound, into the urethra,  and produced a
gonorrhoea; whence it has been concluded that the cause of the two is
identical.   On the other hand, Tode and Duncan, as  well as Bell, in
his experiments, have  never succeeded in producing  a  chancre with

  1 Tode, J.  C. iiber die  Erkenntniss und Heilung des  Trippers.   Koppenh und
Leipzig, 1790.                                              *^
  Hernandez.—Analytical Essay on the Non-identity of the Gonorrhoeal and Syphilitic
Virus.  Toulon, 1812.                                          J *
  Swediaur, F. X.—Practical Observations on the More Obstinate  and Inveterate
Venereal Complaints.  London, 1784.
  Bell, Benjamin.—A Treatise  on Gonorrhcea Virulenta and Lues Venerea   Edin-
burgh, 1793.
  Dcncan.—Medical Cases selected from the  Records of the Public Dispensarv at
Edinburgh.   Edinburgh, 1778.—Ed.                            dispensary at 
         THE  SAME IN  GONORRHCEA AND  CHANCRE?        55

gonorrhceal matter; whilst pus from a  chancre introduced into the
urethra was followed by a chancre in that canal; which facts have, of
necessity, led them to admit a difference in the  intimate nature of the
two diseases.  And yet, all these experiments-are true, although con-
tradictory ; for their difference is only apparent, and dependent upon
an erroneous interpretation.
  In order to draw a rigorous conclusion  from  facts, no circumstance
connected with them should be disregarded.  Every time that experi-
menters, to whatever school belonging, have taken pus from the surface
of a chancre, and have applied  it to a surface  which was exposed to
direct observation, they have produced chancres. It is only then, when
the morbid matter was derived from deeply hidden parts,  the actual
condition of whose tissue could not be directly observed, or when virus
was implanted  in such  parts, that results have seemed different and
conclusions opposed.  We find no experimenter asserting that muco-
pus taken from a gonorrhceal ophthalmia, or from a balanitis free from
ulceration, and inoculated upon the skin, or any  visible mucous surface,
has given rise  to a chancre. M. Puche's cases of inoculation of the
muco-pus of a balano-posthitis,1 that were thought  to  prove the con-
trary, have been withdrawn by M. Puche himself, after farther experi-
ments  more  carefully made.  On the other hand,  when pus from a
chancre has been properly inoculated, on any of the tissues whatever,
without exception, it has invariably produced a chancre; and when a
gonorrhcea alone has seemed to follow its  application to  mucous sur-
faces, one of two  things was true; either, as I have elsewhere said, the
pus did not act specifically, and gave rise only to a catarrhal affection,
which,  in its turn, was incapable of inoculation ; or else  the chancre,
which was produced, escaped observation from its situation, and only
furnished a discharge externally, which was mistaken for a gonorrhoea.
   The  following is a summary of the results of my experiments and
observations, collected during a period of more than twenty years:—
   I. Whenever muco-pus is  taken from a surface free from ulceration
—no matter what the previous  symptoms may have been, the seat of
the disease, its  duration, or its degree of intensity—the results of its
artificial inoculation are  negative, on whatever tissue the experiment
is made.
   II. The  existence of a mere ulceration, without distinction of  kind, -
upon mucous surfaces affected with a running,  is not sufficient to pro-
duce a chancre.  A gonorrhcea, like any other inflammation, may
induce  simple ulceration of the tissues which it  affects; but  to produce
a chancre, there must be pus from a chancre in the stage  of specific
progress.
   III.   When I take muco-pus, or pure pus, from  a mucous surface
that I have not previously explored, and am able to obtain positive
results  by inoculation, I am forced  to  infer the existence of a con-
cealed chancre.   This rational diagnosis is always  verified in women
by means of the speculum, which, in these cases, never fails to reveal

  1 Inflammation of  the mucous membrane of the glans, and  of the  internal surface
of the prepuce.—Ed. 
56
THE VENEREAL POISON.
a chancre.  In man, by separating the lips of the meatus, it  is often
easy to see the specific ulcer at a greater  or less depth in the urethra.
At other times, too deeply situated to be seen, the chancre only shows
itself externally by the development of an  induration  of greater or
less extent, or by  perforating the canal  and involving the  external
parts.
   And, lastly, pathological anatomy has added a final argument, which
ought to carry conviction with it.  I have shown to the Academy of
Medicine two urethras taken from  patients who died with  symptoms
of gonorrhcea, and in whom I had diagnosed urethral chancres.  As
the autopsy proved, both had chancres at different depths of the canal,
and one of them even in the bladder.1  (See  PI. 8.)
   IV.  Deeply-seated chancres of the vagina and uterus are more com-
mon than deeply-seated chancres of the  urethra; and  the  latter  are
found more frequently in women than in men.  We see also—and this
accords with what  authors say—more women than men with apparent
gonorrhoeas communicate chancres; and in women much more than in
men constitutional  symptoms occur preceded only by a running, whose
source has not been explored.
   V. The occurrence of secondary  symptoms in man,  as a  sequence
of an apparently gonorrhceal discharge, is still rarer than the occur-
rence of urethral  chancres; since every chancre, whatever  its seat,
does not of necessity cause syphilitic infection of the system.
   VI.  There does  not exist a single authentic fact  in  science which
proves that an individual, whose mucous membrane was open to inspec-
tion during the course of a gonorrhceal attack, without being compli-
cated with chancre, has afterwards shown any symptoms of constitu-
tional syphilis.
   VII. There are not two kinds of gonorrhoea, the one virulent  and
the other mild; differing only in the nature of their cause, the quality
of their secretion,  and their  possible consequences, but without  any
difference in their effect on the primarily affected tissues.   What authors
have called virulent gonorrhcea, is  only  a chancre concealed in  the
urethra,  vagina, &c, recognizing  necessarily a  specific cause, often
assuming the appearance of a gonorrhceal discharge, but existing only
in virtue of an ulceration, which alone can give rise to constitutional
infection.   No exception to this rule can  be deduced from  a rigorous
observation of facts.
   Since my experiments, the difference in form  and  effect  between
gonorrhoea and a chancre can no longer be sought for, either:—
   1.  In the nature of the  tissues, as Hunter supposed, who  thought
that a secreting surface was only adapted to gonorrhcea, whilst non-
secreting surfaces were favorable to the development of a chancre- or
  2.  In a difference of intensity in the  action of the  specific cause.
For here, whilst Swediaur says that a too powerful action of the virus
produces a running, which, by protecting the surface, prevents ulcera-
tion, the absorption of the  virus  and  the constitutional effects- M.
Lagneau  maintains the contrary, and regards  gonorrhcea  as only  a
1 See my Practical Treatise on Venereal Diseases.  Paris 1858. 
THE  SAME  IN  GONORRHCEA AND  CHANCRE?
57
superficial effect of the venereal virus, which, in this case, is insuffi-
cient to  produce a chancre; he believes, too, that the  virus requires
the neighboring surfaces  to be intact,  in order to be absorbed by them ;  or,
   3.  In  idiosyncrasies, as Thomas Rose does;  or,
   4.  As Hufeland does, in certain conditions of the virus; free in
chancre; and confined in gonorrhcea by  a  covering  of mucus, which,
isolating it from the surfaces which secrete  it, prevents  them from ulcer-
ating !
   At the present day  inoculation proves that gonorrhoea and chancre
are two  distinct diseases; and this is the only  differential pathogno-
monic sign between two affections, which it  is more  important to
distinguish than Hunter supposed.—Ricord.]
   [Editor.__M. Vidal, in his recent work on venereal diseases (Paris,  1853),
while he  admits  the existence of non-virulent gonorrhoea,  still maintains that
in most cases gonorrhcea and  syphilis are due to the same cause, viz., a spe-
cific virus.  From M. Vidal's well-known opposition to M. Ricord  (which
juts out  on every page of his work), and from the  fact that this is one of the
chief points in dispute between Ricord and his opponents, it is to be supposed
that the  work in question sums up all the arguments which science can  furnish
at the present day in favor of the identity of the two diseases, and makes out
the best  case possible.
   After  stating  that gonorrhoea may be produced by many non-specific causes,
 such as the  presence of a foreign body in the urethra, too frequent coitus, etc.
 etc., M.  Vidal says :  " In my opinion, the  most frequent and most effective
 cause of gonorrhcea  is  virulent pus, that  is, pus bearing  syphilitic virus.
 Syphilitic virus is  therefore to come in for a large share of the  etiology of
 gonorrhoea, a fact which should never be forgotten in the treatment." Without
 detailing the arguments which are adduced  to support this opinion, suffice it
 to say that there are none that are new, and none that are not fully discussed
 by M. Ricord in these notes ; that M. Vidal does not admit inoculation as a
 diagnostic sign between simple  and virulent gonorrhoea; that  he denies the
 existence of urethral chancres posterior to  the fossa navicularis (and yet in
 this very book he gives a plate of a chancre in the bladder, with a full report
 of the case, which occurred in  his  own practice!), and that  he makes no
 attempt  to explain why, though " virulent  pus is the most frequent cause of
 gonorrhcea," secondary symptoms, apparently following it, are so rare.
   But how does he distinguish a case of specific  gonorrhcea from one which
 is not ?   What  course does he pursue in his treatment ?  These are  the all-
 important questions for the great majority of practical surgeons, and for the
 patients who apply to them.  M. Vidal's answer to the  former  question is
 not so long but that it may be quoted in toto.  " It is difficult to distinguish
 the two," he says ; "but if you can  satisfy yourself that there was true incu-
 bation  in the case, and if the  discharge tend to a chronic state, you will
 incline to believe it specific, and vice versa; and if syphilitic symptoms after-
 wards appear, the diagnosis will be plain."(!)  Pray, in what case of gonor- 
58                   THE VENEREAL  POISON.
rhcea was incubation (so-called) ever absent?  Does the discharge ever com-
mence immediately after the sexual act?  Again, is not a tendency to become
chronic characteristic of all cases of urethral gonorrhoea; a disease which, left
to itself, rarely terminates in less than three months ?
  But, since Vidal believes that gonorrhcea is most frequently due to virulent
pus, and states that  " this fact should never be forgotten in the treatment,"
we are led to infer that he treats  most of his  patients with antisyphilitics.
We turn to his book, where fourteen pages are devoted to the treatment of
gonorrhoea, but we search in vain to find  anything relative to constitutional
antisyphilitic  treatment.   There  is not a word  on the  subject!   In the fol-
lowing section, however, where six pages  are devoted to the treatment  of
gleet, we find one sentence, and one only, on this  point, as follows :  " When
there is reason to suppose that gleet is a primary syphilitic symptom, which
has become chronic, or that  it is  a consecutive  (secondary) symptom, the
constitutional treatment of syphilis should be followed."
  These quotations are all the light which M. Vidal gives us, to guide our
diagnosis between  a virulent and  non-virulent affection, and to guide our
treatment in warding off a constitutional infection and its sad consequences!
Could there be a more virtual confession that M. Vidal  and his school cannot
distinguish gonorrhcea virulenta from gonorrhoea benigna, and that,  whatever
their theory of the nature of  gonorrhoea may be, in practice they treat it as
a simple inflammation?—Editor.]1

   § 6. Of the Causes  of the Poisonous Quality—Fermentation—Action.

   As the consideration and explanation of  this point will throw some
light upon the disease and cure, I may be  allowed to dwell a little
upon it.  It has been supposed  by some that the poisonous quality of
the matter arises from a fermentation taking place in it  as soon as it is
formed.  But whether this poisonous  quality arises from that cause, or
whether the animal body has a power of producing matter according to
the irritation given, whereby the living powers, whenever irritated in a
particular manner, produce such an action in the parts as to  generate
a matter  similar in quality to that which excited the action, is what I
am now to consider.
   In the examination of this subject, I shall  confine myself to gonor-
rhcea.  In support of either of  the two opinions, it must be supposed
that the venereal matter has, by its specific properties, a power of irri-
tation beyond common matter.  I have already observed  that it has
the power of exciting inflammation even on the common skin, and of
forming a chancre, which power is not  possessed  by common matter.
In the first opinion, it must be supposed that there is no specific inflam-
mation or suppuration produced by the application of the  venereal
matter, but  only a common inflammation and suppuration;  and that
the  matter capable of producing these effects acts as a ferment  upon

   1 This and other points, upon which Ricord and his opponents differ, are most ably
discussed by M. Diday;  Nouvelles Doctrines sur la Syphilis, Paris, 1858. 
CAUSES  OF ITS  POISONOUS QUALITY.           59
the new-formed matter,  rendering it venereal as soon, or nearly as
soon, as it is formed;  and as there is a succession of secretions, there
immediately follows a succession  of fermentations.  Now, let us see
how far this idea agrees with all the variety of phenomena attending
the disease.   First, it  may be  asked, what becomes of  this ferment in
many cases where the suppuration does not come on for some weeks
after the  irritation and  inflammation have  taken place ?   In such
cases, we  can hardly  suppose the original venereal matter to remain,
and to  act as a ferment.  Secondly, when there is a cessation of the
discharge, and no matter formed, which sometimes happens for a con-
siderable time, and yet all the symptoms recur, what  is it that pro-
duces this fermentation a second time?  Nothing can but a new
application of fresh venereal matter.  When,  for example, the irrita-
tion is  translated  to  the testicle, and the discharge is totally stopped,
as often happens, what becomes of the virus, and how  is a new virus
formed when the irritation falls back upon the urethra?1   Thirdly, if
the poisonous quality were produced by fermentation taking  place in
the matter already formed, it would not be an easy matter to account
for the symptoms ever ceasing, for, according to my idea of a ferment,
it would never cease to act if new  matter were continually added; nor
could anything possibly check it but a substance immediately applied
to the part, which could stop  or prevent the fermentation in the new
matter.  But as the venereal inflammation in this species of the disease
is not kept up beyond  a certain time, the production of the  poison
cannot depend  on fermentation.  Fourthly, if it  depended on a fer-
mentation in the  secreted matter, all  venereal cases would be alike,
nor would one be worse than another, except from a greater or smaller
number of fermenting places.   Upon  this supposition, also,  all cases
would be equally easy of cure, for the fermentation would be equally
strong in  a slight case as in a bad one.  It can only be fermentation
in the matter after it  has left the vessels.
   When the venereal matter has been applied to a sore, so as to irri-
tate, it  produces a venereal irritation and inflammation.  But even
this does not always  take place, for the common matter from the sore
may remove the venereal matter applied before it can affect  the sore
so  as to  produce  the venereal inflammation and  suppuration there.
This experiment I have made several times, and have only once pro-
duced the venereal inflammation.  But if the venereal matter were
capable of acting as a  ferment, then it  would  in all cases produce
venereal matter without altering the nature of the sore.
  The effects produced by venereal poison appear to me to arise from
its peculiar or specific irritation, joined with the  aptness of the living
principle to be irritated by such a  cause, and the parts so irritated act-
ing accordingly.  I shall therefore consider it as a poison, which, by
irritating the living parts in a manner peculiar to itself, produces an
inflammation peculiar to that  irritation, from  which a  matter is pro-

  1  This proof is defective, since gonorrhceal epididymitis is no more due to syphilitic
virus than the preceding gonorrhoea is. With this exception, Hunter is right.—Ricord. 
60
THE VENEREAL  POISON.
 duced peculiar to the inflammation.  Let  us consider how far  this
 opinion agrees with the various phenomena attending the disease.
   First, the venereal matter having a greater power of irritating than
 common matter, conveys more the idea of irritation than of fermenta-
 tion.  Secondly, its producing a specific disease with specific symptoms
 and appearances shows that it has a specific  power of irritation, the
 living powers necessarily acting according to that irritation.   Thirdly,
 the circumstance of the inflammation having its stated time of appear-
 ance and termination is agreeable to the laws of the animal economy
 in most cases, as  it is a circumstance that takes place in other diseases
 that have a crisis ; and when the  disease is  longer of duration in some
 than in others, it is  because they are much more susceptible of this
 kind of  irritation; and there  may be perhaps other concurrent cir-
 cumstances.  Fourthly, the venereal inflammation being confined to a
 specific distance, is more agreeable  to  the idea of a specific irritation
 than that of a fermentation.  Fifthly, we have a farther proof of this
 opinion from the  appearance of the disease being translated from one
 part of the body to another, as in the case of the swelled testicle,'in
 which the discharge is often stopped or otherwise affected.   Sixthly,
 the discharge often stops from  the  constitution being attacked  by  a
 fever, and returns after some days or weeks, or not at all, according to
 the continuance of the fever.  Now we can plainly see why the fever
 should put a  stop to the discharge, as the disposition produced by it
 in a part is very different from that disposition which formed  the
 matter;  we  can  plainly see why  the same disposition  to form matter
 should often return;  but how that  return should be venereal,  upon
 the principles of fermentation, we do not see.   Seventhly, the produc-
 tion by art of an irritation  of another kind, which  is not specific,
 removes  the specific irritation;  now  an  irritation of another  kind
 cannot prevent the fermentation from going on, but may destroy the
 venereal irritation.  Eighthly, the circumstance of particular parts of
 our body being much more readily irritated than others by the vene-
 real  poison, when in the constitution, shows that it arises from an irri-
 tation, and that of a particular kind.1  Ninthly, we know of no other

 ^ • The French translator of this work remarks that" in order to understand Hunter's
 views, we must not  lose sight of  the fact that he often uses the word irritation in a
 very different sense from  that  in which it is  almost universally understood at the
 present day. With him, this word expresses the immediate effect of every vital action
 whether morbid or  not; in other words, that modification of the tissues which is
immediately interposed between the application of a cause and the fulfilment of its
 action.  For example, let  a man be attacked  with fever after being exposed to the
influence of a  certain miasm; Hunter expresses this fact by saying that  the miasm
introduced into the constitution excites an irritation, which produces action and this
 action is fever.  Irritation, produced by  a miasm, is nothing else than the organic
modification, whatever its nature is, which is the immediate result of the application
 of the morbid agent, which is followed by the morbid action called fever.
  " Take another example; Hunter admits  that the venereal virus is absorbed and
mingles with the general circulation ; then he says : ' It irritates to action ;' in other
words, it produces an irritation or a stimulation, which causes a morbid action.  Thus
 Hunter's irritation is that state of the tissues which immediately precedes every action
 in the system, and which is produced by the direct influence of the exciting cause of
the action. This explanation is important, lest a theoretical value should be attached
to certain of Hunter's phrases, which they do not possess."__Ed. 
CAUSES OF ITS  POISONOUS QUALITY.
61
animal that is susceptible of the venereal irritation, for repeated trials
have shown that it is impossible to give it to a dog, a bitch, or an ass.1
It is much easier to suppose that a  dog or an ass is not susceptible of
many irritations of which the human body is susceptible, as we find
to be the case in all other specific diseases and most poisons, than that
the matter of the human body is not susceptible of a change, of which
that of the dog or ass is not.2
   This argument is still farther supported by comparing the venereal
poison with  other morbid poisons.   The animal poison productive of
the hydrophobia seems to be produced by a particular irritation affect-
ing certain parts, which  shows  that if the body,  or any part  of  the
body, is irritated, it takes a disposition to act in a peculiar manner,
and that this mode of action is  capable of secreting such juices as will
throw another animal into the  same action.   In the hydrophobia, the
throat and its  glands are  particularly affected;  and how the saliva
should become of  such  a nature from the same kind of matter being
either carried into the constitution or perhaps only  by the general
sympathy of the constitution with a local infection, and more particu-
larly with the parts about the throat, is not easily to be accounted for,
without a supposition either that the absorbed poison circulating can
produce a specific constitutional action capable of affecting the throat
and glands there, just as the poison of the smallpox affects the skin,
or that the circulating poison has power  to affect or irritate the glands
of the mouth only, or that those parts only are capable of immediately
sympathizing with the part irritated, as the muscles of the lower jaw
are when they produce the locked jaw.
   If this theory be just, it  explains why epidemical  diseases,  arising
from particular seasons, particular constitutions of air, &c, irritate in
such a manner as to produce a  fever, the effluvia of which shall irritate
in the same  manner;  for it is not in the least material how the original
irritation  arises;  it  is only necessary that  there should exist in the
animal a  power  of acting according to the stimulus given by that
irritation.

   1 I have repeatedly soaked lint in matter from a gonorrhoea, chancre, and bubo, and
introduced it into the vagina of bitches, without producing any effect.  I have also
introduced it into the vagina of asses, without any effect.  I have introduced it under
the prepuce of dogs without any effect.  I have also made incisions and introduced it
under the skin, and it has only produced a common sore.  I have made the same
experiments upon asses, with the same result.
  2 The intrinsic nature of the venereal virus is certainly unknown, and also the in-
timate modifications which it causes in the tissues which it affects and which repro-
duce it.  It is indisputably true that it does not owe its origin to any alteration which
the secreted pus undergoes, but to a peculiar state of the tissues.  Thus, if you excise
a chancre and remove the whole ulcerated surface, you sometimes see a new chancre
succeed the first, although you may have cut in the non-suppurating tissues; pro-'
vided, however, that your section was not made at too great a distance from the part
which was first contaminated.
  I have seen, as Hunter did, suppurating blistered surfaces bathed with virulent pus
from a neighboring chancre without becoming infected, or any change taking place in
the nature of the secretion.—Ricord. 
62
THE MODE OF  VENEREAL  INFECTION.
                     CHAPTER  II.

             THE MODE OF VENEREAL INFECTION.

  Every infectious disease has its peculiar  manner  of being caught;
and among mankind there is generally something peculiar in the way
of life, or some attending  circumstance, which exposes them at  one
time or other to contract such diseases, and which, if avoided, would
prevent their propagation.  The itch, for instance,, is generally caught
by a species of civility, the shaking of hands; therefore, the hand is
most commonly the part first affected.  And as the venereal infection
is generally caught by the connection between the sexes, the parts of
generation commonly suffer first.  From this circumstance, people do
not suspect this disease when the symptoms are  anywhere else, while
they always suspect it in every complaint of those parts.
  In the lower class of people, one as naturally thinks of the itch when
there is an eruption between the fingers, as in young men of the vene-
real disease whose genitals are affected; but as every secreting surface,
whether  cuticle or not cuticle (as was explained before), is liable to be
infected by the venereal poison when it is  applied to it, it is possible
for many other parts besides the genitals to receive this disease. There-
fore, it appears in the anus, mouth, nose, eyes, ears, and, as  has  been
said, in the nipples of women who suckle children affected by it in
their mouths, which children have been infected  in the birth from the
diseased parts of the  mother.
   [Ricord.—The infection of nurses by children, and children by
nurses, is perhaps one of the most interesting  questions connected
with the propagation of syphilis, and one which we  are  called upon
to answer every day.
   I believe, with Hunter, that children can  communicate only the pri-
mary affection (chancre), which they may contract either during delivery
or after  birth.  Since the first edition of this work, no incontestable
observation to the contrary has  appeared;  and M. Cullerier, Surgeon
to the  Lourcine Hospital, has lately read an interesting paper before
the Academy of Medicine, in support of this opinion.] 
DIFFERENT FORMS  OF  THE DISEASE.
63
                      CHAPTER  III.

         OF THE DIFFERENT FORMS OF  THE DISEASE.

  The venereal poison is capable of affecting the human body in two
different ways;  locally, that is, in those parts only to which it is first
applied ; and constitutionally, that is, in consequence of the absorption
of the venereal  pus which affects parts while diffused in the circulation.
  Between the first and second kind, or the local and constitutional,1
certain intermediate complaints take place in the progress of  absorp-
tion ;  these are, inflammations and  suppurations,  forming what are
called buboes, in which the matter is of the same nature  as that of the
original disease.
  When the  matter has got into the constitution,  and is circulating
with  the  blood, it there irritates to action.   There  are produced from
that irritation many local diseases, as blotches on  the skin, ulcers in
the tonsils, thickening of  the periosteum and bones.
  The local,  or first  kind, is what I have called  immediate,  arising
immediately upon the application of venereal pus.  Of this kind there
are two sorts, seemingly very different from one another.- In the first,
there is a formation  of matter without a breach of  the solids, called a
gonorrhoea;  in  the second, there is a breach in the solids, called a
chancre.   Neither of these two ways in which the disease shows itself
is owing to anything peculiar in the kind of poison applied, but to the
difference in the parts contaminated.2
   The readiness with which  the parts run into violent action, in this
species of inflammation, is greater or less, according to  the nature of
the parts affected, which perhaps does not arise from any specific dif-
ference in the parts, but is according to the common principle of sen-
sibility and irritability;  for  we find  that the vagina is  not so much
disposed to inflammation in this disease as the urethra3 is in the same
sex, because it is not so sensible.  However, it is possible  that  there
may be some specific disposition to irritation and inflammation in the
urethra, in man;  and what would incline me  to think  so is that this
canal  is subject to be more frequently out  of order than  any other,
producing a great variety of symptoms.

  1 I have called this form of  the disease constitutional; yet it is not strictly so, for
every complaint in consequence of it is truly local,* and is produced by the simple
application of the poison to the parts.
  * See Ricord's addition on page 70.
  8 Hunter's statement is not strictly true.  Contrary to Swediaur's opinion, I have
maintained with Bell, and others, that urethral gonorrhoea in women is more common
than is generally supposed; still, daily experience proves that vaginitis is far more
common.—Ricoed.
 * " Local;" yes, but under the influence of a constitutional infection, which does not consist in a cir-
culation of the virulent pus in substance ; otherwise, it would still always be inoculable.—Ricord. 
 64:    LUES VENEREA THE CAUSE  OF  OTHER DISEASES.

               ^ 1.  Varieties in Different Constitutions.
   This disease, when it appears in the form either of a gonorrhcea or a
 chancre, differs very much in the violence of its symptoms in different
 people. In some it is extremely mild, in others extremely violent. When
 mild, it is generally simple in its symptoms, having but few, and those
 of no great extent, being much confined to the specific distance; but
 when violent, it becomes more complicated in its  symptoms, having a
 greater variety, and extending itself beyond the specific distance.  This
 does not arise from any variety in the specific virtue of the poison, but
 from a difference in the disposition and mode of action of the body, or
 parts of the body, some being hardly  susceptible of this or any irri-
 tation, others being very susceptible of it, and of every other irritation,
 so as"to readily run into violent  action.
   The venereal irritation, however, does not always follow these rules;
 for I have known young men, in whom a sore from common accident
 has healed up readily, yet the irritation attending a gonorrhcea has been
 violent, and a chancre has inflamed and spread itself with great rapidity,
 and even has mortified. On the other hand, I have known young men,
 in whom a sore from common violence  has been healed with great diffi-
 culty, yet when they had  contracted a  gonorrhcea or chancre, the dis-
 ease has been mild and easily curable.
   In particular people it is either  mild or  severe, for the  most  part,
 uniformly.  In the first stated dispositions it is not invariably so; but
 then I believe there is some indisposition at the time.  I have known
 several gentlemen who had their gonorrhoeas so slight in common, that
 they frequently cured themselves. But it has so happened that a gonor-
 rhoea has been remarkably severe, and has  obliged them to apply for
 assistance; but then they were soon attacked with the symptoms of a
 fever; and when  the fever has gone off,  the symptoms of the gonor-
 rhoea have immediately become  mild.  I may now also observe, that
• when the disease  is in the form of a lues venerea, different constitutions
 are differently affected.  In some its progress is very rapid, in others
 it is very slow.
                     CHAPTER IV.

OF THE LUES VENEREA BEING THE CAUSE OF OTHER DISEASES.

  Every animal may be said to  have natural  tendencies to morbid
actions, which may be considered  as predisposing causes • and these
may be called into action whenever the immediate cause takes place
which maybe such as to have no connection with these tendencies and
cannot therefore be considered as the cause of the disease.  One disease
excites another, and  therefore is  supposed to be the sole cause of it
Thus, slight fevers, or cold, smallpox, and measles, become frequently
the immediate cause of scrofula; and certain derangements of the na- 
      LUES  VENEREA  THE CAUSE  OF OTHER DISEASES.     65

tural  actions of the .body often bring on the gout, agues, and other
diseases; but these diseases will be always more or less, according to
the constitution and parts; and the constitutions will differ according
to circumstances, which may be numerous; two of these, however, will
be local situation and age.
  In  this country,  the tendency to scrofula  arises from the climate,
which is in  many  a predisposing cause, and only requires  some  de-
rangement to become an  immediate  cause  and produce the  whole
disease.
   The venereal disease also becomes often the immediate cause of other
disorders, by calling forth latent tendencies to action.  This does  not
happen from its being venereal, but from its having destroyed the na-
tural  actions, so that the moment the venereal action and disposition
have  terminated, the other takes place; and I have seen in many cases
the tendency so very strong that it has taken place before the venereal
has been entirely subdued; for, by pursuing the mercurial course, the
symptoms have grown worse;  but by taking up the  new disposition,
and rendering it less  active than the venereal, the venereal  has come
into action anew; and these effects have taken place alternately several
times.  In such cases it is a lucky circumstance when the two modes
of treatment can be united; but where they act in opposition it is very
unfortunate.  If the venereal disease attacks the lungs, although that
disposition  may be corrected,  consumption may ensue; and in like
manner where the bones are  affected, or the nose, scrofulous swellings
or fistula lachrymalis may be the consequence, though the disease may
have  been cured.
   Many of  the diseases arising from this source appear to be peculiar
to such causes, and seem to be formed out of the constitution, the dis-
ease,  and method of cure. It is therefore difficult to say of what nature
such  a disease may be; but it will in general have a particular tendency
from the constitution; and if we are acquainted with the general tend-
ency of a constitution, we are  to  suspect that as the strongest cause,
and that the disease will partake more of it  than the other.  In  this
country, these complaints have most commonly a scrofulous tendency,
and are often truly scrofulous,  the disease partaking more of that  dis-
position than any other.1
   Parts have also their peculiar tendency to diseases, which are stronger
than  those of the constitution  at large, and when injured they  will of
course fall into the morbid action arising from such tendencies.  There-
fore,  when parts have had their natural actions destroyed by a vene-
real  irritation,  those tendencies will be brought into action;  and,
therefore, the diseases arising from the  tendencies of such parts are
to be kept in view.  They will be assisted likewise by local situation
and age.
   In  particular countries, and in young people, the tendency to scrofula
will  be  predominant; therefore buboes  in  them  will  more  readily
become scrofulous.  In old people they may form cancers;  and when

   1 What Hunter says here is entirely confirmatory of my note on pages 34-35.—Ricord.
       5 
66    LUES VENEREA  THE  CAUSE OF OTHER DISEASES.

in parts of the body which have a particular tendency to cancer, that
disease will more readily take place.
   The want of knowledge  and of attention to this subject has been
the cause of many mistakes; for whenever  such effects have been
produced in consequence of the  venereal disease, it  has immediately
been blamed, and not only  as a cause, but it has  been supposed to  be
the disease itself.   This is an inference natural enough to those who
cannot see that a variety of causes are capable of producing one effect;
or, in other words, that where the  predisposing  cause is the same, a
variety of immediate causes may produce the same action.  It shows
great ignorance, however, to suppose the venereal disease can be both
the predisposing and immediate cause.
   When the venereal  disease attacks the urethra, it often  becomes
itself the predisposing cause of abscesses and many other complaints;
when it attacks the outside  of the penis, forming chancres, they often
ulcerate so deep as to communicate with the urethra, producing fistula
in the urethra, and often a continued phimosis.
   In describing diseases,  which, like the venereal disease,  admit of a
great variety of symptoms, we should keep a middle line, first giving
the most common symptoms of the disease in  each form, then  the
varieties which most commonly occur, and last of all the most uncom-
mon ;  but it will not be easy to take notice of every possible variety.
Therefore, when a variety occurs not mentioned, it is not to  be sup-
posed that the author is leading his readers astray, or is unacquainted
with the disease at large.   If his general  principles are just, they will
help to explain most of the singularities of the disease. 
PART  II.
                       CHAPTER  I.

                        OF GONORRHCEA.

  When an irritating matter of any kind is applied to a secreting
surface, it increases that secretion, and changes it from  its natural
state (whatever that be) to some other.  This, in the present disease,
is pus.
  When this takes place in the urethra, it is called a gonorrhcea; and
as it arises from the matter being applied to a non-cuticular surface
which naturally secretes some  fluid, it is of no consequence  in what
part of the body this surface is; for if in the anus, it will produce  a
similar discharge there, and a similar effect on the inside of the mouth,
nose,  eyes, and ears.  It is conceived  by some that gonorrhoeas may
take place without the above-mentioned immediate cause, that is, that
they may arise from the constitution; if so, they must be similar to
what  is supposed to be venereal ophthalmia.  But, from the  analogy
of other venereal affections proceeding* from the constitution, I very
much suspect the existence of either the one or the other; for when
the poison is thrown  upon the  mouth, throat,  or  nose, it produces
ulcers,  and not an increased  secretion like  a  gonorrhcea.   But we
never find an ulcer on the inside of the eyelids in those ophthalmias;
and gonorrhoeas in the urethra  are too frequent to proceed from such
a cause.
  Till about the year 1753, it was generally supposed that the matter
from  the urethra in a gonorrhcea arose from an ulcer or ulcers in that
passage; but from observation  it was then proved  that this  was  not
the case.1
  It may not be improper to give here a short history of the discovery
that matter may be formed by inflammation without ulceration.  In
the winter 1749, a child was brought into the room used for dissection,
in Covent Garden, on opening of whose  thorax a large quantity of
pus was found loose in the cavity, with the surface of the lungs and
the pleura furred over with a more solid  substance similar to coagu-
lable  lymph.  On removing this from those surfaces, they were found
entire.  This appearance being new  to Dr.  Hunter, he sent to Mr.
1 See Ricord's note on page 54. 
68
GONORRHCEA.
 Samuel Sharp, desiring his attendance; and to him it also appeared
 new.  Mr. Sharp afterwards, in the year 1750, published his  Critical
 Inquiry, in which he introduced this fact: "That matter may be formed
 without a breach of substance;" not mentioning whence he had derived
 this notion.  It was ever after taught by Dr. Hunter  in his lectures.
 We,  however, find writers adopting it without quoting  either Mr.
 Sharp or  Dr. Hunter.  So  much  being known, I was  anxious to ex-
 amine whether  the matter in a gonorrhcea was formed  in the same
 way.  In the spring of  1753, there was an execution of eight men,
 two of whom I knew had at that time very severe gonorrhoeas.  Their
 bodies being procured for this particular purpose, we were very accu-
 rate in our examination,  but found no ulceration.   The two urethras
 appeared  merely a little bloodshot, especially near the  glans.  This
 being another new fact ascertained, it could not escape Mr. Gataker,
 ever attentive to his emolument, who was then attending Dr. Hunter's
 lectures, and also practising dissection under me.  He published, soon
 after, in 1754, a treatise on this disease, and explained fully that the
 matter in  a gonorrhoea did  not  arise from an ulcer, without mention-
 ing how he acquired  this knowledge;  and from that time successive
 writers have repeated that doctrine.  Since the period mentioned above
 I have constantly paid particular attention to this  circumstance, and
 have opened the urethra  of many who at the time of their death had
 a gonorrhcea, yet have never found a sore in any; but always observed
 that the urethra, near the glans, was more bloodshot than usual, and
 that the lacunas were  often  filled with matter;  I have, indeed, seen an
 instance of a  sore  a  little  within the urethra, but  this sore was not
 produced  by any ulceration of the surface, but from an inflammation
 taking place, probably in one of the glands, which produced an abscess
 in the part, and that abscess opened its way into the urethra.  The very
 same sore opened  a way through externally  at the fraenum, so that
 there was a new passage  for the urine.   Indeed, the method of curing
 a gonorrhcea might have  shown that it could not depend upon a vene-
 real ulcer, for there is hardly an instance of  a venereal ulcer being
 cured by  anything but mercury, escharotics  excepted.1   We  know
 however,  that most gonorrhoeas are curable  without  mercurv and
 what is still more, without any medical assistance;  which, I believe
 is never the case with a chancre.  This  doctrine, that a gonorrhcea
 does not depend on ulcers, was first taught publicly  by Dr.  Hunter at
 his lectures, in the year 1750; but he did not attempt to account for it.
   [Ricord.—It was believed for a long  time that  the discharge in
 gonorrhoea was composed only of pus.   Hence, Mayerne {Syntagmata
praxeos, London, 1690), who attributed it to an ulceration of the canal
 gave  it the name  of *i>ppo«x.  It is now known that these  discharges
 consist of a mixture  of pus  and mucus, to which I have given the
 name of muco-pus; this renders the term blennorrhagia (p*«Wf mucus)
 invented by Swediaur, as incorrect as that of Mayerne since it is no
 more pure mucus than pure pus.

  1 This is a mistake; for it is a well-established fact at the present  day that chancres
 will heal without the use of mercury; consequently, the effect of mercury upon a sore
 is not a true test of its syphilitic nature.—Ed.                      *^ 
INCUBATION OF  GONORRHCEA.              69
   When blennorrhagic discharges, so called, resulting from the in-
 flammation of mucous membranes, are studied with care, it  is found
 that the more intense the inflammation is, and the deeper it penetrates
 into the submucous cellular tissue, the larger  proportion do  the pus-
 globules bear to the mucous element; and when the secretion comes
 from a  neighboring abscess, or  from an ulcer of the mucous mem-
 brane, the mucus may be entirely wanting.
   It is astonishing that Hunter needed the case of pleurisy with false
 membranes, which he quotes, in  order to understand how matter is
 secreted in the  urethra.  He and his  followers  should have been
 enlightened on this point by what takes place on the glans and prepuce
 in  balanitis, and by the phenomena  observed in coryza, bronchitis,
 and purulent  ophthalmia.
   In this  chapter,  which is so  admirably  calculated  to prove that
 chancre and gonorrhoea  are two  different diseases, we  see what vain
 efforts  Hunter  makes to  prove that the mucous membrane of the
 urethra is incapable of ulceration, although he gives an instance of it
 himself.
   Like all the other mucous membranes, that of the urethra may be
 the seat of ulcers, under  the  influence  either of a chancre or of a
 simple  inflammation;  and if Hunter  thought that  he never met with
 ulcerations  in this canal, Astruc, Frank, Bell,  Wiseman, Howard, Ca-
 puron,  Spangenberg, Swediaur, Thomas Bartholin, Teytaud, Lisfranc,
 and myself, have found them at different depths.—Ricord.]  •

   [Editor.—Cockburne, in his work, entitled Tlie Symptoms, Nature, Cause,
 and Cure of Gonorrhcea, London, 1715, was the first to prove that gonor-
 rhcea is not a flow of  semen.
   The term blennorrhagia, which is in use with the French, is preferable to
 gonorrhcea, but it is thought best to adopt the latter in the present translation,
 both to make it coincide with Hunter's  use  of the word, and because it is
 almost universally in vogue in this country.  It must be understood, however,
 as a generic  term, including not only inflammatory discharges from all  the
 mucous  surfaces of the male and female  genital organs, but also discharges
 from any of the accessible mucous membranes of the body, when directly or
 indirectly dependent upon the former, or upon sexual  intercourse.   Hence
 we  may speak of gonorrhcea of the urethra, of the vagina, of the uterus, of
 the anus, of the eye, etc.]

  § 1.  Of the Time  between the Application of the Poison, and Effect.

  In most diseases there is  a certain time between the  application of
 the cause and the appearance of the effect.   In the  venereal disease
 this time is  found to vary considerably, owing probably to the state of
 the constitution when  the infection was received.  Each form  of the
 disease  also varies in this respect;  the gonorrhoea and chancre being
earlier in their appearance after contamination than the  lues venerea
and of  the  two former,  the gonorrhcea  appearing sooner than  the
chancre.  In the gonorrhcea, the  times of appearance are very differ- 
70
GONORRHCEA.
ent;  I have had reason to believe that in some the poison has taken
effect in a few hours, while in others it has been six weeks; and I have
had examples of it in  all the  intermediate periods.  So far, however,
as we can rely upon the veracity of our patients (and farther evidence
we cannot  have), six,  eight, ten, or twelve days should appear to be
the most common period, though it is capable of affecting some people
much sooner, and others much later.  I was informed by a married
gentleman,  who came  from the country, and left his wife behind him,
that in a frolic he went to a bagnio and had connection with a woman
of the town.  The next morning  he  left  her, and he had no sooner
got to his lodging than he felt a moisture of the part, and upon inspec-
tion he found a beginning gonorrhcea, which proved a very trouble-
some one.  I was told by another gentleman that he had been with a
woman overnight, and in the  morning the gonorrhoea appeared; and
that the same happened  to him twice.   I was informed by  a  third
gentleman that the discharge  appeared  in six and thirty hours after
the application of the  poison.  In  the  above-mentioned patients the
infection must have arisen from the poison applied at those stated times,
as neither of these patients is supposed to have had an opportunity of
receiving the infection for many weeks before.1
   These assertions from men of veracity, and where there could be no
temptation  to deceive, not even an imaginary one, are  sufficient evi-
dences.   On the other hand, upon equally good authority, I have been
informed that six weeks after the application  had passed before any
symptom appeared.  The patient had  strange and uncommon  com-
plaints preceding the running, such as unusual sensation in the parts,
with most of the other symptoms of gonorrhoea, except the discharge.
He had  the same complaint about twelve months  afterwards, and then
it was four  weeks from the application of the poison before it appeared,
  fiving for some part of that time the former  disagreeable sensations;
  ut from his late experience he suspected what was  coming.  From
this I am inclined to believe that it seldom or never lies perfectly quiet
so long, and that the inflammatory state may take place for some con-
siderable time before the suppurative; and in these cases there is less
disposition  for a cure,  as the very disposition which forms a running is
in general  a salutary one, and is an intermediate  step  between the
disease,  which is the inflammation, and the cure; for in the  time of
suppuration a change  has taken place  in the  vessels, producing the
formation of matter.   If this change should never take place, it is not
certain what would be the consequence.  Whether the inflammation
would go off without suppuration, as  in many common inflammations,
I have not  been able to  determine, but  should suspect that it would
continue much longer  than usual, because the  parts have not completed
their actions; and I also suspect  that  such  cases always arise from
some peculiarity of constitution.
   [Ricord.—The incubation of  contagious diseases, and especially

  1 The following case added:—
  "A gentleman had a chancre, which was cured by the internal use of mercury
when the chancre was nearly well, a gonorrhcea made its appearance ; this was nearly
five weeks after the chancre."—Home.                                    j 
             SIMPLE AND  VIRULENT GONORRHCEA.          71

syphilis, is generally admitted;  and is even regarded as peculiar to
these affections.  But experimental inoculation  does not permit us to
admit incubation of the primary ulcers of syphilis. .  There is  not, as
has been asserted, a .time intervening between the application of the
cause and its first effects.  The  moment that the virus is deposited in
the tissues under the necessary  conditions for contagion to take place,
its  action  begins and produces its phenomena with a more  or  less
rapid evolution.  In a word—as any one  may convince himself by
artificially inoculating a chancre—there is  no more  incubation after
the insertion of virulent pus, under the epidermis, than after a thorn
planted in the flesh;  and a chancre is produced in the first case by a
gradual process, just as an abscess is formed  in the second,  after  the
necessary time for suppuration.  No bronchitis, pneumonia, or phleg-
mon arrives at the suppurative  period, immediately after the action of
its exciting cause.
  Since gonorrhcea may be due  to other causes than sexual intercourse,
we should give but little weight to observations, selected to prove the
existence of a period of incubation, in which the disease appears a very
long time after the suspected sexual act.
  There are some patients, such as Hunter  himself observed, more
commonly women, who, a short time after exposure, experience  the
premonitory symptoms of gonorrhcea.  Their organs are red, hot, and
swollen ; the natural secretion of the parts may dry up, as in the cases
which Fabre called dry gonorrhcea, or it may increase;  and-yet, with-
out any pus being formed, the disease stops entirely, and often suddenly,
and does not return.—Ricord.]

  § 2. Of the Difficulty of Distinguishing the Virulent from the Simple
                            Gonorrhoea.

   The surface of the urethra is subject to inflammation and  suppura-
tion from various other causes besides the venereal poison ; and some-
times discharges happen spontaneously when no immediate cause can
be assigned.   Such may be called simple gonorrhoeas, having nothing
of the venereal infection in them ; though those persons  that have been
formerly subject to virulent gonorrhoeas are most liable to them.  It is
given as a distinguishing mark between the  simple and the virulent
gonorrhcea that the simple comes on immediately after copulation, and
is at once violent; whereas the virulent comes on some  days after, and
gradually.  But the simple is not in all cases  a consequence of a man's
having had connection with women; it does not always come on at
once, nor is it always free from pain.   On the  other hand, we see many
venereal gonorrhoeas that begin without any  appearance of inflamma-
tion, and I have been very much at a loss to determine whether they
were venereal or not; for there  is a certain class of symptoms common
to almost all diseases of the urethra, from which it is difficult to dis-
tinguish the few that arise solely from the specific affection.  I have
known the urethra sympathize  with the cutting of a tooth,1 producing
1 Natural History of the Teeth, Part II. p. 110. 
72
gonorrhcea.
all the symptoms of a gonorrhoea.  This happened several times to the
same patient.  The urethra is known to be sometimes the seat of the
gout;1 I have known it the seat of the  rheumatism.  The  urethra of
those who have had venereal complaints is more apt to exhibit symp-
toms similar to gonorrhoea than the urethra of those who never had
any such complaint;  and it is  generally in consequence of the parts
having been hurt by that disease that the simple gonorrhcea comes on,
which, perhaps, is also a reason why they are in some measure similar.
A discharge, and even pain, attacks the urethra; and strange sensations
are  every now and then felt in these  parts, which may be either a
return of the  symptoms of the venereal  disease without virus, may
arise as it were spontaneously, or may be a consequence of some other
disease.   When it  happens in consequence of some former venereal
gonorrhcea, it is seldom constant, and may be called a temporary gleet,
ceasing for a time  and then returning; but in such  cases  the parts
seldom swell, the glans does  not change to the ripe cherry color, nor
does it sweat a kind of matter.   Such a complaint as a discharge with-
out virus is known to exist, by its coming on when there has been no
late connection with women, and likewise by its coming on of its own
accord where there had  never been any former venereal complaint,
nor any chance of infection.  From its commonly going off soon, both
in those who have had  connection with women, and those who have
not, it becomes very difficult in many cases to determine whether or
not it is venereal;  for it is often thought venereal when it really is not
so; and, on the other hand, it  may be  supposed to be only a return
of the gleet when  it is  truly venereal.  But, perhaps, this  is not so
material a circumstance as might at first be supposed.  These diseases,
when they are a consequence of former venereal complaints,  may be
considered only as an inconvenience entailed on those who  have had
the venereal gonorrhoea.   No certain cure for them is known ; they
are similar to the fluor albus in women.
  [Ricord.—Neither a suspicious  connection as  an antecedent, an
apparent period of incubation, the greater  or  less intensity of the
symptoms,  their duration with or without remission, the  dark or
greenish color of the discharge, its peculiar odor, the color of the parts
affected, nor the seat of the disease, can indicate its intimate nature, or
betray the exact cause to which it should be attributed.   I appeal to
the confession of Hunter himself, who eludes the question, as Hecker
did; and I would refer especially to the recent  discussion in the
Academy of Medicine, in which it was  evident to all candid minds
that there is no virulent gonorrhoea, except that complicated  with, or
dependent upon, a concealed chancre, which is rigorously demonstrable
by inoculation.]

  § 3.  Of the Common Final Intention of Suppuration not answering in
                        the present Disease.
  When a secreting surface has once received the inflammatory action
its secretions are increased and visibly altered.  Also, when the irrita-

  1 Essays and Observations, Physical and Literary, of Edinburgh, vol. iii. p. 425 
EFFECT OF  HABIT.
73
tion has produced inflammation and an ulcer in the solid parts, a secre-
tion of matter takes place, the intention of which in both seems to be
to wash away the irritating matter; so that it is the end of irritations
to produce their own destruction, like a mote in the eye, which, by in-
creasing the secretion of tears, is itself washed away.  But in  inflam-
mations arising from specific or morbid poisons, this effect cannot be
produced;  for although the first irritating matter be washed away, yet
the new matter formed has the same quality with the original;  and
therefore, upon the same principle, it would  produce a perpetual suc-
cession of irritations, and of course secretions, even if there were  no
other cause for the continuance than its own matter.  But the venereal
inflammation  is not kept up by the pus which is formed ; but, like
many other specific diseases, by the specific quality of the inflammation
itself.  This inflammation, however, it would appear, can only last a
limited time, the  symptoms peculiar to it vanishing of themselves, by
the parts becoming  less  and less  susceptible of  irritation.  This  cir-
cumstance is not peculiar to this particular form of the venereal disease;
it is,  perhaps,  common  to  almost every disease that can affect  the
human body.   From hence it will appear, that the consequent vene-
real matter has no power of continuing the original irritation;  and
indeed if this  were  not the case there would be no end to the disease.
   As the living principle, in many diseases,  is not capable of continu-
ing the same action, it also loses this power  in the present, when the
disease is in the form of a gonorrhcea; and the effect is at last stopped,
the irritation ceasing gradually.  This cessation will vary according to
circumstances; for if the irritated parts are iri a state very susceptible
of such irritations, in all probability their actions will be more violent
and continue longer; but in all cases, the difference must arise from the
difference in the  constitution, and  not from any difference in the poison
itself.
   The circumstance of the disease  ceasing spontaneously only, happens
when it attacks a secreting surface, and when a secretion of pus is pro-
duced; for when it attacks a non-secreting  surface, and produces its
effects there, that is, an ulcer, the parts so affected are capable  of con-
tinuing the disease, or this mode of action,  forever, as will be taken
notice of when we shall hereafter consider chancre.  But this difference
between spontaneous and non-spontaneous cure seems to  depend more
on the difference in the two modes of action than on the difference in
the two surfaces; for when the disease produces an ulcer on a secreting
surface, which it  often does from the constitution, as  on the tonsils, it
has no disposition to cure of itself;  nor  in  the  urethra, if ulcers  are
formed there,  would they heal more readily than when formed in  any
other part.
   The common practice proves these facts;  we every day see gonor-
rhoeas cured by the most ignorant; but in chancre, or the  lues venerea,
more  skill is necessary.  The reason is obvious; gonorrhoea cures itself,
whilst the other forms of the disease  require the assistance of art.1

  1 Ricord.—When we read attentively what Hunter says on the differences existing be-
tween gonorrhoea and the ulcerous form of venereal disease, in respect to the symptoms,
progress, termination, and even the treatment of the two affections, we are astonished to 
74
GONORRHCEA.
   It sometimes happens that the parts which become irritated first get
well, while another part of the same surface receives the irritation, which
continues the disease, as happens  when it shifts from the glans to the
urethra.
   From this circumstance of all gonorrhoeas ceasing without medical
help, I should doubt very much the possibility of a person getting a
fresh gonorrhcea while he has  that disease, or of his increasing  the
same by the  application of fresh  matter of its  own kind.1   And this
observation holds in  all the forms of the disease; for it has been proved
that the application of the matter from a gonorrhcea to a bubo does not
in the least  retard the cure of that  bubo; nor does the matter of a
chancre applied to a bubo, nor the matter of a bubo applied to a chancre,
produce any  bad effect; though if venereal matter  is applied to a com-
mon sore it will often produce the venereal irritation.2  By all which I
am led to believe that the venereal matter formed in a gonorrhoea does
not assist in keeping up that gonorrhoea;  for it is only an application
of matter, the poison and effects of which are  exactly similar to  the
effects upon the solids already  produced; and  that nothing could in-
crease or continue the effect but something that  is capable of increasing
the disposition of the parts themselves  to  such  inflammation,  or of
making them more susceptible of it.   We find, besides, that a gonor-
rhcea  may be cured while there  is a chancre, and vice versa; now, if
fresh venereal matter were capable  of keeping  up the disease, no  go-
norrhoea  could ever  get  well while there  is this  supply of venereal
matter.3  From all this it is reasonable to suppose that  such a surface

find him persist in the idea that they recognize only one and the same specific cause,
and that they differ only in their seat and their form, and may produce the same con-
stitutional effects.  We are especially  astonished, if we admit, as Hunter did himself,
the possible existence of urethral chancres, to account for the constitutional symptoms
in some apparent cases of gonorrhoea.—Ricord.
  •^ This assertion is too contrary to daily observation to allow it to pass without refu-
tation.  The contrary may be proved,  viz., the more numerous attacks of gonorrhcea
have been, the more easily the disease is contracted anew ; and the succeeding affec-
tion is developed with the more ease and rapidity in proportion to the traces remain-
ing of the previous attack. It is well  known that the most common cause of relapse,
especially in gonorrhcea, is the too hasty repetition of sexual intercourse before the cure
is perfect, and even before convalescence commences.—Ricord.
  * If these remarks are understood literally, they may lead to  sad mistakes.  It is
indeed true that pus from a gonorrhcea, which is not a virulent affection, can have no
effect on a chancre, any more than on any other wound. Likewise, pus from a chancre
applied to an open virulent bubo, adds nothing to the sore ;  but pus from the same
bubo, placed in contact with a chancre undergoing cicatrization, will make it relapse
into the stage of virulent ulceration.—Ricord.
  3 When treating of pus, in my lectures, I observed that I was inclined to believe that
no matter, of whatever kind, can produce any effect upon the part that formed it • nor
do I believe that the matter of any sore, let it be what it will, ever does or can do any
hurt to that sore; for the parts which formed the matter  are of the same nature  ana
cannot be irritated by that which they produced, except  extraneous matter is idined
^th*i*' * ^6 g    which forms the poison of the viper, and the duct which conveys
it to the tooth, are not irritated by the poison ; and it would appear from Abbe Fontana's
experiments, that the viper cannot be  affected  by its own poison.  Vide Traite* sur la
Venin de la  Viphre, par M. F. Fontana, vol. i. p. 22.  If what I have now advanced is
true, wiping or washing away matter, under the idea of keeping  the parts clean is in
every case absurd.                                           *        '
  [Ricord.—Pus has, perhaps, no injurious effect on the part which secretes it so lonjr as
it does not become putrid after its secretion.  But, as I have said before, if fresh irritating 
EFFECT OF HABIT.
75
of an animal body is not capable of being irritated by its own matter;
nor is it capable of being irritated beyond  a certain time;  and, there-
fore, if  fresh venereal matter were continued to be applied to the ure-
thra of a man having a gonorrhoea, that it would go off just as soon
as if no such application had  been made, and  get as soon well as  if
great pains had been taken to wash its  own matter away.  • The same
reasoning holds good in chancres.
   I carry this idea still farther, and  assert  that the parts  become less
susceptible of the venereal irritation ; and that not only a gonorrhcea
cannot be continued by the application of either its own or fresh matter,
but that a man cannot get a fresh gonorrhcea, or a chancre, if he applies
fresh venereal matter to the parts when  the cure is nearly completed,
and continues the application ever  after, or at least at such intervals
as are within the  effect of habit.  I can conceive that  in  time  the parts
may become so habituated to this application as to be insensible of it;
for by a constant  application the parts would never be allowed to forget
this irritation, or rather never become unaccustomed to it; and there-
fore this supply of fresh matter could not affect the parts so as to renew
the disease till they first recovered their original and  natural state, and
then they would  be capable of being affected again.  *
   This  opinion  is not  derived from theory only, but  is  founded on
experience and observation.  A man, immediately after having suffered
a gonorrhcea, shall have frequent connections with women  of the town,
and that for years successively, without being infected; yet  a fresh
man shall contract it immediately from  the very same woman; and if
the first-mentioned man were to be out of the habit  of  this irritation
for some time, he then would be as easily infected as the other.  Where
this habit is not so strong as to prevent altogether the parts from being
affected, still it will do it in part; and it is a strong proof of this  that
most people have their  first gonorrhoea the most severe, and the  suc-
ceeding ones generally become milder and  milder, till  the danger  of
infection almost vanishes.1

matter be applied to a gonorrhceal surface while it is healing, the disease will resume
the acute stage ; and, in the same way, a fresh application of pus from a progressing
chancre to another chancre which is about cicatrizing, will reproduce a virulent ulcer.
  In opposition to what Hunter says on the harmlessness of letting virulent pus remain
on the ulcers which secrete it, and on the inutility of lotions and cleanliness, I would
recall to mind the bad effects which are universally admitted to result from the reten-
tion of simple pus in many abscesses, especially  when the air penetrates into the sin-
uses, where the pus stagnates ; and also the irritating properties which pus acquires by
decomposition, and the changes  brought about  by putrefaction. I would especially
insist on the greater  ravages produced by chancres confined within a narrow prepuce,
whose surface is constantly bathed with virulent matter; and, above  all, on what takes
place in an inoculated pustule, which extends  rapidly when it is not evacuated, or
when the succeeding ulcer is allowed to cover itself with a crust which confines the pus.
  The comparison which Hunter makes between the poison of  a viper and virulent
pus, is not fair; there is all the difference between them that there is between physio-
logical and morbid phenomena.  The gall-bladder is not irritated by the bile, nor the
bladder by the urine; but if these fluids penetrate into the cellular tissue, they pro-
duce grave results.—Ricord.]
  1 Ricord.—Without repeating what I said above, I will add that, what Hunter regards
as a general rule, is only an exception, which we shall consider hereafter.  We find
many more patients who complain of not being able  to  touch a  woman without a re-
turn of their disease, than we find in the opposite condition.   Most men, who are pre- 
76
GONORRHCEA.
   This seems to be explained by the following facts: A married man,
 who  had had a communication with his wife only for several years,
 slept with a woman with whom he had formerly cohabited.  She gave
 him a severe  gonorrhoea, and declared that she was not conscious of
 beinf diseased.  He put himself and  her under my care; and while
 they  were going on with their  cures  they still continued their inter-
 course, which  I readily allowed.  He  got well, and it was supposed
 she got well also.  The intercourse was continued between them for
 many months after, without any mischief received on his side, or any
 suspicion of remaining disease on  hers.  At last this connection was
 broken off, and she formed another attachment. She no sooner formed
 this  new attachment than she gave her new lover a gonorrhcea; she
 now flew to me for a cure, and declared that she had no connection
 but with the two gentlemen before mentioned, and therefore that the
 present disease must be the same for which I had attended her formerly.
 Her second lover was not a patient of mine; but I gave her medicines,
 which she very much neglected to take.  Her lover continued his con-
 nection, as the first had done, for several months after he had got well,
 without any farther infection from her.   But, unfortunately, her first
 lover returned about a twelvemonth  after; and thinking himself secure,
 as she lived in peace with the present,  renewed his acquaintance with
 her, and but once; the consequence, however, was a gonorrhcea.
   Had the woman the  gonorrhoea all this time ?   And what was the
 reason why those gentlemen did not catch the disease, except after that
 the acquaintance had been interrupted for some  time ?   Was  it the
 effect of habit, by which the parts lost  their susceptibility of that irri-
 tation ?
   The case of a young woman from the Magdalen Hospital is a strik-
 ing proof of  this, as far as circumstances can prove a fact.  She was
 received  into that house, and continued the usual time, which  is two
 years.  The moment she came out she was picked up by one who was
 waiting for  her with a post-chaise to carry her off immediately. She
 gave  him a gonorrhoea. .
   This opinion of parts being so habituated to this irritation as hardly
 to be  affected by it is strengthened by observing that in the gonorrhcea
the violent symptoms shall often cease, and the disease shall still con-
tinue, spinning itself out to*an amazing length, with no  other symp-
toms  than a discharge; yet that discharge shall be venereal.   This I

vented by a foolish confidence, or by their good-nature, from accusing women who
have made them sick again, attribute to their first attack all those which follow • and
this idea is so general that some men believe in a relapse even after an interval of
years ;  but this is, in most cases, only a fancy.
  It is  true that the more attacks of gonorrhoea the same person has, the less pain they
produce ; but it does not follow on that account  that they are absolutely less severe.
They may occupy as large an extent of surface, give rise to a secretion as purulent and
as abundant;  be just as contagious, last as long, and generally longer, than the first
which  was only attended with more pain.  Here, as we see, habit has no influence on
the action of the cause, which, in most cases, acts as energetically the second as the
first time ; but the repetition of the inflammation in the same part, tending, from that
very repetition, primarily or secondarily to a chronic form, deadens the sensibility, and
diminishes or annuls the pain, which is not a necessary symptom of every inflamma-
tion.—Ricord. 
EFFECT OF HABIT.
77
have frequently seen; and the following is an abstract of a singular
case of this kind:—
  A gentleman had connection with a woman of the town, and received
a venereal gonorrhoea in the beginning of April, 1780.  He at first
could hardly believe it to be venereal, as  he had kept the woman in
the country, where she had  scarcely ever  been out of his sight; but
the violent pain in making water, great running, chordee, and swelled
testicle convinced him that it was venereal.  When the cure was going
on tolerably well, and h« had got the better of one swelled testicle, the
other began  to swell; however, all  the symptoms gradually disap-
peared, except  the  chordee, hardness of the epididymis, and a small
gleet, which was slimy.  On the 12th of June he went into the country;
while he was in the country  the chordee went off, and the hardness of
the epididymis entirely disappeared;  but still a slimy gleet remained,
although but trifling.
  September the first, he married a young lady, and  endeavoring to
enter the vagina, he found great difficulty, which brought on a return
of the chordee, and an increased discharge.   On the 10th, she began to
complain of heat and pain, and of a difficulty and frequency in making
water; and when she made water there was forced out some matter;
she had also a dull heavy pain, and a sense of weight at the bottom of
her belly and round her hips, with great soreness of the parts when
she sat.  These symptoms had been preceded by an itching about the
orifice of the vagina.
  By taking  a mercurial pill, and rubbing the parts with mercurial
ointment, in about eight days the violence of the symptoms abated.
They were now allowed to cohabit; but whenever they came together
the pain which she  suffered was  excessive.  The parts were washed
with a solution of corrosive sublimate and sugar of lead, and anointed
with mercurial ointment, which applications being continued for some
time, the soreness went off   He was treated medically, and afterwards
all was well.
  Here was a venereal gonorrhoea contracted about the beginning of
April; all the symptoms had disappeared by the first of June, and
there only remained  some of the consequences, such as chordee, hard-
ness of the epididymis, and a discharge of a little slimy mucus, which
could only be observed in the morning.  In a short time, the chordee
and hardness in the epididymis had entirely gone off",  and  merely the
small discharge of mucus, which appeared only in the morning, re-
mained; yet three months after he communicated the disease to his
wife.
  I was consulted in the following case by  the surgeon who attended.
July 13th, 1783, a person had connection with a woman of the town;
the 30th, that is, seventeen days  after, a gonorrhoea came  on, which
was violent.  He took mercurial pills  and  gentle purges.   In twelve
days the  violent symptoms abated, and about  the 4th of September
the discharge was stopped.   On the 9th it began to appear again, but
only lasted a few days; and would come and go in this way sometimes
every two days, often six or seven days.  On the 28th of September
he had connection with his wife, while he had a small  discharge.  The 
78
GONORRHCEA.
9th of October he had connection again; and three days after she com-
plained of heat in making water, with'a discharge and other symptoms
of gonorrhoea, which were violent.  About the latter end of October
her complaints were almost removed, some only of the symptoms ap-
pearing and disappearing till January, 1784, when he had connection
with her to try whether she could give it him, viz., three months after
the second connection; and in fourteen days after this he had all  the
symptoms of a gonorrhcea.   April 29th, 'he was not perfectly well,
having a discharge, with a pain in the perineum ; and she also had a
discharge.  If this last attack, in January, 1784, in him, was a gonor-
rhoea, then of course she must have had it; and also of course he must
have lost his in the intermediate  time, between the 9th of October,
1783, and January, 1784; for if he had it also then, it could not have
produced any effect upon him.
  It was impossible to say whether they had now the infection or not,
for any trials upon themselves would prove but little, except one of
them only had it so as to infect the other; but if both had it, no altera-
tion could take place in either, as it could  not be ascertained whether
they had the disease or not; and as there were suspicious symptoms in
both, when joined with all the circumstances, I agreed, with the attend-
ing surgeon, that it was most prudent to treat  them as if actually af-
fected with a gonorrhoea.
  If it is true, as is asserted  in the Voyage Round the  World, that the
venereal disease was carried to Otaheite, it shows that it can be long
retained after all ideas of its existence have ceased; and when it is
retained for such a length of time, it is most probably in the form of
gonorrhoea.1
  In like manner, a venereal  bubo, if it could  be kept a considerable
time between the point of suppuration and resolution, would become
indolent from habit, continue in that point of suspension, and remain,
perhaps, almost incurable.  Such, I think, I have seen.
   [Ricord.—All observers have established a state of  habit, or a kind
of acclimation (if I may be allowed the word), but we must  beware of
regarding habit in the absolute sense that Hunter gives it, or of explain-
ing, by its means," all the  observations which he reports in its favor.
   There are men who contract runnings every time that they have con-
nection with women during their menses, whilst others catch nothing.
Leucorrhcea gives a running to some  and not to others.   The same
woman, affected with uterine catarrh, often causes runnings,  at greater
or less intervals, in a man who habitually cohabits with her; in  this
way I have seen  many liaisons broken and many connections given up,
the parties believing that they could not get along together.  In some
more fortunate cases the man, becoming less susceptible, ceases to catch
anything, although the woman continues in the same state; but then,
as Hunter says, if  any interval occur in  their sexual connections, the
disease reappears when they are  afterwards renewed, as it may do also
if the woman has new lovers.
   In all these cases, though  frequent exposure to the same irritation
' Vide page 48. 
SEAT OF THE  DISEASE.
79
always equally severe, may render a man less susceptible, we must yet
take into consideration other circumstances.   Thus, in marriage, or in
a long connection with the same woman, sexual intercourse is less fre-
quent and less passionate, and the organs are less disposed to irritation.
Women, warned of the condition in which  they may be caught, and
which they do not like to acknowledge, are more careful, and often
take precautions at their toilet, which are not always observed in new
and often unexpected connections, in which a greater orgasm, and
especially  hasty repetitions of the act, dispose the parts to inflamma-
tion.   I have seen women with leucorrhcea, who, after communicating
a gonorrhoea to their lover under the  influence of a  new excitement,
gave the same to their husbands, who  had seen them with impunity
up to that time.  Again, though it is possible  that a person  may be-
come accustomed, in a certain degree, to the causes which give rise to
gonorrhceal  discharges, and which women escape perhaps more fre-
quently than men, it  may be asserted that there is no immunity against
the contagion of chancre unless it be a perfect integrity of the tissues.
   I will not undertake, in  this  place, to criticize the cases which
Hunter reports.  Their little value will be understood from  the  pre-
ceding considerations.—Ricord.]

                   § 4. Of the  Venereal Gonorrhoea.

   In treating of the seat, extent, and symptoms of gonorrhoea, I shall
begin with such particulars as are constant, or most frequent, and take
them, as much as possible, in the order they become  less so, for there
is a considerable variety in different gonorrhoeas.

              § 5.  Of the Seat of the Disease in both Sexes.

   The  seat  of this  disease, in both  sexes, is commonly the  parts of
generation.  In men, it is generally the urethra, though it sometimes
takes place on the inside of the prepuce and surface of the glans.  In
women, it is the vagina, urethra, labia, clitoris,  or nymphas.1
   The disease has its seat in these parts from the manner in  which it
is caught.  But if we were to  consider the  surface of contact simply
in  men, we should naturally suppose that the glans penis,2 or the ori-
fice of the urethra would be the first, or, indeed, the only parts affected;
yet most  commonly they  are not; for though  there  are cases where

  1 The general application of the speculum to the study of venereal diseases in women,
which I was the first to  introduce, proves, as Brugnone previously stated, that even
the womb may be the seat of gonorrhoea; it also explains, as Daran did, the frequency
of leucorrhcea after apparently venereal discharges.
  In respect to the seat of this disease, we should, doubtless, add  the conjunctiva, the
inferior portion of the rectum and the anus,  the pituitary membrane, the mucous
membrane of the mouth, according to some authors (which I have never  observed),
the external meatus auditorius, the umbilicus, and those regions where the skin may
undergo a kind of mucous transformation, as the genito-crural fold, &c.—Ricord.
  [Cases of  gonorrhoeal inflammation of the external meatus are  reported by Lincke,
in his Treatise on Diseases of the Ear; and by Mr. Harvey, in the London Journal of
Medicine, for February, 1850.—Ed.]
  8 Inserted—"inner surface of the prepuce, near to the glans."—Home. 
80                        GONORRHCEA.
the glans  is affected, and where the disease  goes no farther, I believe
it seldom attacks the orifice of the urethra without passing some way
along  that canal.  How far it ever can  be said to affect the prepuce
only, I am not quite certain, although I  believe it sometimes happens,
for I have seen inflammation there, as well with as without a discharge
from the urethra, which appeared to me  to be venereal.1   I have seen,
in such cases, the inflammation extending into the. loose cellular mem-
brane of the prepuce, and producing a phimosis;  and this inflamma-
tion I suspect to be of the erysipelatous  kind.
   When the disease attacks the glans and other  external parts, as, for
instance, the prepuce,3 it is principally  about the  root of that body
and the beginning of the prepuce, the parts where  the cuticle is thin-
nest, and  of course where the  poison  most  readily affects the  cutis;
but sometimes it extends over all the glans, and also the whole exter-
nal surface of the prepuce.  It  produces there a soreness or tenderness,
with a secretion of thinnish matter, commonly without either excoria-
tion or  ulceration.  I am not  certain, however, that it does not  some-
times excoriate those parts, for I once saw a case  where almost the
whole cuticle was separated from the glans.3  The patient assured me
that  it was venereal, and from  the particular circumstances which he
related, I  had no reason to think his opinion ill founded.  He  never
had had any such complaint from connection with women before that
time.   Perhaps  the disease begins oftener on those parts than is com-
monly imagined, but being defended by a cuticle, they are but little
susceptible of this kind of irritation; and this may be the reason why
a permanent effect  is not produced, and why it is often so slight as not
to be observed.  When the glans or prepuce, or  both, suffer the vene-
real inflammation,  it often  rests there, and goes no farther, not  being
attended with a discharge of matter, nor pain  in the urethra.   This,
the following case illustrates.
   A young gentleman, from Ireland, slept with a woman at Bristol,
and a fortnight afterwards, he  had intercourse with  another woman, in
London, which last happened to be on a Monday, and on the Tuesday,
or the day following, he observed a discharge from the end of his penis,
when covered with  the prepuce.  On the Saturday following, he applied
to me.  Upon examination, I  found that the running  came from the
inside of the  prepuce, near to  the glans;  and the  corona glandis, as
also that part of the prepuce which is behind it, appeared to be in a

  1 This  is  a variety of external gonorrhcea to which M.  Desruelles  has given the
name of posthitis.—Ricord.
  2 Inserted: " I believe it is principally in those patients whose glans is commonly
covered with the prepuce, and----."—Home.
  3 Excoriations and ulcerations of various depths are very common in balanitis of
which Hunter is here speaking.  They appear under two different forms, which it  is
important to distinguish.  In simple balanitis, the ulcerations are ill defined of an
irregular outline, and resemble the different phases of a blistered surface ; whilst in
balanitis depending upon a syphilitic eruption on  the glans, or internal surface of the
prepuce, the ulcerations, which appear at the same time with secondary eruptions on
the skin, are clearly defined like the latter, and of a circular form.  In simple balani-
tis, whether complicated with ulcerations or  not, and in balanitis  accompanying
secondary symptoms, inoculation fails; this distinguishes such cases from those which
are complicated with chancres, the matter of which is always inoculable.__Ricord 
SEAT OF  THE DISEASE.                  81
tender and excoriated state, and covered with matter.  He told me he
had once had a gonorrhcea before, and upon being asked if it was in
the same place, he said  it was.  Not being certain how far this might
be venereal, I made the following inquiry: whether he had been sub-
ject to such excoriations before he had visited women; and his answer
was that he never had; and that he had  not  this complaint always
after  coition,  but only twice, as has been  above mentioned, which,
being uncommon, inclined him to suppose the effect to be venereal.
  I suspect that when the prepuce swells, in a gonorrhoea of the ure-
thra,  producing a phimosis, which is often the case, it arises from the
same disease having affected its inside, and that, not being sufficient to
produce ulceration, it  goes no farther.  It  seems probable  that this
inflammation is of the erysipelatous kind: a circumstance  very neces-
sary to be known in the cure.
  The urethra is the part in which this form of the venereal disease is
most frequent; and although the inflammation attending the disease in
this part has many of the common symptoms of  inflammation, yet it
can hardly be called inflammatory when moderate, at least it does not
constantly produce all the effects of common inflammation, though there
is a tendency towards it.  The parts seldom have all the characteristic
symptoms; for there is no throbbing sensation; there is but little pain,
except from the irritation of the urine and distension of the parts; the
inflammation seldom goes deeper than the surface, and we  have there-
fore rarely  any tumefaction  or thickening  of the parts.  It should
rather seem to be an error loci on the surface of the urethra, like a
bloodshot eye.
  The secretion of pus with so little inflammation is perhaps owing to
these parts being naturally in a state of secretion; therefore the transi-
tion from a healthy to a diseased secretion is more  easily produced.  It
sometimes happens, however, that the parts do inflame  considerably,
and the inflammation goes deep into the cellular, or rather reticular,
membrane of the corpus spongiosum urethrae, especially near the glans.
Sometimes it extends farther along the corpus spongiosum urethras, pro-
ducing tumefaction, that is, an extravasation of the coagulable lymph,
which is the common cause of chordee.  It may be observed in general,
that in most cases when suppuration  is produced there is a decrease of
inflammation.   The inflammation in the reticular membrane of the sur-
rounding parts would appear not to be always confined to the  adhesive
stage, for in those parts we have sometimes suppurations, especially in
the perineum, which suppurations I suspect to be in the glands, as will
be taken notice of hereafter.
  The gonorrhoea does not always attack an urethra otherwise sound;
nor does it always attack  an urethra the relative  parts of which  are
always sound.  Thus we find people contracting this disease while they
are  affected with  strictures, a swelled prostate gland, as  also diseased
testicles, or such testicles as very readily run into disease, by which the
malady becomes more complicated, and requires more attention in the
method of cure.  Sometimes such diseases are relieved by the gonor-
rhoea, at other times increased.
       6 
82
GONORRHCEA.
§ 6.  Of the most  Common Symptoms, and the Order of their Appearance.

  Although the irritations must always begin first, yet it is not certain
which of the  symptoms, in consequence of that  irritation, will first
appear, for any one may appear singly without the others, though this
is rarely the case.  The first symptom, when carefully  attended to, is
generally an itching at the orifice of the urethra, sometimes extending
over the whole glans j1 a little fulness of the lips of the urethra: the
effects of  inflammation are next observable, and soon after a running
appears;  the itching changes into pain, more particularly at the time
of voiding  the urine;  there is often no pain till  some time after the
appearance of the discharge, and other symptoms; and in many gonor-
rhoeas there is hardly any pain at all, even when the discharge is very
considerable; at other times the pain, or rather a great degree of sore-
ness, will  come on long before any discharge appears.2
  There is generally, at this time, a greater fulness in the  penis, and
more especially in the  glans, although it is  not  near so full as when
erected, being rather in a state of half-erection.  Besides this fulness,
the glans  has a kind of transparency, especially near the beginning of
the urethra, where the skin is distended, being smooth and red, resem-
bling a ripe cherry; this is owing to the reticular membrane,  at this
time loaded with a quantity of extravasated serum, and the  vessels
filled with blood. Near the beginning of the urethra, there is in many
cases an evident excoriation, which  is marked by the termination of
the cuticle all around.3   The surface of the glans, also,  is often in a
half-excoriated state, which gives  it a degree of tenderness, and there
oozes out from it a kind of matter, as has been before observed.4  The
canal of the urethra becomes narrower, which is known by the stream
of the urine being smaller  than  common.   This proceeds from the
fulness of the penis in general, and from the  internal  membrane of
the urethra  being swollen by the inflammation, and also from its being
in a  spasmodic state.   Besides these changes, the  fear of  the  patient
whilst voiding his urine  assists in diminishing  the stream of urine.
The  stream, as it flows  from the urethra, is  generally much scattered
and broken as soon as it leaves the passage, which is owing to the
internal canal having become irregular, and is not peculiar to a vene-
real  gonorrhcea,  but common to every disease  of the urethra that
alters the exact  and  natural figure of the  canal, even  although the
irregularity is very far back. This we find in many diseased prostate
glands.5

  1 These symptoms are most carefully observed by those who are under apprehen-
sions of having the disease, and therefore are attentive to every little sensation about
those parts.
  2 Added:  " and extend a little way down  the canal.  I have known these sensations
to be felt half way down the urethra."—Home.
  3 These erosions are sometimes due to urethr/il chancres, which are  not generally
recognized.—Ricord.
  * Added: " but this is more evident in those whose glans penis is commonly covered
by the prepuce;  for  when denuded the cuticle becomes  thicker, and  is less easily
irritated."—Home.
  6 Added: " In some instances, the first symptoms  are unusual sensations in  the
penis, especially while making water, which come on a few days after receiving the 
SYMPTOMS.                         83
  There is frequently some degree of hemorrhage  from the urethra.
This, I suppose, arises  from the distension of the vessels, more espe-
cially when there is a chordee, or a tendency to one.
  There are often small swellings observable along the lower surface
of the penis in the course of  the  urethra.   These.  I  suspect, are the
glands of the urethra, so enlarged as to be plainly felt on the outside.
They inflame so much in some cases as  to suppurate, and, according
to the laws of ulceration, the  matter is brought to the skin, forming
one, two, or more abscesses, along the under surface  of the urethra;
and some of these breaking internally, form what  are called internal
ulcers.   I have observed in several cases a tumor on  the  under side
of the penis, where the urethra is, which would swell at times  very
considerably, even to the  size of a small flattened nut, inflame, and
then, a gush of matter flowing from the urethra, would almost imme-
diately subside.  The discharge has continued for some time, gradually
diminishing till it has entirely gone off, and the tumor has been almost
wholly reduced;  yet, after some months it  has  swelled in  the  same
manner again, and terminated in the same way.  How far these tumors,
and the matter they discharge, are really venereal  when they appear
first, may be doubtful ;l  and  it is difficult to determine this, for the
patients  in  general have  recourse to medicine  immediately; but in
their subsequent attacks they  are certainly not venereal, for they cure
themselves.
   I have suspected these tumors to be  the  ducts or lacunas of the
glands of the urethra, distended with mucus, from  the mouth of the
duct being closed, in a manner similar to what happens to the duct
leading from the  lachrymal sac to the nose; and in  consequence of the
distension of the  ducts or lacunas, inflammation and suppuration come
on and ulceration takes place, which opens  a way into the urethra;
but this opening soon closes up and occasions  a  return.   Cowper's
glands have been suspected to inflame, and hardness and swelling have
been felt externally very much in the situation of them, which, coming
to suppuration, have produced considerable abscesses in the perineum.
These tumors break either internally or externally, and  sometimes in
both ways,  making a  new passage  for  the urine, called  fistula in
perinaso.2

infection, attended with constitutional irritability, sensations in the testicles, neck of
the bladder, and anus ; these continue for about ten days, when a discharge comes on,
and they disappear."—Home.
  1 They are venereal, when they are due to an urethral chancre; and not so when
they depend on simple phlegmonous inflammation of the follicles of the urethra, or
of the cellular tissue.
  In any case, it is not well to wait for these abscesses to open themselves into  the
urethra.—Ricord.
  2 In acute gonorrhcea, true abscesses  often form in the follicles of the affected
mucous membrane, or in the cellular tissue.  In man, these abscesses are most com-
mon at the sides of the frenum ; next in order of frequency, along the spongy portion,
and  finally in the perineal and posterior portions of the canal.  The inflammation,
which produces these abscesses, does not always  terminate in suppuration ; and in
that case, induration sometimes results, and may last an unlimited time.  It is well
known that Widekind thought that the previous swelling or subsequent induration
was a diagnostic sign between gonorrhcea virulenta and gonorrhoea benigna; but it is
evident, from what I have said elsewhere, that this induration can have no diagnostic
value, except when dependent on urethral chancre.—Ricord. 
84
GONORRHCEA.
   A  soreness is often felt by the patient all along the under side of
the penis, owing to the inflamed state of the urethra.  This soreness
often extends as far as the anus, and gives great pain, principally in
erections;  yet it is different from  a chordee, the penis remaiuing
straight.
   Erections  are  frequent  in  most gonorrhoeas.  These, arising from
the irritation at the time, often approach  to  a priapism, especially
when  there  is  the above-mentioned soreness,  or  when there is  a
chordee.
   Priapisms often threaten mortification in men; and  I have seen an
instance of it in a dog.  The erection never subsided, and the glans
penis could not  be covered by the prepuce from the swelling of the
bulb.  The penis  mortified and dropped off;  the bone  in it was
denuded, and an exfoliation followed.  As opium is of great service
in priapism, there is reason to. suppose the complaint is of a spasmodic
nature.

                       § 7.  Of the Discharge.

   The natural slimy discharge from the glands of the  urethra is first
changed from a  fine transparent, ropy secretion to a watery, whitish
fluid, and the natural exhaling fluid of the urethra,  which is intended
for moistening its surface, and which appears to be of the same kind
with  that which lubricates cavities  in general,  becomes  less trans-
parent ; and both these secretions, becoming gradually thicker, assume
more and  more  the qualities of common  pus.  In  some  cases of
gonorrhoea, the glands that produce  the  slime which is  secreted in
consequence of lascivious ideas are certainly not affected; for I have
seen cases when,  after the passages had been cleared of the venereal
matter by making water, the pure slime has  flowed  out of the end of
the penis on such occasions.   When this  matter is  more in quantity
than what lubricates the urethra, it is forced out of the orifice by  the
peristaltic action  of that canal, and appears externally.1
   The matter of gonorrhoea often changes its color and  consistence,
which is owing  to  the disposition of the parts which form it; some:
times from a white to  a yellow, and often to a greenish color.  These
changes depend on the increase  or decrease of the  inflammation, and
not on the poisonous quality of the matter itself;  for any irritation on
these parts, equal to that produced in a gonorrhoea, will produce the
same appearances;  and the changes in the  color of  the matter  are
chiefly observable  after it has  been discharged upon  a cloth and
become dry.  The appearance upon the cloth is  of various hues; in
the middle, the matter is thicker, or more in quantity, and  it is there-
fore generally of a deeper color; the circumference is paler, because

  1 That the urethra has considerable powers of action is evident in a vast number of
instances; and that action is principally from behind forwards. We find that  a
bougie may be worked out by the action* of the  urethra.  This action I believe is
often inverted, as in spasmodic stranguries.                               '
  [Hunter's statement, the truth of which may be verified every day, is contrary to
the late assertion of M. Amussat and others, who maintain that there is no such thing
as spasmodic contractions or spasmodic strictures of the urethra.__Ricobd ] 
SYMPTOMS.
85
the watery or serous part of the matter has spread farther;  and at the
outer edge  of all  it is darkest; this last appearance is owing to its
being only water with a little slime, in which some of the tinge is sus-
pended, which, when dry, gives a transparency to the part that takes
off from the white color  of the linen.   It  is very probable that there
is a small extravasation of red blood in all the cases where the matter
deviates from the common color, and  to this the different tinges seem
to  be  owing.  As this matter arises from a  specific inflammation, it
has a greater tendency to putrefaction than common matter  from a
healthy sore, and has often a smell seemingly peculiar to itself.1
   As it should appear that  there is hardly a sufficient surface of the
urethra inflamed to give  the quantity of matter that is often produced,
especially when we consider that the inflammation does in common go
no farther than  two or  three  inches from the external orifice, it  is
natural to suppose  that the discharge  is produced from other parts, the
office of which is to form mucus for natural purposes, and which are,
therefore, more capable  of producing  a great quantity upon slight
irritations, which hardly give rise to inflammations. These parts, I
have observed, are the glands  of the urethra.  In many cases where
the glands have  not been  after death  so much  swelled  as  to be felt
externally, and where I  have had an opportunity of examining the
urethra of those who have had this complaint upon them, I have always
been able to discover that the ducts or lacunas leading from them have
been loaded with matter, and more visible than in the  natural state.
I have observed, too, that the formation of the matter is  not confined
to these glands entirely,  for the inner  surface of the urethra is  com-
monly in such a  state as  not to suffer the urine  to pass without con-
siderable pain, and therefore, most probably, this internal membrane
is also affected in such  a  manner as to secrete a matter.
   This discharge, in common cases, should  seem not to arise much
farther back in the urethra than where the pain is felt, although it  is
commonly believed that it comes from the whole of the canal, and even
from Cowper's glands and the prostate, and even what are  called the
vesiculas seminales.2  But the truth of this I very much  doubt.   My
reason for supposing that it comes only from the surface where the
pain is, are  the following: If the matter arose from the whole  surface
of  the urethra, and from the glands near the bladder, there would
certainly be many other symptoms than do actually occur; for instance,
if all the parts of the urethra beyond the bulb, or even  in  the bulb,
were affected so as to secrete matter, that matter would be  gradually

  1  It is a great mistake to look for a specific sign in the peculiar odor of gonorrhceal
discharges, or to believe that virulent pus has a greater tendency to putrefaction than
ordinary pus.   I have preserved, for a very long time, specimens  of pus from inocula-
ble chancres ;  muco-pus from gonorrhoeas, and pus furnished by non-venereal affec-
tions, and I have observed  no marked difference in them, except, perhaps, that the
virulent pus continued liquid the longest. As to the difference in the smell, it is due
to the peculiar seat of the secretion,—Ricord.
  2 These bags are certainly not reservoirs for the semen.   The difference  between
the contents of them and the  semen gave me the first suspicion of this ; and from
several experiments on the human body, as also a comparative view of them in other
animals, I have been able to prove that they are not.
  [Hunter is here mistaken.—Ricobd.] 
86                        GONORRHCEA.
squeezed into the bulb as the  semen is, and from thence it would be
thrown out by jerks; for we know that nothing can be in the bulbous
part of the urethra without stimulating it to action, especially when in
a state of irritation and inflammation.  In such a state we find that
even a drop of urine is not allowed to rest  there ;  and, also, if an in-
jection of warm water only is thrown  into, the urethra as far as the
bulb, the musculi acceleratores are uneasy till they act and  throw it
out.  Hence  it  is  natural to  suppose  that if the membranous  and
bulbous part of the urethra, with the vesiculas seminales, prostate, and
Cowper's glands assisted in forming the matter, whenever it collected
in the  bulb it would probably be immediately thrown forwards by the
muscles above mentioned, and we should be sensible of it every moment
of the  day.   But such symptoms are seldom observed.   Sometimes,
indeed, a spasmodic contraction of these muscles occurs,  which may
probably arise from this  cause, though  it is  more frequently felt im-
mediately after the urine is discharged.
   When the inflammation is violent, it often happens that  some of the
vessels of the urethra burst, and a discharge of blood ensues, which is
in  greater quantity at the close of  voiding urine.   This, however,
happens at other times, and generally gives temporary ease.  Sometimes
this blood is  in small quantity, and only gives the matter a tinge, as I
observed when treating of the color of  the  discharge.  The erections
of the  penis often stretch the part so much as to become a cause of an
extravasation of blood.   This extravasation generally increases the
soreness at the time of emptying the bladder, and in such a state of
the parts the urethra is  usually sore when pressed; yet the bleeding
diminishes the inflammation, and often gives ease.1
   [Ricord.—If we take  the seat of the  pain in urethral gonorrhoea as
an absolute index of the extent  of the disease, we may often be de-
ceived.  All parts of the  urethra are  not equally  sensitive.  The
difference which exists in this  respect  between the glans and fossa
navicularis, and the rest  of the canal, is well known.   This difference
is observed not only in the absolute sensibility of the part, but also in
its sympathetic sensations; hence M.  Jourdan has  called the  fossa
navicularis the rendezvous of urethral sympathy.  When, however, the
disease has progressed in extent and depth, the pain which  is generally
felt in all the inflamed parts during micturition, is increased in most
cases by external pressure or  by contact with a foreign body, such as
a sound, &c.
   As to the  amount of suppuration, it is certainly in proportion to the
greater or less intensity of the inflammation, and especially to the ex-
tent of the disease; and though neighboring parts not yet affected may
yield  pure  mucus, which mingles with the  discharge, they furnish
purulent matter only when they become involved in the disease
   It would not be  right to infer, as  Hunter  did, that in  many cases

   ' ?ithe/ ln conje(luence of mechanical lesions, as Hunter observes, or from the in-
tensity of the inflammation, discharges are often tinged with blood.   The assertion
has lately been made that a red bloody color in the discharge indicates that it was
contracted by cohabitation with a woman during her menses.  There is no need of mv
showing the incorrectness of this assertion.—Ricord. 
SYMPTOMS.
87
gonorrhceal matter does not come from the bulb, or from parts posterior
to it, because it is not thrown out by jerks.
  It is easily shown, in many patients, that the gonorrhceal discharge
is furnished by the posterior part of the  canal; and that although  it
generally accumulates in the  enlarged part of the canal at the fossa
navicularis, especially during  the  upright  position, yet by external
pressure from behind forwards in the course of the canal, it may be
derived from the perineal region.  The same thing takes place here as
in those cases in which the  canal has in a measure lost its elasticity,
and the urine continues to  drop for some time after the  stream has
stopped, or the patient is obliged to evacuate the urethra by repeated
pressure along its whole accessible extent.
   Gonorrhcea commences in that point which was subjected  to the
exciting cause, and may extend gradually to  the  follicles, the cellular
tissue, or to those parts which are continuous or contiguous.—Ricord.]

                        § 8. Of the Chordee.

   The chordee  appears to  be  inflammatory  in some cases, and spas-
modic in others.  We shall  treat first of the inflammatory chordee.
   When the inflammation is not confined merely to the surface of the
urethra and its glands, but goes deeper and affects the reticular mem-
brane, it produces in it an  extravasation of  coagulable lymph, as  in
the adhesive  inflammation,  which, uniting the cells together, destroys
the power of distension of the corpus spongiosum urethras,  and makes
it unequal in this respect to the corpora cavernosa penis, and therefore
a curvature takes place in the time of erection, which is called a chordee.
The curvature is generally  in the lower part  of the  penis, arising from
the cells of the corpus spongiosum urethras having their sides united
by adhesions.1  Besides the effect of inflammation,  when the chordee
is violent, the inner membrane is, I suppose, so much upon the stretch
as to be in some degree torn, which frequently causes a profuse bleed-
ing from the urethra, that often relieves the  patient, and  even some-
times proves the  cure.   As chordee arises from a greater degree  of
inflammation than common, it is an effect which may, and often does,
remain when  all infection is gone, being merely a consequence of the
adhesive inflammation.

    § 9.  Of the Manner in which the Inflammation affects the Urethra.

   In what manner the disease extends itself to the urethra is a ques-
tion not yet absolutely determined.  I  suspect that it is communicated
or creeps along from the glans to the urethra, or at least from the be-
ginning or lips  of the urethra to  its inner surface; because it  is im-
possible to conceive that any of the venereal  matter from  the woman
can get into the canal during coition, although the contrary is commonly
asserted.  It is impossible, at least, that it can get so far as the common
seat of the disease, or into those parts of the urethra where it very often
1 The preceding sentence omitted.—Home. 
88
GONORRHCEA.
exists, that is, through the whole length of the canal.  The following
case amounts almost to a proof of this opinion.
  A gentleman, on whose veracity I have  an entire confidence, when
in Germany, where he had not lain with a woman for many weeks, sat
in a necessary-house some time.  Upon arising,  he found  something
that seemed to give the glans penis a little sharp  pull, and he found a
small bit of the plaster of the necessary-house sticking to it.   He paid
no farther attention to it at that time than merely to remove what stuck
to his penis; but five or six days after, he observed the symptoms of a
clap, which  proved a pretty severe one.   The only way of accounting
for this is, that some person who had a clap had been there before him,
and had left some venereal  matter upon this place, and that the penis
had remained in contact with it a sufficient time for the matter to dry.1
  When the disease  attacks the urethra, it  seldom extends farther
than an inch  and a half, or two  inches at most,  within the orifice,
which distance appears to be  truly specific, and what I have  called
the specific  extent of the inflammation.2
  As the cause of a gonorrhoea  is  commonly an  inflammation, it is
accompanied with pain and the formation of matter.  In such a state,
neither the sensations of the patient nor the actions of the parts them-^
selves are confined to the real seat of the disease.  In consequence of
the neighboring parts sympathizing, a variety of symptoms are pro-
duced, many of which do not exceed what might arise from an irritable
state.  An uneasiness partaking of soreness and pain, and  a kind of
weariness, are everywhere felt about the pelvis; the scrotum, testicles,
perineum, and  hips become disagreeably sensitive to the patient, and
the testicles often require being suspended; and  so irritable are they,
indeed, in such cases,  that the  least accident, or  even exercise,  which
would have no such effect at another time, will make them swell. The
glands of the groin are often affected sympathetically, and even swell
a little, but do  not come to suppuration.  When they inflame from  the
absorption of matter, they in general suppurate.  I  have seen cases
where the irritation has extended so far as to affect with real pain  the
thighs, the buttocks, and the abdominal muscles, so  that the patient
has been obliged to lie quiet in an horizontal  position.   The pain  has
at times been  very acute, and the parts have been very sore  to  the
touch;  they have  even swelled, but the swelling has not been  of  the
inflammatory kind; for notwithstanding  a visible fulness,  the parts
have been rather soft.  I knew one gentleman who never had a gonor-

  1 This explanation would be satisfactory, if every gonorrhoid discharge were neces-
sarily a consequence of contagion.—Ricord.
  2 It is to be here remarked, that specific diseases, among which I shall reckon such
as arise from morbid poisons, have their specific distance  or extent as one  of their
properties ; but this can only take place where the constitution is not susceptible of
erysipelas, or any other uncommon mode of action; for where there is an erysipela-
tous disposition, no bounds are set to the inflammation.
  [Many syphilographers have attempted to assign a specific seat to gonorrhcea as
Hunter does.  It is very true that some regions, which are more exposed to the action
of the causes of gonorrhoea, are also more easily affected than others ;  but in the pre-
sent state of science, it is impossible to draw the conclusion,  that the disease is there-
fore confined to these regions, and cannot extend, or to found a diagnosis on its seat
as has often been done.—Ricord.]                                        ' 
SYMPTOMS.                         89
 rhcea but that he was  immediately seized universally with rheumatic
 pains; this had happened to him several times.  The blood at such
 times is generally free from the inflammatory appearance, and there-
 fore we may suppose that the constitution is but little affected.1
   When the gonorrhoea (exclusive of the affections arising from sym-
 pathy) is not  more violent than I have described, it may be called
 common  or  simple venereal gonorrhcea; but if the patient  is very
 susceptible of  such irritation, or of any other  mode of action which
 may accompany the venereal,  then the symptoms  are  in  proportion
 more violent.  In such circumstances we sometimes find the irritation
 and inflammation  exceed the specific distance, and extend through the
 whole of the urethra.   There is often  also a considerable degree of
 pain in the perineum; and a frequent though not a  constant symptom
 is a spasmodic  contraction of the accleratores urinas, which is always
 attended with  contractions of the erectores muscles.  Whether these
 spasms arise from a secretion of matter, which being collected in the
 bulbous part of the urethra produces uneasiness, and excites contrac-
 tions in order to its own expulsion, like the last  drops of urine, I have
 not been able to determine.  I have seen such  spasms in  the time of
d making water, from the urine irritating the parts in its passage through
 the urethra, and throwing the  musculi acceleratores into contractions,
 so that the water has come by jerks.  This kind of inflammation some-
 times is considerable, goes deep into the cellular membrane, and pro-
 duces tumefactions without any other effect.8  In other cases it goes
 on  to suppuration, often  becoming one of the causes of fistulas in
 perinaso.   I  have  sometimes,  as I have akeady observed, suspected
 Cowper's glands to be the  seat of such suppurations; for I have ob-
 served externally  circumscribed swellings in the  situation of those
 glands.   The small glands likewise of the bulbous part  of the urethra
 may be affected in a similar manner; and the  irritation is often ex-
 tended even to the bladder itself.3
    When  the bladder is affected it becomes more susceptible of every
 kind of irritation, so that very disagreeable  symptoms  are often pro-
 duced; it will not allow of the usual distension, and therefore the patient
 cannot retain his water the ordinary time; and the  moment the desire
 of  making water takes place, he is  obliged  instantly to make it with
 violent pain in the bladder, and still more in the glans  penis, exactly
 similar to what happens in a fit of the  stone.  If the bladder be not
 allowed to discharge its contents immediately, the pain becomes almost
 intolerable;  and even when the water is evacuated, there  remains for
 some time a considerable pain both in the bladder and  glans, because

   1 Hunter refers to gonorrhceal rheumatism, of which we shall speak hereafter.—Ricord.
   8  Added: " There is often a pain in the urethra after making water, in the same
 part in which it is usually felt while the water passes ; this I  believe to be the effect
 of the contraction of  the internal membranes, which lasts for some time after the
 action has ceased."—Home.
   8  Added: "This happens more commonly towards the going  off of the gonorrhoea."
 —Home.
   [It is very rare, indeed, for the bladder to become affected at the commencement of
 a gonorrhoea.  Without being, in every case, one of the final phenomena, different
 degrees of the irritation most frequently occur after the disease has lasted some time.
 —Ricord.] 
90
GONORRHCEA.
the very contraction of the muscular coat of the bladder becomes a
cause of pain.
  The ureters, and even the kidneys, sometimes sympathize, when the
bladder is either very much inflamed, or under a considerable degree
of irritation; however, this but rarely happens.  I have even reason to
suspect that the irritation maybe communicated to the peritoneum by
means of the vas deferens.  This suspicion receives some confirmation
from the following history:  A gentleman had a gonorrhoea, which was
treated in the antiphlogistic way.  The discharge being in some degree
stopped, a tension came upon  the lower  part of the belly, on the right
side, just above  Poupart's ligament, but rather nearer to the ilium.
There was hardness and soreness to the  touch, which soreness spread
over the whole belly, producing rigors every third day, with a low pulse,
which to me indicated a peritoneal inflammation, arising, in my opinion,
from the  vas deferens of that side being affected in its course through
the belly and pelvis.
  When  the inflammation, or perhaps only the irritation, runs along
the whole surface of the urethra, attacks the bladder, and even extends
to the ureters and the kidneys, so as to cause a disagreeable sensation
in all these parts, the disease is generally very violent, and I suspect is -
something of the erysipelatous kind;  at least it shows an irritable sym-
pathizing habit.
  This disease  sometimes produces  very uncommon  symptoms.  A
gentleman had  a gonorrhcea, and when the inflammatory symptoms
were  abating, the urethra lost both the involuntary  and voluntary
powers of retaining the urine.  His water came away involuntarily,
nor could he stop it.   I  advised him to do nothing,  and to wait for
some  time, as probably the method of cure might be more disagreeable
than the disease  itself, although it was very troublesome to him when
in company.   The  complaint gradually lessened, and in time went
entirely off.

                   § 10. Of the Swelled Testicle.

  A very common symptom attending  a gonorrhcea is a swelling of
the testicle.  This, I believe, like the affection of the bladder, and many
of the symptoms mentioned before,  is only sympathetical, and not to
be reckoned venereal, because  the same symptoms follow every kind of
irritation on the  urethra, whether produced by strictures, injections, or
bougies.  It may be observed here, that those symptoms are not similar
to the actions arising from the application of the true venereal matter,
whether by absorption or otherwise, for they seldom or never sup-
purate; and when suppuration happens, the matter produced is not
venereal.
  The testicles seem, as it were, in many cases, rather  to be acting for
the urethra than for themselves, which is an idea applicable to all sym-
pathies.  Thus the swelling and inflammation appear suddenly, and as
suddenly disappear, or  in a few minutes go from one testicle to the
other, the affection depending  upon the state of the urethra, and not at
all upon the part itself.  A part, however, of the testicle, the epididy- 
SWELLED  TESTICLE.
91
mis, assumes all the characters of inflammation, remaining swelled even
for a considerable time after the inflammation has subsided.
  The first appearance of swelling in the testicle is generally a soft
pulpy fulness of the body of the testicle, which is tender to the touch;
this increases to a hard swelling, accompanied with considerable pain.
The hardest part is generally the epididymis, and principally that por-
tion of it which is at the lower end of the testicle, as may be distinctly
felt. The hardness and swelling, however, often run the whole length
of that body, and form a knot at the  upper part.  The spermatic  cord
is likewise often affected, and more especially the vas  deferens, which
is thickened and sore to the touch.  The veins of the testicle sometimes
become varicose.   I have seen such a state of  the veins accompany a
swelling of the testicle in two  instances.  A pain in the small of the
back generally attends inflammations of the testicles of all  kinds, with
a sense of weakness of the loins and pelvis.  The bowels generally
sympathize with most complaints of the testicle; in some  by colicky
pains,  in others by an uncommon sensation both in the stomach and
intestines.  Sickness is a common symptom, and even vomiting; the
powers of digestion by this means are impaired, and a disposition for
the accumulation of air takes place, which is often very troublesome.
Here we have from  the testicles a chain of sympathies, as we had in
consequence of the irritation running along the whole urinary passages;
first, the testicle is affected from the urethra;  then the spermatic cord,
the loins, intestines, stomach; and from thence in some measure the
whole body.
   In a case of swelled testicle, I have known the buttocks swell; but
 the swelling was not of the inflammatory kind, and in making water
 pain was felt  in  that part.  Whether this symptom arose from the
 swelling of the testicle  or  from the same common cause, that  is, the
 gonorrhcea, is not easily determined, although the latter supposition is
 the most probable.
    It  has  been asserted, but without proof, that in cases of swelled
 testicles  in consequence of a  gonorrhoea, it is  not the  testicle that
 swells, but the epididymis.   The truth is, it is both the one and the
 other.  Any man that is accustomed to distinguish between a  swell-
 ing of the whole testicle and that of the epididymis only, will imme-
 diately be sensible  that in the hernia humoralis the whole testicle is
 swelled.   The testicle assumes the same shape that it does from other
 causes, where  we know, from being obliged to remove  it,  that the
 whole has swelled.  The pain is in every part of the testicle.   I have
 seen such swellings suppurate on the fore part, and have known seve-
 ral instances of adhesions between the tunica albuginea and vaginalis
 from  such causes.   This has only been discovered after  death, or  in
 the operation  for a partial hydrocele.   Such changes could not have
 taken place if the  body of the testicle had  not been in a state of
 inflammation.  This inflammation of the testicle most probably arises
 from  its sympathizing with the urethra, and  in  many cases  it  would
 appear to arise from what is understood by a translation  of the irrita-
 tion from the urethra to the testicle.   Thus, a swelling of the  testicle
  coming on  shall remove the pain in making water and suspend the 
92
GONORRHCEA.
discharge, which shall not return till the swelling of the testicle begins
to subside;  or the irritation in the urethra first ceasing,  shall produce
a swelling of the testicle, which shall continue till the pain  and dis-
charge return, thus rendering it doubtful which is the cause and which
the effect.   I have nevertheless known cases where the testicle has
swelled, and yet the discharge has become more violent; nay, I have
seen instances where  a  swelling  has come on after the  discharge has
ceased, yet the discharge has returned with violence, and remained as
long as the swelling  of the testicle.  Sometimes the epididymis only
is affected, sometimes the vas deferens, and  at other times only the
spermatic cord, producing varicose veins.   No reason can be assigned
why one of these parts is  affected more than another, and  indeed the
immediate cause in all is as yet unknown;  for although an action in
the urethra is the remote cause, yet it is still impossible to say whether
it be the cessation of that action that  is the cause of the swelling in
the testicle,  or the swelling in the testicle the cause of the cessation.
It is described as arising from an irritation taking place in the mouths
of the vasa  deferentia.  Were  this  the cause, it ought  in  general to
affect both testicles at the same time;  but  I have seen this complaint
happen as  often where  the inflammation has gone no farther back in
the urethra  than about  an inch and a half or two inches as where it
has extended farther; and  the circumstance  of the  swelling shifting
suddenly from one testicle  to the other shows it to  arise from some
other principle in  the animal economy.
  A strangury often  attends such  cases of sympathy, and more fre-
quently when the running stops than when it is continued  along with
the swelling of the testicle.   Indeed, any sudden stoppage of the dis-
charge gives a tendency to a strangury.1
  As singular  a  circumstance as any respecting the swelling  of the
testicle is, that  it does  not always  come on when the inflammation in
the urethra  is at the height.  I think it oftener happens when the irri-
tation in the urethra is going  off, and sometimes even after it has en-
tirely ceased, and when the patient conceives himself to be quite well.
  I may be allowed to  remark that swellings in the  testicle, in conse-
quence of venereal irritation in the urethra,  subject it to  a suspicion
that every swelling of this part is  venereal; but from  what I have
said of its nature when  it arises from a venereal cause, which was that
it is owing to sympathy only, and from what I shall now say, that it is
never affected with the  venereal disease, either local  or constitutional,
as far as my observation goes, it is to be inferred that such suspicions
are always ill-founded.   This, perhaps, is an inference  to  which few
will subscribe.2
  I  have known the gout produce a swelling in the testicle  of the

  1 Added: " When the testicle is swelled, blood comes away with the semen ; this
may either be thrown out in the act of secretion or come from the bloodvessels of the
urethra in the act of emission."—Home.
  2 This assertion is contradicted by experience.  There is an affection of the testicle
which occurs so often in combination with venereal symptoms that it must be allowed
to be a constitutional effect of the virus.  It will be described hereafter among the
secondary symptoms of lues  venerea.—G. G. B. 
SWELLED  TESTICLE.
93
inflammatory kind, and therefore similar to the sympathetic swelling
from a  venereal cause, having many of its characters.   Injuries done
to the testicle  produce swellings; but they are different from those
above mentioned, being more permanent, having the disease or cause
in the part itself.  Cancers and the scrofula produce swellings of the
testicle; but these are generally slow in their progress, and not at all
similar  to those arising from an irritation in the urethra.
   [Ricord.—The importance which the  Academy of Medicine has
attached to the affection of the testicles following gonorrhcea, and the
debate which followed the memoir that I read on  this subject before
that learned Society, induce me  to detail briefly what any observer
free from prejudice may learn from every day's experience.
   It seldom happens that the disease involves the scrotal organs during
the first fortnight of a urethral gonorrhoea.
   Balanitis, and with stronger reason  other discharges foreign to the
canal, have no  influence on this affection.   It most commonly appears
during  the third, fourth, fifth, or  sixth  week, from the commencement
of a discharge, or even later.   When it occurs at a later period, we
generally find that the old running which preceded it has been lately
revived.
   It is  almost  always when the discharge has involved the posterior
parts of the urethra that this affection  takes place.
   The  statistics which I have had drawn up prove, contrary to the
ideas generally professed by those who think that the disease is driven
from the urethra into the testicles, that  it is undoubtedly most frequent
in patients who have had no treatment at all.
   Fatigue, constipation, chastity, untimely sexual intercourse, external
 violence, and especially the want of a good suspensory bandage, pre-
 dispose to this affection more  than the use of injections, which are
 often wrongfully accused, unless they have been  made far too irri-
 tating,  and contrary to all the rules of art. Sudden changes of tem-
 perature, especially passing from heat to cold, have a great influence,
 and sometimes produce true epidemics of affections of this nature.
   The  left side appears to me to be most frequently attacked.   This
 difference in frequency of the two sides appears to correspond to the
 position that patients give their scrotum, relatively to the seam of their
 pantaloons; those who "dress" on the  left side—and they are the most
 numerous—have the affection on that side, and vice versa; so that it is
 that organ which is not supported by the pantaloons that is the most
 easily affected.  But exceptions to this rule are not rare, and are ex-
 plained by the action of other predisposing causes which may some-
 times preponderate.
   The disease extends from  the urethra to the organs which secrete
 the semen, in two distinct ways; either by sympathy and without ap-
 preciable alteration of tissue between the urethra and the affected part
 of the testicle; or—and this process is the most common—gradually,
 by extension of the inflammation, with swelling of the tissues involved.
   There is no  gonorrhoeal  affection of  the  scrotal  organs without
 swelling of the epididymis.   The epididymis is the first part in which
 the disease appears; it is also the last to get well, or it may continue 
94
GONORRHCEA.
permanently engorged. In case of inflammation by direct propagation,
the vas deferens may be involved at the same time, but never alone.
  This regularity in the commencement of the affection, which is very
often confined to the epididymis during its whole duration, and which
in every case terminates in it, should, correctly speaking, give it the
name of gonorrhoeal epididymitis.
  It is more common  to  see  one side  alone affected than the two to-
gether  or consecutively.  When the inflammation passes suddenly
from one side to the other, which I call see-saw epididymitis [epididy-
mite d  bascule), it  is generally sympathetic; and when the opposite
epididymis is seized,  it is not uncommon for the first to return sud-
denly to  its normal state.  In primary double epididymitis the cords
are almost always engorged.
  In its simplest form this affection is confined, as I have said, to the
epididymis alone, or to the vasa  deferentia in addition; but if it is at
all severe, and constitutional,  or other causes favor its progress, it ex-
tends and becomes complicated.  The most common complication is
undoubtedly  effusion  into the tunica vaginalis,  or  hydrocele.  This
effusion, which M. Rochoux believed to be the  principal affection, is
sometimes  due to a transparent serous exhalation, of a pale-yellow
color, as in passive dropsy, caused by obstruction of the circulation;
sometimes,  on the contrary—and these are the rarer  cases—it is the
consequence  of true inflammation of the serous membrane, and pre-
sents all the shades of color of pus, false membranes, and diluted blood,
which are generally met with in  serous inflammations.  These differ-
ences, which  may be already distinguished by the  greater or less trans-
parency of the effused fluid, are placed beyond a doubt in those cases
in which the  fluid is evacuated by puncture.
  The effusion into the tunica  vaginalis generally takes place suddenly,
and often disappears in the same manner.  Sometimes, however, it is
produced gradually, and lasts  as long as the swelling of the epididymis.
It constitutes then one of the  forms of  chronic hydrocele.
  The  most common complication, next to the one just mentioned, is
engorgement of the celluar tissue beneath the scrotum and around the
cord.  The skin is in that case no longer movable upon the subjacent
parts;  the vas deferens is lost in  a solid cord,  the component parts  of
which cannot be distinguished, and which is sometimes so large as  to
be strangulated by the tissues that it traverses.  These engorgements,
which under  some circumstances are only cedematous,  are sometimes
decidedly inflammatory, and may terminate in suppuration and abscess.
And, finally,  the skin may be involved, and take on oedema or erysi-
pelas.
  The body  of the testicle itself is certainly one of the  parts most
rarely involved. And yet it has been thought, and some persons think
yet, that  this is the principal seat of the affection, as the name of or-
chitis or syphilitic testicle, which many pathologists still retain, indi-
cates.  In most cases any one may convince himself of the contrary,
and of the  truth of my opinion, by carefully examining the affection
in its different stages.
  At first, there is felt only an engorged spot, of greater or less extent. 
swelled  testicle. ■
95
and more or less painful, situated beneath and behind the body of the
testicle, and very easily recognized.  When the disease  progresses, as
we have above described, and effusion takes place, fluctuation, more or
less marked, is soon detected.  This is due to the liquid contained in
the tunica vaginalis, and is situated, in the great  majority of cases, at
the anterior part of the scrotum on the affected side, where there is
frequently found, as I have pointed out, a transparency in  a  part of
the tumor which leaves no farther doubt as to its nature.   The signs
furnished by an effused fluid can be mistaken for  those of an inflamed
testicle, only in case an excessive distension of the tunica vaginalis pre-
vents displacement  of the fluid and its ballottement on percussion, and
changes the sensation of fluctuation into that elastic feel which the
sound testicle  presents.   But, in that  case, superficial pressure of this
part of the tumor determines an entirely different  pain from that which
the testicle on the opposite side experiences when examined in the same
way.   Moreover, the tumor  of the affected  side  is  divided, in these
cases, into  two portions; the  one hard, and situated behind;  the other
fluctuating or elastic, and occupying the anterior part.  Again, com-
paring the diseased with the  well side, we find that the softer  portion
in front is of the same size as the opposite testicle or larger.   In the
latter  case, which is due to  the effusion, if  we draw off the fluid  we
again find  the body of the testicle set into the epididymis; its form,
position, and consistence precisely similar to the well organ  on the
opposite side.   Moreover, by puncturing, in these cases of epididymitis
complicated with hydrocele, we may convince ourselves that, although
a large part of the  tumor is due to the effusion, the remainder, consti-
tuting no inconsiderable portion of it, consists of the epididymis and
surrounding cellular tissue.  Whenever the testicle is swollen by in-
flammation, and there is true  orchitis, the pain is intolerable, in con-
sequence of the constriction exercised by the tunica albuginea. But
the constant pathognomonic sign that maybe verified on the dead and
living subject, is  the rapid induration, either general or partial, which
at once deprives the organ of that elasticity, which, I may almost say,
is peculiar to itself.  In these cases, which are of  all the most rare, if
we evacuate  a coexisting hydrocele, we find only a hard  ma'ss left,
whose elements are more or less indefinitely blended.
   Authors are not agreed as  to what takes place with regard to the
urethral discharge.   As a  general  rule, epididymitis never follows a
sudden suppression of the running.  It is, perhaps, true, that it does not
supervene  during the acute and copious stage of a discharge; but the
running generally does not diminish in quantity until the epididymitis
has set in and made some progress, and it rarely  dries up  completely,
unless the epididymitis takes  place at a time when  the gonorrhcea is
decidedly on  the decline.   The persistence of the  running,  during
epididymitis, even  constitutes an important diagnostic sign.  In the
passage of the inflammation from the urethra to the epididymis, the
symptoms  are those of revulsion rather than metastasis.
   The secretion  of the  semen may be increased, diminished,  or sup-
pressed ; sexual desire heightened or extinguished.  The semen which
is  discharged in  nocturnal pollutions or sexual intercourse generally 
96                       GONORRHOEA.
 preserves its normal character.  Yet I have seen it in some rare cases
 combined with pus, and the mixture of the two did not appear to have
 taken place in the urethra; in other cases it is accompanied with blood,
 especially in a state  of intimate combination, when, contrary to  the
 general rule, the  body of the testicle is involved.
   Epididymitis being a local disease, and usually acute in its progress,
 may excite  a general febrile reaction, sympathetic pains in the loins,
 and symptoms analogous to those of strangulated hernia, such as hic-
 cough, vomiting,  and in rare cases peritonitis.
   Its  usual termination  is by resolution;  which, in the most compli-
 cated cases,  commences in the superficial tissues and terminates in  the
 deeper;  the subcutaneous cellular tissue loses its oedema, and  the
 serosity of the tunica vaginalis disappears; the induration of the cord
 vanishes; and when the  testicle is involved it may become atrophied,
 whilst the  epididymis remains  indurated, or is the last to undergo
 resolution.
   When suppuration supervenes, it most frequently takes place in  the
 subcutaneous cellular tissue, next around the epididymis, and finally
 in the body of the testicle,  in cases of orchitis.  As soon as an abscess
 has formed,  if the scrotum is not already adherent over  it, it soon
 becomes so; it is encircled by an induration, in the centre of which
 fluctuation becomes well marked, and the skin overlying it is smoother
 and of a darker tint than the neighboring parts.   The clearly defined
 indurated circle, the difference in the color of the skin, and the central
 fluctuation,  are sufficient to prevent our mistaking the abscess for  the
 testicle, which  may often be recognized in its  neighborhood, or  for
 oedema, diffused engorgements, or especially for simple effusion into
 the tunica vaginalis.
   In  simple cases, the prognosis of gonorrhoeal epididymitis is not
 grave, for its termination is almost always speedy and favorable, espe-
 cially in sympathetic epididymitis.  Gonorrhceal epididymitis is not a
 virulent affection, and its presence after a gonorrhoea is by no  means
 an indication that syphilitic symptoms are to be feared.  When sup-
 puration takes place, the pus is not inoculable.
 ^  The gravity of this affection  is only in proportion to its complica-
 tions.  Thus, in scrofulous individuals, it may be the accessory cause
 of the development  or evolution of tubercular sarcocele, which, in
 Germany, has been wrongly considered a direct consequence of gonor-
 rhcea virulenta, so called; in a cancerous diathesis  it may be followed
 by cancer of the testicle, and in  patients already infected with consti-
 tutional syphilis it may occasion true syphilitic sarcocele.
  Pathological anatomy has confirmed all that  careful observation at
 the bedside  of the patient had anticipated.   In simple cases, the epi-
 didymis is alone  affected, of which I  have shown specimens  to the
 Academy of Medicine. In one subject, the changes of tissue (engorge-
 ment,  injected bloodvessels, induration, and superficial suppuration)
 extended from the epididymis to the vesicula seminalis, and thence to
the ejaculatory duct.   I have found the tunica vaginalis, containing
fluid or empty, presenting pus or false membranes.  When the testicle
showed any changes, it was seen that  they commenced near the epi- 
GONORRHCEAL BUBO.                   97
 didymis, and that they consisted in simple cases of an effusion of plastic
 lymph, as Sir Astley Cooper has so well shown, together with  com-
 pression or more or less complete obliteration of the vasa seminifera;
 but in every case the normal elasticity of the organ was entirely lost.
   MM. Gaussail, Rochoux, Velpeau, etc., have  lately presented  facts
 in pathological  anatomy similar to those which  I have collected, but
 with explanations systematically different.—Ricord.]

         § 11. Of the Swellings of the Glands from Sympathy.

   Since our knowledge of the manner in which substances get into
 the circulation,  and our having  learned that many substances,  espe-
 cially poisons, in their course to the circulation, irritate the absorbent
 glands to inflammation and tumefaction, we might  naturally suppose
 such swellings, accompanying complaints in the urethra attended with
 a discharge, to be owing to the absorption  of  that matter,  and there-
 fore, if it be a venereal discharge, that they must also be venereal.  But
 we must not be  too hasty in drawing this conclusion, for we know that
 the glands will sometimes swell from an irritation at the origin of the
 lymphatics, where  no absorption could possibly have taken place.
 They often swell and  become painful upon the commencement of in-
 flammation, before any suppuration has taken place, and subside upon
 the coming on of suppuration, because when the suppuration begins,
 the inflammation abates.  I have known a prick in the finger with  a
 clean sewing-needle produce a red streak all up the forearm, pain along
 the inside of the  biceps muscle, a swelling  of the lymphatic gland
 above the inner condyle of the humerus, and also of the glands of
 the armpit, immediately followed by sickness and a rigor, all which,
 however, have soon  gone off.  As it  should therefore appear that the
 absorbent system is  capable of being affected as well by irritation as
 by the absorption of matter, in all diseases of this system arising  from
 local injuries attended with matter, one must always have these two
 causes in view,  and endeavor, if possible, to distinguish from which
 the present affection proceeds.  For in those cases arising from an ir-
 ritated surface in consequence of poison, especially the venereal, it is
 of considerable consequence to be able to say from which  of the two
 it arises,  since  it sometimes happens, although but seldom, that the
 glands of the groin  are affected in a common gonorrhoea with the ap-
 pearance  of beginning buboes, but which I suspect to be similar to
 the swelling of the  testicle,  that is, merely sympathetic.   The  pain
 they give is but very trifling, when compared  to that of the true vene-
 real swellings arising from the absorption of matter, and they seldom
 suppurate.  However,  there are swellings of these glands from actual
 absorption of matter in gonorrhcea, and which consequently are truly
 venereal; and as it  is possible to have such, they are always to be
 suspected.  As  they have  sometimes arisen upon a cessation of the
 irritation  in the  urethra, similar to the  swelling of  the testicle, it has
 been supposed  that  the  matter was  driven, as it were, into them by
 unskilful treatment.  From our acquaintance with the absorbing system
we know  that the matter can go that way;  but we also know that we
       7 
98
GONORRHCEA.
 have no method of driving it that way;  and if we had, there is no
 reason why more should not be formed in the urethra.   This therefore
 does not account for the cessation of secretion of matter in that part.
   It is difficult to say what is the nature of those sympathetic diseases.
 They are not venereal, for they subside  by the  common treatment of
 inflammation,  without the use of mercury;  and I have known an
 instance of a swelled testicle from a venereal gonorrhcea that suppu-
 rated, and was  treated by my  advice  as a  common suppuration, and
 healed without a grain of mercury being given.  Neither can they be
 called truly inflammatory, having rarely any of the true characters of
 inflammation, such as thickening  of the parts, symptomatic  fever, or
 sizy blood, except in swellings of  the testicle and glands.  The swell-
 ing of the testicle has several peculiarities attending it; it is often verv
 quick in its increase, and not being of the  true inflammatory disposi-
 tion, it  requires less time for the removal of the inflammation; but
 even where it appears to have more of the true inflammatory action,
 we find that the removal of the inflammation and tumefaction takes
 place more rapidly than when proceeding from other causes. A swelled
 testicle  in  consequence of the radical cure of the hydrocele does not
 subside, after inflammation  is gone, in as many weeks as the swelled
 testicle, in consequence of its sympathy with other parts, does in days;
 and  probably the reason of this is, that it arises from sympathy;  for
 an inflammation arising from real disease in a part, or from an external
 injury, as in the hydrocele, must always last either till the disease be
 removed, or the injury repaired ; but that from sympathy will vary as
 the cause varies, which may happen very quickly; for we find a testi-
 cle swell in a few minutes, and in as little  time subside; and also the
 swelling move  suddenly from  one testicle  to the other.   These sym-
 pathies are often peculiar to constitutions, and even to temporary con-
 stitutions, insomuch  as to  be in some degree epidemic; for there is
 often such an influence in the atmosphere  as predisposes the body to
 this kind of irritation, and bodies  so  predisposed require only the im-
 mediate cause to produce the effect.
   [Ricord.—Without going into all the details relative to buboes in
 general, which we shall consider hereafter,  I may be allowed to point
 out some facts, which observation  and experiment have taught me.
  Compared with the frequency of gonorrhoea, an accompanying bubo
 is very rare.
  It commonly appears at the outset, or during the acute stage, of a
 discharge.
  Unless it occur in persons otherwise disposed to glandular  engorge-
 ments, in consequence of a  lymphatic temperament, or a scrofulous
 diathesis, it has little tendency to suppuration, and its  resolution is
 generally rapid.
  The greater or less degree of inflammation and pain attending a
bubo, to which  we would give the epithet " gonorrhoeal," cannot serve
to distinguish a bubo by absorption from a  sympathetic bubo, as Hun-
ter seems to think.   The severity of the inflammation and pain, the
duration, the mode of termination, and the influence of treatment, in 
      DISEASES OF THE  LYMPHATICS IN  A GONORRHCEA.   99

this disease, depend  on collateral causes, pertaining to the individual,
and foreign to the gonorrhcea, which is not here a specific cause.
   A  bubo accompanying gonorrhoea  is never syphilitic, as  Hunter
supposes, unless there exist, at the same  time, a chancre, of which the
bubo is the consequence.
   Glandular engorgements occurring during the course of a  gonor-
rhoea, and  terminating in suppuration, never furnish inoculable  pus;
nor, in this case,  are constitutional symptoms ever observed.  We
shall see hereafter that buboes following the absorption of pus from a
chancre, or virulent buboes so-called, furnish pus which can always be
inoculated.
   The explanation of those cases in which a patient has a true viru-
lent bubo, with symptoms of gonorrhoea as  the antecedent,  is,  that
there was  a chancre somewhere.—Ricord.]

        § 12. Of the Diseases of the Lymphatics in a Gonorrhoea.

   Another symptom, which sometimes  takes place in a gonorrhoea, is a
hard cord leading from the prepuce along the back of the penis, and
often directing its course to one of the groins, and affecting the glands.
There is most commonly a swelling in the prepuce at the part where
the cord takes its rise.  This happens sometimes when there is an exco-
riation and discharge from the prepuce or glans, which may be called
a venereal gonorrhoea of these parts.   Both the swelling in the groin
and the hard cord, we have reason to  suppose,  arise from the absorp-
tion of pus, and that, therefore, they are  the first step towards a lues
venerea; but as that form of the disease seldom happens from a gonor-
rhoea, I shall not take any farther notice of it in this place.  However,
I  may remark that, from this observation of the lues venerea being
seldom produced from a gonorrhcea, it should appear that a whole sur-
face, or one only inflamed, does not readily admit of the absorption of
the venereal  poison; and, therefore, although the venereal matter lies
for many weeks in the passage, and over the whole glans, it seldom hap-
pens that any absorption takes place.1   I have seen a case where blood

  1 Added:  "As a farther proof that these cords often arise from an inflammatory
excoriation and tumefaction of the prepuce, a  gentleman had a chancre on the right
side, at the root of the prepuce, close to the penis, besides which there was an excoria-
tion of the penis everywhere, with a thickening of that part.   Although the chancre
was on the right side, and the excoriation principally on the left, yet there was a hard
cord along the left side of the penis, leading to an enlarged gland in the groin."—Home.
  [Hunter's explanation of this case may be incorrect, since we frequently see  chan-
cres on one side give rise to buboes on the opposite side, which proves that the lym-
phatics cross the median line.  This fact has also been proved by anatomical researches,
and especially by those of M. Huguier.  (Mimoires de V Acadimie de Medecine, t. xiv.
et xv.)
  Otherwise, I am entirely of Hunter's opinion with regard to the nature of the cords
which form on the back of the penis.  They are true cases of lymphitis or angeioleu-
citis, and not always phlebitis of the dorsal veins, as has latterly been believed.  They
are more rarely met with in true gonorrhoea, and are then simple cases of inflamma-
tory lymphitis.  They more commonly succeed the different varieties of chancre, and
they present the same differences as the buboes which follow them.—Ricord.]
  [These inflammations of the dorsal vessels sometimes give rise to chordee, in which
the concavity of the arc is directed upwards towards the pubis.—Ed.] 
100
GONORRHCEA
has been discharged from the urethra, and the above mentioned symp-
toms have come on.  I at first suspected that the absorption had taken
place where the vessel gave way; but as this symptom rarely happens,
even where there has been a considerable discharge of blood, I am
inclined to think that wounds are also bad absorbing surfaces, espe-
cially when I  consider that few  morbid poisons are absorbed from
wounds.

      § 13. Short Recapitulation of the Varieties in the Symptoms.

  From what has been advanced above, it must appear that the variety
of symptoms  in a gonorrhoea, and the difference of  them in different
cases, are almost endless.   I shall now recapitulate a few of the most
material or common varieties. The discharge often appears without
any pain, and the coming on of the pain is not at any stated time after
the appearance of the discharge. There is often no pain at all, although
the discharge be considerable in quantity, and  of a bad appearance.
The  pain often goes off  while the discharge continues, and will some-
times return again.  An  itching in some cases is  felt for a considerable
time, which sometimes is succeeded by pain, though  in many cases it
continues to the end of the disease.   On the other hand, the pain is
often troublesome and considerable, even when the discharge is trifling,
or none at  all.  In  general, the inflammation in the urethra does not
extend beyond an inch or two from the orifice;  sometimes it runs all
along the urethra to the bladder, and even to the  kidneys; and in some
cases  spreads in the substance of the urethra, producing a chordee.
The glands of the urethra inflame, and often suppurate;  and I suspect
that Cowper's  glands sometimes do the same.  The neighboring parts
sympathize, as the glands of the groin, the testicle, the loins, and pubes,
with the upper parts of the thighs and abdominal muscles.  Sometimes
the disease  appears soon  after the application of the poison, as in a few
hours, at other times not till after six weeks. It is often not possible
to determine  whether it is venereal, or only an accidental discharge
arising from some unknown cause.
  It may not be improper  to mention here that I have seen a chancre
on the^prepuce produce  a pain in the urethra in making water, which
most  probably depended upon a  sympathy similar to that by which
the application of venereal matter to the glans  produces a discharge
from the urethra, as was observed above.   If the application of vene-
real  matter to the glans can produce a discharge from the urethra, it
is possible that any acrid matter, though not  venereal, may have a
similar effect.   The  discharge from the vagina, in  cases of what is
called fluor albus, is sometimes extremely irritating, insomuch as to
excoriate the labia and  thighs; and the following history shows that
it may sometimes produce effects similar to venereal matter.
  Mr. and Mrs.----have been married these twenty years and upwards.
She  has, for many years past, been at times troubled with the fluor
albus.  When he has connection with her at such times, it has gene-
rally, although not  always, produced an excoriation  of the glans  and
prepuce, and a considerable discharge from the urethra, attended with 
IN WOMEN.
101
a slight pain.  These  symptoms commonly take a considerable time
before they go off, whether treated as  a gonorrhoea or as a weakness.
Is this a new poison ?   And does it go no farther because the connec-
tion takes place only between two ?  What would be the consequence
if she were to have connection with other men, and these with other
women ?   Such cases, as far as I have seen, have only been in form of
a gonorrhoea.  They have not produced sores in the parts, nor, as far
as I know, do they ever produce constitutional diseases.1
                      CHAPTER  II.

                OF THE GONORRHCEA IN WOMEN.

   The venereal disease in the form of a gonorrhoea in women is not
so complicated as in men; the parts affected are more simple, and fewer
in number.  But  it is not so easily known in them as it is in men, be-
cause the parts commonly affected in women are very subject to a dis-
ease resembling the gonorrhoea, called fluor albus ; and the distinguish-
ing marks, if there are any, have not yet been completely ascertained.
A discharge simply from these parts in women is less a proof of the
existence of the venereal infection than even a discharge without pain
in men; therefore, in general, little or no attention is paid to it by the
patient herself, and we often find the venereal virus formed  in those
parts without any increase of the natural discharge.  The kind of mat-
ter gives us no assistance in distinguishing the two diseases, for it often
happens that the discharge in the fluor albus puts on all the appear-
ances of the venereal matter;  and an  increase of the discharge is no
better mark by which we can distinguish the one from the other. Pain,
or any peculiarity in the sensations of the parts, is not a necessary
attendant upon this complaint in women, therefore not to be looked for
as a distinguishing symptom.
   The appearance of the parts often gives us but little information; for
I have frequently examined the parts of those who confessed all the
symptoms, such as increase of discharge, pain in making water, soreness
in walking, or when they were touched; yet I could see no difference
between these and sound parts.  I know of no other way of judging in
cases where there are no symptoms  sensible  to the person herself or
where the patient has a mind to deny having any uncommon symptoms,
but from the circumstances preceding the discharge, such as her having

  1 In fact, this was a true case of gonorrhoea, which might have been communicated
to others.  Most gonorrhoeas arise in exactly the same way, as I have had the means
of proving hundreds of times during the last twenty years.  It is impossible to dis-
tinguish gonorrhoeas, which are produced under such circumstances, from those which
are supposed to be due to specific contagion; it is the same disease, with the same
consequences, and requires the same treatment.  There is no more constitutional infec-
tion in one case than in the other; and no more need of mercurial treatment, unless
an infecting chancre, due to another contagion, supervene.—Ricord. 
102
GONORRHCEA
 been connected with men supposed to be unsound, or her being able to
 give it to others, which last circumstance, being derived from the testi-
 mony of another person, is not always to be trusted to, for very obvious
 reasons.  Thus, a woman may have this species of the venereal disease
 without knowing it herself, or without the surgeon being able to dis-
 cover it, even on inspection. It may appear very strange that a disease
 which is so violent and well-marked in men should be so obscure in
 women;  but when we consider that this  poison generally produces
 symptoms according to the nature of the parts affected by it, it becomes
 an easy matter to account in some measure for this difference.
  When we attend to the manner in which this disease is contracted
 by women, it is evident that it  must principally attack the vagina, a
 pari; that is not endowed with much sensation, or action  of any kind.
 While it is confined to the vagina, it may be compared  to  the same
 disease on the glans penis in men.  In many cases, however, it extends
 much farther, and becomes the cause of disagreeable feelings, produc-
 ing a considerable soreness in all the parts formed for sensation, such
 as the inside of the labia, nymphas, clitoris, carunculas myrtiformes, the
 orifice of the meatus urinarius, and often affecting that canal in its whole
 length.   Those parts  are  so sore in some cases as not to bear being
 touched; the person can hardly walk; the  urine gives pain in its  pas-
 sage through the urethra, and  when it washes  the above-mentioned
 parts, which can  hardly be  avoided.   Such symptoms are not much
 increased at one time more than another, excepting at the  time of mak-
 ing water, and then principally in those who have the urethra affected;
 for, as these parts are less exposed to circumstances of change, the in-
 creased irritation  arising from such change of parts must necessarily
 in this sex be less.  But in  men the urethra, which is the part most
 commonly affected, has great sensibility, is capable of violent inflam-
 mation, is often distended with a stimulating fluid, and the body of the
 penis, urethra, and glans, stretching the  passage with erections, always
 produce an increase of the symptoms, especially of the pain.
  But as this disease frequently attacks parts more  sensible  than the
 vagina, and which are more susceptible of inflammation, as has been
 observed, under such circumstances women  have nearly the same symp-
 toms as men; a fulness about the parts, almost like an inflamed tonsil,
 a discharge from the urethra, violent pain in making water, and great
 uneasiness in sitting, from pressure on those parts.
  The bladder sometimes sympathizes, producing the  same symptoms
 as in men, and it  is probable that the irritation may be communicated
 even to the kidneys.   It has been asserted  that  the ovaria are some-
times affected in a similar manner to the testicles in men. I have never
 seen a case of this kind, and I should very  much doubt the possibility
 of its existence; for we have no instance, in other diseases, of the ovaria
 sympathizing with those parts, or at least  producing such symptoms
 as would enable us to determine that they did.  That there do how-
 ever, uncommon symptoms now and then  occur, should  appear from
the following case:—
  A lady had all the  symptoms of a venereal  gonorrhcea such as a
discharge, pain and frequency in making water,  or rather a continued 
IN  WOMEN.
103
 inclination to void it, and a heaviness approaching to pain about the
 hips and loins.  The  uncommon symptoms in this case were great
 flatulency in the stomach and bowels; this last symptom was most pro-
 bably a sympathy with the uterus.  There may possibly be sympathies
 therefore with the ovaria.
   The inflammation frequently goes  deeper than the  surface  of the
 parts; often running along the ducts of the glands, and affecting the
 glands themselves, so as to produce hard swelling under the surface of
 the inside of the labia, which sometimes suppurate, forming small ab-
 scesses, opening near the orifice of the vagina.  These are similar to
 the inflammations  and suppurations of the  glands in the  urethra in
 men.  The different surfaces or parts which the disease attacks, make
 no  distinction in the disease itself.   It is immaterial whether it is a
 large or small surface; in one case the  parts are  more  susceptible of
 this irritation than in another; but the method of cure may be more
 complicated.
   It sometimes happens that the venereal matter from the vagina runs
 down the perineum to the anus, producing a gonorrhoea or chancres
 there.
   How far the gonorrhoea in women is capable of wearing itself out,
 as in men, I cannot absolutely determine, but  am much inclined to
 believe that it may, for I have known many women who have got rid
 of a violent gonorrhcea without having used any means to cure it;
 and, indeed, the great variety of methods of cure employed in  such
 cases, all of which cannot possibly do good, though the patients get
 well, seems to confirm this opinion.  One circumstance, which appears
 as curious  as any, is  the  seeming continuance of the disease  in the
 vagina for years; at least, we have reason to believe this, as far as the
 testimony of patients can be relied on; and this long continuance of
 it, without wearing itself out as it does sometimes in men, is probably
 owing to its being less violent in the vagina.1

   1 A case is here added:—
   " Home.—The following account of a lady, having all the symptoms of gonorrhoea im-
 mediately after connection, shows how early in some cases the disease is produced ; it
 was sent to me from Bath for my opinion upon it, drawn up by her medical attendant.
   " A lady, of a delicate habit of body, great sensibility of mind, and extreme irrita-
 bility of the whole nervous system, in general had enjoyed good  health until her
 present illness, which began in the following manner: The morning after her marriage,
 she complained of great soreness and swelling of the pudenda, attended with a good
 deal of pain, and difficulty in making water; this was considered as  the  natural
 consequence of her connection, and she continued her journey in a postchaise, though
 in much pain, the whole day.  The following morning, her complaints were much
 increased, and a considerable discharge came on from the parts.  In this situation,
 she came to Bath a few days after, when I was desired to see her.  I found her in an
 agony of distress, her husband having informed her that, from circumstances attend-
 ing himself, he was apprehensive her complaints might prove venereal.  Upon ques-
 tioning him, I found that for some months he had had a running from the urethra,
 attended with heat of urine ; that he had been under the  care  of a surgeon in the
 country, who had assured him  his disease was not venereal ; that, confiding in this
 assurance, he had married, not doubting that he was perfectly well, except a trifling
gleet which remained still; he farther stated that, in having connection with his wife,
from the natural tightness of the parts, he had not been able to penetrate;  that, in
the attempt, she complained of much pain, and some blood was discharged;  upon
examining his shirt, some discharge was observed upon it, and he still was troubled 
104                           GONORRHCEA
           § 1. Of the Proofs of a Woman having this Disease.

   It may be  asked, what proof there  is of a woman having  a gonor-
rhcea when  she is not sensible of having any one symptom of the
disease, and none appears to the surgeon on examination ?  In such a
case, the only thing we  can depend  upon is  the  testimony of those

with heat of urine.  I was at  first inclined to hope that (as women  are not so easily
infected with the venereal poison as men) all these complaints might be the conse-
quence of a first connection, followed by a long and rapid journey in a postchaise ; I
therefore ordered an opening mixture, and desired the parts might be fomented with
a decoction of poppy-heads in  milk and water, and a soft poultice of bread and milk
applied.  Finding no advantage from the use  of these means, I examined the state of
the parts affected, and found there was  a considerable discharge of matter, principally
from the urethra, the orifice of which was much swelled and inflamed, as well as the
ducts of the glands on each side the urethra ; there did not appear to be any discharge
from the vagina ; the hymen still appeared unbroken, and very firm and fleshy; the
lacunae from Cowper's glands on each side were very much inflamed ; and  there was
a hard tumor on one side of the hymen, which afterwards suppurated.  There was no
appearance of disease anywhere about the labia or nymphae.   It was treated as vene-
real, and she went through a course of mercury, which was persisted  in for some time ;
the abscess above mentioned burst;  her mouth  grew a  little tender; her complaints
were so much mended that there was no doubt of a speedy and happy termination of
her disorder, when she was seized with a most violent diarrhoea, which was with the
utmost difficulty restrained.  Mercurials of every kind were then left off; the former
symptoms grew more troublesome ; the heat of  urine increased, and extended to the
bladder, as appeared by the continuance of the pain for an hour or two after she had
made water.  She was now desired to rub about  a drachm of mercurial ointment upon
the thighs, labia, and inside of the pudenda.  About this time, another abscess formed,
in nearly the same situation with the former, which was opened with a lancet; this
gave her much relief; the heat of urine went off in a great measure, but the  discharge
from the urethra still continued as much as before ; she continued the mercurial fric-
tions with great freedom during the healing of the abscess, insomuch that her mouth
was greatly affected; she then left off  the ointment for a little time, and soon after,
the orifice of the urethra swelled and  inflamed very much, the discharge greatly in-
creased  in quantity, and there was likewise a discharge of matter from the vagina;
an injection of crude mercury, rubbed down with mucilage of gum  arabic till it was
extinguished, and mixed with  water, was ordered to be used twice or thrice a day;
she had all along taken the almond emulsion with gum arabic for her constant drink,
and this was continued in large quantities; she also again resumed the use of the
ointment as before, by which her mouth was at times made exceedingly sore.
   " The  disease had now continued nearly five months ;  the catamenia regularly ap-
peared ever since her first complaint;  at  the  last return of them  she was free from
pain, and the discharge as little as it had been at any time during her illness, and she
continued free from uneasiness during  that period, but soon after  its  cessation the
heat of urine again returned in a most violent degree, and continued  for an hour or
two with unabating violence;  the orifice  of the urethra again swelled as  much as
before.  The discharge from the vagina at present  is much the same, to  which is
superadded a shooting pain in almost  every direction of that passage and  the parts
adjacent, which frequently recurs during the day.  I can feel no swelling of  any other
part within the  reach of my finger; nor does the pressure give pain  in any  direction.
Being now fully persuaded that the venereal virus must be fully subdued, all mercu-
rials are left  off, and she uses only an injection of opium and thin starch, keeping the
bowels open with a little castor oil now and then.   Every fresh return 'of  the ardor
urinae has been accompanied  with  a train of  most distressing nervous symptoms
hysterics, and extreme dejection of spirits, and the pain is generally most violent in
the night, though she  drinks  an astonishing  quantity of diluting liquors with gum
arabic, pulvis tragacanth. comp., &c, and  has frequently taken opiates, from which
she has certainly received relief; but as they always increase her nervous symptoms          '
she is greatly overcome by their use."—Home.                                    '         I
  [Is  it  possible to deceive one's self more perseveringly on the cause, nature  and
treatment of the disease in this unfortunate lady 1  And all because a gonorrhcea must
be virulent, like a chancre I—Ricord.]                                                     | 
IN WOMEN.
105
whom we look upon as  men of veracity.  Such men have asserted
that they have been affected by a woman in the situation above de-
scribed, having had no connection for some months with any other
woman.  From this evidence it is reasonable to  suppose that  the
disease has been caught from such women;  and it should seem to  put
it beyond a doubt when the same woman gives the disease in this way
to more than one man.  The case of the woman giving the disease to
two men alternately, at an interval of twelve months each  time,1 which
gives a space of at least two years for the continuance of the disease,
proves that its communication is almost the only criterion of its pre-
sence.  The case, too, of the young woman at the  Magdalen Hospital3
confirms the same opinion.  Yet all this does not amount to an abso-
lute proof;  for a sound woman  may have  had a connection with a
man who had  a gonorrhoea, or  a man with chancres, and soon after,
that is, perhaps within forty-eight hours, she may have admitted  the
embraces of a sound man.   In such a case, it is very possible that he
may receive the infection from that matter which was lodged in  the
vagina by the  unsound man, and yet the woman may not catch  the
disease, for  the matter  may be washed away before it  irritates  the
vagina; and this woman may be suspected of having a  gonorrhcea,
and apparently with great justice.  A repetition of these circumstances
may be the  cause of many  women appearing to have the disease for
years without really having it.   Again,  I have seen a bubo come on
at  a time when the patient was not sensible of any disorder till that
appeared.  This, one would think, is an absolute proof that there may
be  a gonorrhoea and the patient not be conscious of it. But even this
is not altogether without fallacy, for there may have been an absorp-
tion of venereal matter deposited in the vagina by some infected man,
which may  not have produced any irritation in that part.3
   [Ricord.—As any one may convince himself from  the writings of
authors preceding Hunter, of Hunter himself, and of those who have
followed this great master, the knowledge of gonorrhoea in women was
necessarily incomplete and enveloped in mystery, until the use of  the
speculum enabled me to better  appreciate  a multitude of important
circumstances connected with it.
  1. Its seat.—Gonorrhoea may affect the vulva, the urethra, the vagina,
or the uterus, either singly or all together;  or again, it may occur in
different combinations of these parts, such as the vulva and uterus to-
gether, or these parts in connection with the vagina, etc., which con-
stitute so many varieties.
  2. Relative frequency of situation.—1, the vagina;  2, the  urethra;  3,
the vulva; 4, the uterus.  In case of combination: 1, the vulva, ure-
thra, and vagina together; 2, the vagina and uterus; 3, the vulva, urethra,
vagina, and  uterus.
  3. Its extension.—It extends from the vagina to the neighboring parts;
also from the superficial and external  to the deeper parts, which are
the last affected and the most difficult of cure.
1 See p. 76.
3 The last three sentences omitted.—Home.
2 See p. 76. 
106                      GONORRHCEA
  4. Its commencement.—Difficult of accurate appreciation  in women,
in consequence of the possible existence of previous discharges.
  5. Alterations of  tissue.—Simple  redness, either circumscribed or
general;  more or less decided tumefaction;  erosions and ulcerations,
presenting the same varieties as are met with in balanitis or urethritis
of the male.   The follicles of the vagina are often very much  developed,
and present a granular, mammillated aspect, which has led me to apply
to this variety the  name of psorelytrie.  The os uteri often presents
granular ulcerations.   These granulations, which  resemble ordinary
granulations, or those appearing on certain vesicated surfaces, or the
granulations  met with on other inflamed mucous membranes, may last
a very long time; they are generally ill-defined, and  may, notwithstand-
ing what has been  said  on the subject, occupy indifferently the two
lips of the os, or extend  into the cavity of the neck.   It is not very
uncommon to see these granulations pass into the state of true vegeta-
tions.
  These granulations are not necessarily the consequence of one specific
inflammation, rather than another, as some superficial observers have
supposed.
  6. Symptoms.—All the symptoms of catarrhal inflammation, varying
only according to the seat  of the disease; thus, when situated in the
urethra, pain in micturition; in the vulva, pain from friction and "walk-
ing, tension, often severe itching, and sometimes increased sexual desire;
in the vulva  and vagina,  pain in copulation; in the uterus,  sometimes
symptoms of metritis, always those of uterine catarrh.
  Discharge.—Mucous at first, it soon becomes  purulent; afterwards,
towards its termination, or  in a chronic state, it is  often lactescent or
creamy.  It is bloody in cases analogous to those which I  have men-
tioned in speaking of the disease in man; but  any mixture with the
menses must be taken into  account.  It is liquid, and free from visci-
dity, in the urethra, vulva,  and vagina; glutinous,  flaky, or ropy, like
the white of eggs, when it is furnished by the uterus.  It is alkaline in
the vulva, urethra, and uterus, whilst it is acid in the vagina;  it may
possess a more or less marked odor, resembling the smell of some fishes
in a state of decomposition, or in the deeper parts of the vagina, it may
assume a very decided smell of sulphuretted hydrogen.
  7. Complications.—Phlegmonous inflammation in the neighborhood,
terminating frequently, when acute, in abscesses in the  labia; inflam-
mation and  suppuration of the glands of the vulva.   Chancres may
coexist, situated externally, or concealed in the vagina or urethra, on
the os or in the cavity of the neck; and it is only in these cases that a
discharge, gonorrhoeal  in appearance, can give rise to chancres, as it
flows over the neighboring parts or upon the anus, or can communicate
chancres to persons who  are exposed to infection from it.
  The ovaries may  be affected, as the epididymis is in  man.  I have
had the opportunity of observing this  complication, whose existence
Hunter dares neither to deny nor fully to admit; and if any one will
take the trouble to look for it, he will find it often  enough  to be con-
vinced of the fact.
  I will cite the two following cases. 
                           IN WOMEN.                       107

   A patient, in my wards, aged thirty-two, affected, for the first time,
 with a very acute gonorrhoea of the uterus and  genital organs, was
 suddenly seized with swelling of the left iliac fossa.  On handling the
 part, the tumefaction was well marked, the temperature of the part in-
 creased, and the examination occasioned  much pain; nausea and  a
 febrile movement ensued, with a full pulse.  The patient lay on her back,
 inclined a little to the left, her thighs slightly flexed on the pelvis.  The
 discharge from the urethra and genital organs had almost entirely dis-
 appeared.   On examination per vagi nam, I found  the following: pres-
 sure on the neck with the index finger was not painful, but pain was
 excited, and a sensation of tension in the left broad ligament, when the
 finger, placed on the  left side of the womb, thrust this organ  towards
 the  right iliac fossa; the same thing done on the other side, for the sake
 of comparison, caused scarcely any inconvenience;  defecation, emission
 of urine, and in general all movements of the abdomen were painful.
 These  symptoms, treated  by  antiphlogisties, disappeared about  the
 twelfth day, and, as their intensity diminished, the  discharge gradually
 became again more abundant; when, suddenly, the  discharge decreased
 again, and the same series of symptoms appeared, but this time on the
 right side.
   Again, the pupils who follow my clinique, have been able to observe
 a case almost precisely similar to the one just reported, in which  the
 left  side alone was affected.1
   Buboes are very uncommon; they rarely appear unless the urethra
 is affected.
   8. Progress.—Acute  at the  outset, with a decided tendency to  a
 chronic stage, under which form it  may even commence.
   9. Duration.—Rarely  short, often indefinite.
   10.  Terminations.^-The  cure of  gonorrhcea  is  rarely spontaneous,
 but generally  follows proper  treatment.  There  are,  however, many
 cases which one is inclined to believe incurable, perhaps owing to the
 want of thought and care on the part of women, who are very different
 in this respect from men.  Such cases are  disguised under the conve-
 nient and common name of " whites."
   11.  Causes.—From all that precedes, can we infer the existence of a
 distinct and specific cause ?   I will not repeat what I have said else-
 where. If the arguments already presented  be not forgotten, and to
 them be added what Hunter says in this chapter, any one will be con-
 vinced that different  causes may produce effects  analogous to those
 that have been thought characteristic of the action of a peculiar virus.
   12.  Diagnosis.—Nothing but the presence of a chancre, or its conse-
 quences, can absolutely  prove  a woman to be what Petronius called
 an infected female.
  As  we have proved,  the signs  given  by Gault, Charleton, Van
 Swieten, and  De Graff, dependent  on the locality which they assign

  1 M. Mercier has lately proved, by several post-mortem examinations, that the in-
flammation may involve the peritoneum, and obliterate the Fallopian tubes, thus pro-
ducing sterility.  He inquires if this may not be the principal cause of barrenness in
prostitutes ; but so great a degree of importance can hardly be attached to it.—Ed. 
108  EFFECTS OF GONORRHCEA  ON  THE CONSTITUTION.
 to gonorrhoea, in the neighborhood of the meatus urinarius, are of no
 value.
   The cessation of the gonorrhoeal discharge, whilst leucorrhoea may
 continue, during the menstrual period, as John Fernel, Liebault, Mer-
 catus, &c, thought, and which Baglivi regarded as an infallible sign,
 is also illusive.
   The absence of pain, according to Pinel, and that felt  in the emis-
 sion  of urine, according to Charleton, have no more value than the
 whitish  and  copperish  stains, and the  pale red  tint,  given  by M.
 Richerand.
   After what I have said  above, we also know what value to attach
 to the  alterations  in the  tissues, with regard to  which  M. Lagneau
 entirely agrees with me.
   As to the power of infection of the discharge in  a female, as  well as
 in the male, it depends rather on its acrid, irritating nature, than on
 anything else, and can lead to no rigorous conclusion.
   Finally, if we refer to the age of the patient, to the moral presump-
 tion in the case, or to the antecedents, we are still  left in the dark, as
 Hunter himself justly remarks; for whatever the causes of the  disease
 may be, the symptoms produced are identical.
   Hence, by means of the preceding signs, we can only establish dif-
 ferent varieties in those inflammations in women  which  are reputed
 gonorrhoeal, without approximating nearer to a  knowledge of their
 cause; but in every case, any one can distinguish,  as I have done, the
 discharge from a chancre, by means of the speculum or inoculation.
   One fact, which I ought to mention, giving it only that degree of im-
portance which it deserves,1 is, that in every case of urethral gonorrhoea
 that I have met with, the woman  confessed that she had  caught  the
 disease, or at  least that she had been exposed to it.—Ricord.]
                     CHAPTER   III.

 OF THE EFFECTS OF THE GONORRHCEA ON THE CONSTITUTION
                         IN BOTH SEXES.

  The  disease I have  been describing, both in men  and women, is
local, and generally confined  to  the  part  affected; yet it  sometimes
happens that  the whole constitution  is more or less  affected by it.
Thus we find, before there is any appearance of matter from the parts,
that some patients complain of slight rigors; these are most consider-
able when the suppuration is late in taking place.  A remarkable

  » I have Italicized M. Ricord's words, that he may not be misunderstood to lay this
down as  an absolute rule.  M. Vidal, in his  late work, represents him as making
urethritis m the female an absolute diagnostic sign of contagion t  It is almost need-
less to say that M. Ricord would be the last person in the world to entertain an opinion
so contrary to his first principles.—Ed.                               v 
TREATMENT  OF GONORRHCEA.
109
instance of this happened in a gentleman who had the infection twice.1
The first time he assured me that it was six weeks between the time
it was possible for him to have contracted  the disease, and its appear-
ance ; and that for a considerable part of that time he had often  been
indisposed with slight rigors, attended with a little fever and restless-
ness, for which he could assign no cause, nor was he relieved  by the
usual remedies prescribed in such cases.  A violent gonorrhcea came
on, and these symptoms went off, which appeared to me to explain the
case.  The second time it was a month from the time of infection before
the gonorrhoea  appeared, and for  some weeks of that time he was
subject to a similar indisposition, which went off as before when the
running came on.  Here it would appear that we have something of
a suppurative fever, which, perhaps, often happens in this disease; but
the inflammation being small, and the fever  therefore inconsiderable,
it is commonly little noticed by the patient.  The above  gentleman,
not suspecting any such complaint in the first attack, had  connection
with his wife as usual, and was afraid, when the disease appeared, that
he might have given it to her; but she never complained, which is  a
strong circumstance in confirmation of the principle laid down above,
that it  cannot be communicated but by matter.2
  These constitutional sympathies from local specific diseases are the
same, from whatever  cause  they proceed; they  are the sympathetic
effects of irritation or of violence;  and it  is probable that all remote
sympathies are, at least in this respect, similar; for if they were simi-
lar to their cause, it is most probable that they would produce in the
constitution the  same  kind of disease that gave rise to them.3
                      CHAPTER  I.V.

              OF THE CURE  OF THE GONORRHCEA.

   From the idea which I have endeavored to give of the venereal dis-
ease in general, namely, that,  in whatever form  it appears, it always
arises from the same cause, it might be supposed  that, since we have a
specific for some of the forms of the disease, this specific should  be a
certain  cure for every one, and therefore that it  must be  no difficult
task to  cure the disease when in the form of inflammation  and suppu-
ration upon the secreting surfaces of any of the ducts or outlets of the
body.   But from experience we find the gonorrhoea the most  variable
in its symptoms while  under a  cure, and the  most  uncertain  with

  1 The case is mentioned before, p. 76.
  2 That  this husband should have confidence in his wife, was natural  and even for-
tunate ; but that Hunter should share the  confidence of the husband, was neither
natural nor scientific.—Ricord.
  ' What Hunter says of the effects of gonorrhoea on the constitution in both sexes
is perfectly just, and conformable to rigorous observation. They are additional reasons
for believing gonorrhoea and chancre two entirely different affections.—Ricord. 
110
GONORRHCEA.
respect to its cure, of any  of the forms of this disease;  many cases
terminating  in a week, while others continue  for months, under the
same treatment.
   The  only  curative object is to destroy the disposition  and specific
mode of action in the solids of the parts;  and, as that is changed, the
poisonous quality of the matter produced will also be destroyed.  This
effects the cure of the disease, but not always of the consequences.
   I have already observed that this form of the disease  is not capable
of  being continued beyond a certain time  in any constitution, and
that, in cases where it is violent, or lasts long, it is owing to the parts
being very susceptible of such irritation, and readily retaining it.   As
we have  no  specific medicine for the gonorrhoea, it is fortunate  that
time alone will effect a cure; it is therefore very reasonable to suppose
that every such inflammation ceases of itself; yet, although this appears
to be nearly  the truth, it is worthy of consideration whether medicine
can be of any service in  this form of the disease.  I am inclined to
believe it is very seldom of any kind of use, perhaps not once in ten
cases; but even this would be of some consequence if  we could dis-
tinguish the  cases where  it  is of service from those where it is  not.
Upon  the idea  that  every gonorrhcea cures  itself, I gave certain
patients pills of bread, which were taken with great regularity.1   The
patients always got well; but some of them, I believe, not  so  soon as
they would have done had  the  artificial methods of cure been em-
ployed.
   The methods of cure hitherto recommended, and still followed by
different  people  of the  profession, are of two kinds.  They consist
either of  internal remedies or local applications.   But in whichsoever
of these two ways this disease is to be treated, we are always to  pay
more attention to the nature of the constitution,  or to any attending
disease  in the parts themselves, or parts  connected with them, than to
the disease itself.
   The nature of  the constitution is principally to be learned from the
local effects;  for  the local effects of this poison are so different in dif-
ferent  people as to require great variety of treatment; but  this has
been too little attended to, every one endeavoring to attack the imme-
diate symptoms, as if he had a specific for a gonorrhoea.
  The first thing to be considered  is the nature of the  inflammation,
whether violent or mild, whether common or irritable.  Yet even when
this is ascertained, we have not in all  cases the cure in our power; for
I have already observed that some people are very susceptible of'this
irritation  who are, as it  were, insensible to others; and, on the con-
trary, many  are easily  affected by common inflammation who  are
insensible to  this.   These last are rather uncommon dispositions, and

  i We are constantly astonished at seeing Hunter confound gonorrhoea and chancres
together, although he was so well aware of the differences which exist between these
two diseases m  respect to their pathology and  therapeutics. But Hunter found certain
points of resemblance, which necessarily deceived him, because he was not acquainted
with masked chancres.  It may be said, contrary to Hunter's views, a chancre oftener
gets well alone than a gonorrhcea.  A gonorrhcea almost always requires the interven-
tion of art and the results of treatment are very satisfactory.  If we have no specifics
for gonorrhoea, we have very powerful special remedies.—Ricobd          b^bbium 
TREATMENT.
Ill
the cure  being always easy, they demand little attention.  When the  '
symptoms are violent, but of the common inflammatory kind, which
is to be  collected .from the attending circumstances, particularly the
extent  of the inflammation not exceeding the specific distance, the
local mode of  cure may be either irritating or soothing,  Irritating
applications in the present case may be attended with less danger than
in the  irritable inflammation,1 and may alter the specific action; but
to produce this effect it must  be greater than the irritation from the
original injury.  The  parts  will afterwards recover of themselves, as
from any other common inflammation.  After all, however, I believe
the soothing  plan is the best at the beginning.  If the inflammation
be great,  and of the irritable kind, no violence is  to be  used in the
cure (for  it will only increase the symptoms), unless we know that the
great degree  of inflammation  arises entirely from  a susceptibility of
this irritation, and that there is no general irritability  in the constitu-
tion, which seldom can be ascertained.  In cases where the symptoms
run high, nothing should be  done that may tend to stop the discharge,
either by internal or external means;  for nothing would be gained
thereby, as we  may stop the discharge and not put  an end to the
inflammation.  The constitution is to be altered, if possible, by reme-
dies adapted to each disposition, with a view to alter the actions of the
parts arising from such dispositions, and reduce the disease to its simple
form.   If the constitution cannot be altered, nothing is to be done but
to allow the action to wear itself out.
   When  the inflammation has Considerably abated, and the disease
only remains in a mild form, its cure may be attempted either by in-
ternal remedies or  local applications.  If a local cure be attempted,
violence is still to be avoided, because it may bring back the irritation.
At this period gentle astringents  may be  applied with a prospect of
success;  or, if the disease has begun mildly, and there are no  signs of
an inflammatory disposition, either of the common kind or the irritable,
in order to get rid of the specific mode of action quickly, an irritating
injection  may be  used, which will increase the symptoms for a time,
but when it is left off they will  often  abate or  wholly disappear. In
such a state of parts, astringents may be  used ; for the only  thing to
be done is  to procure a cessation of the discharge,  which is now the
principal  symptom.2
   In those cases where the itching, pain, and other uncommon sensa-
tions are  felt for some time before the discharge appears, I should be

  1 It is very difficult to give clear ideas of distinctions in disease when they are not
marked by  something permanent as to time, space, &c. I have used the term "irri-
table inflammation," because  I think this kind of  inflammation takes place more in
weak, irritable habits than in  others;  it appears to be guided by  no law  that I am
acquainted with. It may be called an ill-formed infiammation, as not going through
the usual process to a natural termination, but continuing with little variation; and
if such inflammation were to  take place in the oellular membrane, it would rather
produce an oedematous swelling than such as arises from the extravasation of coagu-
lable lymph, which takes place in what I would call the true inflammation.
  2 Added: "It  is very common when the discharge is stopped by an injection, even
of a mild kind, to have an uneasy sensation in the perineum, and continued on to the
bladder, producing frequency  in making water, and. on the  return of the  discharge
these sensations  immediately cease."—Home. 
112
GONORRHCEA.
inclined to recommend the  quieting or soothing plan instead of the
irritating, with a view to bring on the discharge, as that effect is a step
towards a resolution of the irritation ; but how far it would really be
the proper plan I cannot  absolutely say, not having had experience
enough in  such cases.  One thing, however, I think I may assert from
reasoning,  that to use astringents would be bad practice, as they would
rather tend to prevent the discharge from taking place, which might
prolong the inflammation and protract the cure.   In cases of stricture,
or in cases of diseased testicles, I believe astringents should not be
used;  for we find in either case, while the discharge lasts, both com-
plaints are relieved: therefore, in such cases, we should proceed with
more caution than when all the parts are otherwise sound.  If we had
a specific for venereal gonorrhcea, it would still be a question whether
this  specific could cure the irritation before the full action had taken
place.

   § 1. Of the different Modes of Practice.—Evacuants—Astringents.

  The internal remedies commonly recommended in a gonorrhoea may
be divided into evacuants and astringents.  The evacuants are princi-
pally of the purgative or diuretic kind, and these  not confined to any
particular medicines; for every practitioner supposes that he is in pos-
session of the best.   Some use mercurial evacuants, while others care-
fully avoid mercury in every form.  The neutral salts have been given,
from the idea of their being cooling.   Some of the profession  have
kept principally to diuretics, perhaps  with  two views, as  evacuants
acting upon the urinary passages mechanically, to wash off the vene-
real  matter, or as specifics for the latter purpose; nitre has been given
with this view; besides, it has been supposed to lessen inflammation;
but its virtues in this way I very much doubt.  Under these different
modes of treatment the patients always get well, and the  cures are
ascribed by each practitioner to his own method of treatment.
  To keep the body open  in most cases, even when the patient  is in
other respects in health, must no doubt be proper;  but what idea can
we form of an irritation, produced all along the intestinal canal, curing
a specific inflammation in the urethra ?  Yet there are cases where a
brisk purge has been of service, and even in some has  performed a
cure.  But I suspect that in such cases the disease has been continued
by habit only, and that this practice would not have succeeded in the
beginning.   A gentleman had a gonorrhoea, all the symptoms of which
continued for two months, and by taking at once ten grains of calomel
which purged him most violently, he was almost immediately cured!
The  calomel could not  have acted specifically, but by a kind of deriva-
tion  ; that is, an irritation produced in one part cured one  that sub-
sisted in another.   But, even if  it should be granted that  in  some
constitutions purges have the power of making the  solids less suscep-
tible of this irritation, it cannot be supposed they will have this  effect
in every case; in  some constitutions they might debilitate, increase
irritability, and of course  increase the symptoms.  These' contrary
effects must take place in different constitutions in which a medicine 
treatment.                      113
has no specific action.  On the supposition of the cure being promoted
by an evacuation from the blood, what service can purging  out some
of the blood in form of a secretion from one part do to an inflammation
of another part?  On such a supposition, would not a sweat, or an
increase of saliva by chewing tobacco, or stimulating the nose by snuff,
all tend equally to cure a gonorrhoea?  But humors have been con-
sidered as the universal cause of every disease, especially those in
which  pus is  formed or  a discharge produced, and purging  having
been supposed to be  the  cure for  humors, purgatives were  of course
made use of in  this disease; and  as the patients  have always been
cured,  the practice became generally established.
  Those who  recommend mercury in this form of the disease, did it
most probably from the opinion that this medicine was a specific for
the venereal disease in all its forms.  On this supposition, we can see
some reason for their  practice, as it would be absorbed from  the intes-
tines, circulate through the inflamed vessels of the urethra, and thereby
destroy the venereal irritation.  Here we can only suppose it to act by
its specific virtue;  but  I doubt very much of mercury having  any
specific virtue in this  species of the disease, for I find that it is as soon
cured  without mercury as with it; and where  this medicine is only
used as a purge, or purged off the next day, and therefore allowed to
act merely upon the bowels, I cannot conceive that it could have any
more  effect upon the venereal inflammation in the urethra than an
irritation in the bowels arising from any other purgative.  So little
effect, indeed,  has this medicine upon a gonorrhoea, that I have known
a gonorrhcea take place while under a course of mercury sufficient for
the cure of a chancre.  Whether the gonorrhoea arose  from the same
infection that  produced the chancre I cannot say; nor can it be easily
determined in such cases.  Men have also been known to contract a
gonorrhoea when loaded with mercury for the cure of a lues venerea;
the gonorrhoea, nevertheless, has been as difficult of cure as in ordinary
cases.1
  A gentleman committed himself to  my care, on  the 27th of June,
for the cure of two chancres and a bubo.  I dispersed the bubo;  but
as he disliked  the unction I was obliged to substitute mercurius calci-
natus daily instead  of it, giving two grains in the evening and one in
the morning.  About the middle of July his mouth became sore,  and
the mercury was left off; we began its use again in a week, and he
appeared  to be quite well of his venereal complaints.  I, however,
continued the use of mercury, keeping his  mouth sore; on the 16th
of August, while in this  state, he had a  connection with a woman,
both on that and the following evening, and  in five days after a gonor-
rhoea appeared, and proved to be very violent.2
  The same general  observations may be  made with regard  to  the
effects  of  diuretics,  considered as evacuants.
  It is possible that specific medicines taken into the constitution (if

  1 And that, because gonorrhoea and chancre are two different diseases.—Ricord.
  2 Added: " Another gentleman, while under a  course of mercury for the cure of
chancres, had connection with a woman before he  left off the use of mercury, and in
two days a gonorrhcea made its appearance."—Home.
       8 
114
GONORRHCEA.
we had such), and passing off by the urine, might act upon the urethra
in their passage through it.  The balsams and turpentines pass off in
this way, and become specifics for  many irritations in the  urinary
passages; but how far medicines which have the power  of affecting
particular parts when sound, or when under diseases peculiar to those
parts, have also the power of affecting a specific  irritation in these
parts, I know not; but do not believe that they have any considerable
power in this way.   It is possible, however, that they may  remove
any attending irritation, although not the specific one.1   Diuretics
have, nevertheless, their advantages, for  if they produce  a  greater
quantity of water they do good; but I believe this had better be effected
by simple water, or water joined  with  such things as will encourage
the patient to drink a good deal; as tea, syrup of capillaire, orgeate,
and the like.
   Astringents, although often given, yet have always been condemned
by those who have called themselves the judicious and regular practi-
tioners ;  because, according to them,  there is  something to be carried
off, and if that is not  carried off  a lues venerea is to be the conse-
quence.  This reasoning is not just;  and therefore the question to be
considered is, do they or do they not assist us in the cure of the gonor-
rhoea ?   I believe they do not, in any case, lessen the venereal inflam-
mation ;  but certainly they often lessen the discharge.  As that effect,
however, does not constitute  a cure, it is not necessary to produce it.
   I can conceive that a combination of astringents, especially the
specific astringents of those parts, as  the balsams, with any other
medicine which may  be thought to be of service, may help to lessen
the discharge in proportion  as  the  inflammation abates; and this I
have often seen, as will be explained  more at length hereafter.


 § 2.  Of Local Applications—Different Kinds of Injections; Irritating,
                   Sedative,  Emollient, Astringent.

   Local  applications may be either internal to the urethra, external to
the  penis, or both;  all  of which will in many cases be necessary.
The internal, applied  to the urethra,  should seem  the  most likely to
cure this species of disease,  by coming immediately in contact with
the diseased parts; for if they have any power of action, whatever
that be, it must be in opposition to the venereal irritation.  Therefore,
we might suppose that most  irritations that  are not venereal would
tend to a cure;  but certainly this is  not universally the case.  If, on
the contrary, the applications are such as quiet  irritation, they must
also be of service.
   Local applications  to the urethra  may be either in a solid or fluid
form, each of which has its advantages and disadvantages.   A fluid is
only a temporary application, and that of very short duration, and is
similar to the washing  of a  sore, which is, I believe, in most cases

   « The special action of the balsams on the urethra, is an established fact.  As I
have experimentally demonstrated, it is the urine, charged with the active, specific
elements of copaiba and cubebs, which acts locally on the urethra —Ricord 
treatment.                       115
unnecessary; for I imagine that matter from any sore whatever is
always such as cannot stimulate that sore into any action.   It can be
of no consequence, therefore, whether the matter is allowed to lie upon
it or not;  but it being removed, the medicines are allowed to come in
contact with the inflamed surface.   I apprehend it is only in this way
that the removal of it can be of service.  The solid applications may
remain a long time, and are similar to the  dressings in the case of a
wound.   When  the parts are not so much inflamed as to prevent the
use of them, they would appear to  have an advantage  over the  fluid
applications by continuance; but they in general irritate immediately,
in consequence of their  solidity alone.  These applications must be in
the form of a bougie; but  I should be inclined to suppose that the
less use that is made of bougies, when these  parts are in an inflamed
state, the better, although I cannot say that I  ever saw any bad effects
from them in any case, when  applied with caution.
  Fluid applications to  the inside of the urethra are commonly called
injections, and, like the  internal remedies, are without number; every
practitioner thinking, or wishing to make the world think, that his
own is the best.  But, as every venereal inflammation  is frequently
removed under  the use of injections of various kinds (which was
observed with respect to internal medicines), have we not here a strong
corroborating  circumstance in  favor of an opinion  that every  such
complaint will in time cure itself?  I think, however, it appears  from
practice, that an injection will often have almost  an  immediate effect
upon the symptoms, and that, therefore, they must have some powers;
and yet the kind of injection which would  have the greatest specific
powers  I believe is not yet  known;  if an injection has no specific
powers, it must  be very uncertain  in its effects,  and can only  be of
service as far as it may  be  adapted  to a peculiarity of constitution  or
parts. As injections are only temporary applications, it becomes neces-
sary to use them often, especially in cases where they are found to be
of service;  they should therefore be applied as  often as convenient,
perhaps every hour, or  even oftener;  but this must be regulated, in
some measure, by the kind of injection, for if it  be irritating it will
not be proper to use it so often, as it may be productive of bad conse-
quences.
  Many injections immediately, or at least soon after the application,
remove  the symptoms, and prevent  the formation  of matter, which has
given rise to the notion of their shutting up  the disease, and driving
it into the constitution;  but this supposed  mode  of producing a con-
stitutional complaint is the reverse of what really happens, for I have
already  endeavored  to  prove that matter  is the only  substance in
which the poison is contained, and that the  formation of the poison is
inseparable from the formation of matter; therefore, if we can prevent
the one, the other  cannot take  place, and of  course  there can  be no
room for  absorption; so that  there  can neither be any power  of
infecting the constitution in the same  person, nor of communicating
the infection to others.1

    1 Vide, p. 43, what was said of the method of contracting the lues venerea. 
116
GONORRHCEA.
  When the discharge is an effect of present inflammation, it may be
stopped by injections, though the inflammation still continue in some
degree, and  may afterwards be removed without the discharge ever
reappearing.  But I believe that by this  practice little is gained, for
the effect of the inflammation is not the disease which we wish to
remove.  However, we find that the same method which  stops the
discharge also removes the inflammation, although not always, and
only I believe when the inflammation is slight.
  I shall divide injections, according to their particular effects upon the
urethra, into four kinds; the irritating, sedative, emollient, and astrin-
gent.   The specific,  I believe,  is  not yet  discovered,  although  a
mercurial injection, in some form  or other, is by most people supposed
to be  possessed  of such a  power, and of  course this mineral makes
part of many of  the injections now in use.
  Irritating injections, of whatever kind, I suspect  in this disease act
upon the same principle; that is, by producing an irritation of another
kind, which ought  to be greater  than the venereal, by which means
the venereal is destroyed and lost, and the disease  is cured, although
the pain and discharge may still  be kept up by the injection.  Those
effects, however, will soon go  off  when  the  injection  is laid  aside,
because they arise  only from  its irritating qualities.  In  this way
bougies, as well  as many injections,  may be supposed  to form a cure;
and although they increase the  symptoms for the time, they never
can increase the  disease itself, any more than the same injection which
would produce  the same  symptoms,  if applied to the urethra of a
sound man, can communicate  the  disease.   Most of  the  irritating
injections have  an  astringent  effect,  and  prove simply astringents
when mild, their irritating quality  depending chiefly  upon  their
strength.
  As irritating injections do not agree with all inflammations arising
from the venereal poison,1 it may be asked, In what cases are the irri-
tating injections to  be used with advantage?   This I have not  been
able to determine absolutely; but I think irritating injections should
never be used where there is already much inflammation, especially in
constitutions which cannot bear a great deal of irritation, as a previous
knowledge of the disease in the  same person sometimes teaches us;
nor should they be used where the  irritation has spread beyond the
specific distance; nor where the testicles are tender; nor where,  upon
the discharge ceasing quickly, they  have become sore; nor where the
perineum is  very  susceptible  of inflammation, and especially if  it
formerly has suppurated;  nor where there is a tendency in  the  blad-
der to irritation, which is  known from the patient having had for
some  time a frequency in making water.   In such cases I have not
succeeded with  them; they not only do no good, but  they often do
harm, for I have seen them make the inflammation spread farther in
the urethra ;a and I think I have  had reason to suspect that they have

  1 For I have already  remarked, that the inflammation varies according to the con-
stitution.
  2 It is, however, to be remarked, that this symptom is not always to be attributed
to the injection, for it often happens when none has been used. 
treatment.
117
been the cause of abscesses in perinaso.  But in cases that are mild, and
in constitutions that are not irritable, injections often succeed, and
remove the disease almost immediately. The practice, however, ought
to be attempted with caution, and not, perhaps, till milder methods
have  failed.   Two  grains of  corrosive sublimate, dissolved in  eight
ounces of distilled water, are nearly as good an injection as any of the
kind.  But an injection of only half this strength may be used  where
it is  not  intended  to  attempt a cure ' so quickly.  If, however, the
injection, even  in  that proportion,  gives  considerable pain  in its
application, or if it occasions a great increase of pain in making water,
it should be diluted.
  Sedative injections will always be of  service in cases  where the
inflammation is considerable;  not by lessening the disease itself, but
by  lessening  the diseased  action, which always allows the natural
actions of the part  more readily to  take place.  They are likewise
very useful in relieving the painful feelings of the patient.  Perhaps
the best sedative we have is opium, as well when given by the mouth
or anus, as when applied to the part  affected in the form of an  injec-
tion.   But even opium will  not  agree, or act as a  sedative,  in all
constitutions or parts.  On the  contrary, it  has often  opposite effects,
producing great irritability.   Lead may be reckoned a sedative, so far
as it abates  inflammation, while  at the same time it may act as a
gentle astringent.  Fourteen  grains  of saccharum saturni, in  eight
ounces of distilled water, make a good sedative astringent injection.
  The drinking freely of diluting liquors may, perhaps, be considered
as having a sedative effect,  as it in part removes some of  the  causes
of irritation, rendering the urine less stimulating, either to the bladder
when the irritation  is there, or  to the urethra in its passage through
it;  and it is  possible that  diluting may lessen  the susceptibility  of
irritation. The vegetable mucilages  of certain seeds and plants, and
the emollient gums, are recommended; but I suspect that this practice
is founded on a mechanical  notion, and that none of them are of much
service.   I believe the advantage arises chiefly from  the quantity of
water that is drunk, and that if  the water be joined with anything,
spirits excepted, that can induce the  patient to drink freely, the pur-
pose  is  fully answered.  I have, however,  been informed by some
patients, that they have thought that when the liquids they  drank
have been impregnated with  mucilaginous substances, they have had
less uneasiness in making water.
   Emollient  injections are the properest applications where the inflam-
mation is very great.  They are most probably useful by first simply
washing away the matter, and then leaving a soft application  to the
part, in which way I can conceive them to  be of singular service, by
lessening the irritating effects of the urine.  Indeed,  practice proves
this; for we often find that a solution of gum Arabic, milk and water,
or sweet oil,  will lessen the  pain and other symptoms,  when the more
active injections have  done nothing, or  have seemed to  have done
harm.
  It very often happens that the irritation is so great  at the orifice of
the urethra that the point of the syringe cannot be suffered to  enter. 
118
GONORRHCEA.
When this is the case, nothing should be done in the way of injection
till the inflammation abate.  Emollients may likewise be used exter-
nally, in form of fomentation.
  The astringent injections can only act by lessening the discharge.
They can have no specific effect upon the inflammation;  but, as they
must affect the actions of the living powers, it is possible they may alter
the venereal disposition.  They should only be used towards the latter
end of the disease, when it has become mild, and the parts begin to itch.
But this should be according to circumstances, and, if the disease begins
mildly, they may be used at the very beginning; for by gradually lessen-
ing the  discharge, without  increasing the inflammation,  we complete
the cure, and prevent a continuation of  the  discharge called a gleet.
Injections of this kind  very probably stimulate  in such a way as to
make the vessels of the part contract, and probably hinder the act of
secretion.   We can hardly suppose that they act  chemically by coagu-
lating the juices.  They will have an irritating quality if used strong,
which in some measure destroys their astringency, or rather makes the
parts act contrary to what they would do from the application of a simple
astringent.   Thus, they  often increase the discharge, instead of lessen-
ing it; by which means the disease also may be cured, in the same way
as by irritating injections, that is, by altering the disposition of the in-
flammation.  When more mild they often stop the discharge, without,
however, in all cases, hastening the  cure;  for the inflammation may
still continue even longer  than it otherwise would have done if the
tendency to secretion had not been stopped.  I have already observed,
that a surface that discharges has assumed the complete action of the
disease, which is one step towards a cure or termination.  However, it
sometimes happens that an astringent injection will cure  a  slight irri-
tation in a very few days.   My experience has not taught me that one
astringent is much better than another.
  The astringent gums, as dragon's-blood, the balsams, and the turpen-
tines,  dissolved in water; the juices of many vegetables, as oak bark,
Peruvian bark, tormentil root;  and perhaps all  the metallic salts, as
green, blue, and white vitriols, the salts of mercury, and also alum, pro-
bably all act much in the same way, although we may assert that they
do not always act equally well in every gonorrhoea, for, on our chang-
ing the injection, we sometimes succeed after several others have been
tried  in vain.
  The external applications are generally poultices and fomentations,
but they can be of little service, except when the external parts, such
as the prepuce, glans, and orifice of the urethra are in some degree in-
flamed ; the- last, indeed, is almost always more or less affected.
  When the glands of the urethra are so much swelled as to be felt
externally, the application of mercurial ointment to the part may be
proper; but most probably this will be of more service after the inflam-
mation has subsided.  Indeed, mercurial  ointment is often applied to
all the external surfaces of those parts when in a  state of inflammation,
with an emollient poultice over it.  I am not perfectly satisfied of the
utility of this practice. 
TREATMENT.
119
                      CHAPTER  V.

          OF  THE  CURE OF  GONORRHCEA IN  WOMEN.

  In women, the cure of the gonorrhcea is nearly the same as in men;
but the disease itself is milder, and the secondary symptoms less nume-
rous in women.  This arises from there not being so many parts to be
affected, and from those parts not being either of so great extent, or so
liable to inflammation.  Hence the cure becomes more simple.
  When the disease is in. the vagina only it is easily cured.  Injections
are the best means that can be used, and, after the use of them, it may
be proper to anoint the parts, as far up as possible, with mercurial oint-
ment,1 and also to wash the external parts often with the injection.
  If the inflammation has attacked the urethra, injections there cannot
be so conveniently  used, as it  is almost  impossible for the  patient to
throw  an injection into that canal.
  The injections recommended in the cure of men are equally service-
able here; but they may be made doubly strong, as the parts of women
are not nearly so irritable as the common seat of this disease in men.
  If what I have said of the  disease  in women be just, we  must see
that it will be a difficult thing to say, with any degree of certainty,
when the patient is well; because whenever the symptoms have ceased,
the surgeon and the patient will naturally suppose the cure to be  com-
plete; but a new trial of those  parts may prove the contrary, or in cases
where the disease has never affected the urethra, but only the vagina,
and still more where no symptoms have ever been observed, it will be
more difficult to fix the date of the cure; but general experience  must
direct the practitioner.
  When the inflammation runs along the ducts of the glands, whether
those of the mouth of the vagina or urethra, or affects the glands them-
selves, the same  method is to be followed; in particular, the mercurial
ointment is to be freely applied to the parts.  If the inflammation on
the mouths of the ducts is so great as to shut them  up, the duct and
glands will suppurate, and form abscesses; in such cases  it will be
necessary to open them, or enlarge the opening  already formed, and
dress the abscess as a chancre  or bubo.
  In the case of a simple running, the constitutional treatment will be
taken notice of hereafter; but  if any suppuration follow, the constitu-
tion is to be treated as in chancres or buboes, for most probably absorp-
tion will take place, and its effects must be guarded against.

  1 How far mercurial ointment assists in the cure, I have not been able to determine ;
the use of it arises more from a kind of practical analogy than real experience in such
cases. 
120
GONORRHCEA.
                     CHAPTER  VI.

OF THE TREATMENT OF THE CONSTITUTION IN THE  CURE OF
                       THE GONORRHCEA.

  In the cure of the gonorrhoea, the constitution is in some cases to be
as much attended to as the parts affected, if not more; but in general
this is not necessary.  The knowledge of the constitution is to be ob-
tained in a great measure from the local symptoms; and as far as the
constitutional treatment can  be made similar, to the local, they should
correspond.
  We find in many strong plethoric constitutions, where both the powers
and actions are great, that the symptoms are violent.  These constitu-
tions have  generally a strong tendency to fever of the inflammatory
kind; and probably the most distinguishing mark of such a constitu-
tion is that of the symptoms not extending beyond the specific distance.
Many medicines which might be of service in another constitution will
often prove hurtful here, insomuch as to increase the very symptoms
which they are meant to relieve.   I have seen  even opiate clysters,
though they relieved at first, yet in the end produce or increase fever,
and by that means increase all the symptoms.  I have seen the balsam
capivi, given in such cases, increase the inflammatory symptoms, pro-
bably by stopping the  discharge in part, which appears to be salutary.
The treatment of  such a constitution, when affected with this disease,
consists chiefly in evacuations, the best of which are bleeding and gentle
purging.  To live sparingly, and above all to use little exercise, is
necessary;  for although such a treatment does not lessen the venereal
irritation, yet it lessens  the violence of the inflammation, and allows
the parts to relieve themselves. In this kind of constitution, therefore,
the disease is in the end soonest cured, as there is not a tendency to a
continued inflammation.
  In the weak and irritable constitution the symptoms are frequently
very violent, arising from great action in the parts, and often extend
beyond the specific  distance, the inflammation running along the ure-
thra, and even affecting the bladder.  Instead of evacuations, which
would rather aggravate the symptoms than relieve them, the constitu-
tion should be strengthened, and thus it will be less susceptible of irri-
tation in general.
  I have seen patients whose constitutions were  such that they were
never sure of twenty-four hours' health, where the inflammation  has
been both considerable and extensive.  I have seen evacuations  tried,
and the symptoms increased; but as soon as the bark was given freely
they have become almost immediately mild,  and without  usino- any
other medicine the patients have soon recovered.  The medicine here 
TREATMENT.
121
acted upon the constitution, destroyed the irritability, gave the parts a
true and healthy sense of the venereal irritation, and brought the in-
flammation to that state in which it ought to be in a healthy subject,
whereby the constitution was enabled to cure itself.
  So capricious sometimes is this form of the disease in its cure, that
the accession of an accidental fever has stopped the discharge, the pain
in making water has ceased, and the gonorrhoea has finally terminated
with the fever.  In others, I have seen all the symptoms of the gonor-
rhoea cease on the accession of a fever, and return when the fever has
been  subdued.   In some, I have seen  a gonorrhoea begin mildly, but a
severe fever  coming on, and continuing for  several days, has greatly
increased the symptoms, and on the fever going off' the gonorrhoea has
also gone off.  Although a fever does not always  cure a gonorrhoea,
yet, as it possibly  may, nothing should be done while the fever lasts;
and if it continues after the fever is gone, it is then to be treated ac-
cording to the symptoms.1.
  Unfortunately, there are cases where no known method lessens the
symptoms; evacuations have produced no abatement; the strengthen-
ing plan has been  as unsuccessful; sedatives and emollients have pro-
cured no relief; and time alone has performed the cure.  In such cases
the soothing plan, I believe, is the best, till we know more of the disease.
Astringents should not be used, their action upon the inflamed  parts
being uncertain; for they often do not lessen the inflammation or the
pain, although they may perhaps lessen  the discharge.  The turpen-
tines, especially the balsam capivi and Canada  balsam, lessen the dis-
position of the parts to form matter, which effect has always a salutary
appearance;  but as they have not at the same time the power of lessen-
ing the inflammation, they can be of  little service.
  Besides the various effects arising from the difference of constitution
in the gonorrhoea, we find that it is considerably affected by the patient's
way of life during the inflammatory state, and also by other diseases
attacking the constitution at the same time.  But this is common to all
other diseases, for whenever we have  a local disease (in which light I
have considered a gonorrhoea) it is always affected by whatever affects
the constitution.   Most things that hurry or increase the circulation,
aggravate the symptoms; such as violent exercise, drinking too much
of strong liquors, eating strong indigestible food, some kinds  of which
act specifically on these parts, thereby increasing the symptoms more
than by simply heating the body;  such as peppers, spices, and spirits.
  From what has been said in general, it must appear that  a gonor-
rhoea is to be cured in the same way as every other inflammation; and
it must also appear that all the methods used are only to be considered
as correctors of irritation in  general, and  of  disordered circulation.
In cases that have begun mildly, where the inflammation has been but
slight, or in those cases where the violent  symptoms above taken notice
of have subsided, such medicines as have a tendency to lessen the dis-

  1 Added : " A gentleman, while using an injection for a gonorrhoea, was seized with
a vomiting and purging, which brought on a fit of the piles ; they bled profusely ; as soon
as he recovered from these attacks he found that all the symptoms of gonorrhoea had
gone away."—Home. 
122
GONORRHCEA.
charge may be given, along with the local remedies before mentioned.
The turpentines, I believe, are the most efficacious.  Cantharides, the
salts of some metals, such as of  copper, zinc, and lead, and also  some
earths, as alum, are strongly recommended as astringents when given
internally.
   Whatever methods are used for the cure, locally or constitutionally,
it is always necessary to  have in view the  possibility of some of the
matter being absorbed, and afterwards appearing in the form of a lues
venerea, to prevent which I should be inclined to give small doses of
mercury internally. At what time this mercurial course should begin,
is not easily ascertained;  but if the observation be just, that a dispo-
sition once formed is not to be cured  by mercury, but that mercury
has the power of preventing a disposition  from forming, as was for-
merly explained, we should begin early, and continue it to the end of
the disease, till the formation of venereal matter ceases, and even for
some time after. The mercurial ointment may be used where mercury
disagrees with the stomach and intestines.
   This practice appears  to be more necessary if the discharge haa
continued  a considerable time,  and especially if the treatment has
been simply by evacuants; for, in the  former case, there is  a  greater
time for absorption; and in the latter we may suppose a greater call
for it, such medicines having no  effect in carrying off the virus.
   To prevent a lues venerea being produced from absorption, a grain
of mercurius calcinatus taken every night, or one at night and another
in the morning, may be sufficient, but should be continued in propor-
tion to the duration of the disease.
   The success  of  this practice in any particular  case can never be
ascertained, because it is impossible to  say  when matter has  been
absorbed, except in cases of buboes; and where it is not known  to be
absorbed, it is impossible to say that  there would have been a lues
venerea if  mercury had not been given, as very few are infected from
a gonorrhoea, although they have taken no mercury.  It is, however,
safest to give mercury, as we may reasonably suppose it  will  often
prevent a lues venerea, as it does when given during the cure of a
chancre or bubo, where we know, from experience, that without it the
lues venerea would certainly take place.
   [G. G. B.—The  principles which the author has laid down for the
treatment of gonorrhoea, though generally correct, yet require  some
modification.  In one or  two instances he seems to have been misled
by opinions, which are at the least very questionable.
   It is pretty well established  that a course of mercury  is  neither
necessary nor useful in a gonorrhoea; it has no peculiar influence on
the course of  the  disorder, and  it is an error to suppose that it is
necessary for the  sake of preventing secondary symptoms; and this
is equally true, notwithstanding the occurrence of suppuration in the
glands of the urethra, or  in the  groin, or of breach of surface  from
any other cause.  At the same time mercury is not particularly hurt-
ful, except it be given in  such doses and  for such a length of time as
would materially depress the general tone, render  the  urine alkaline,
or induce universal irritability of the system. 
TREATMENT.                       123
  From the opinion, " that no matter of whatever kind can produce
any effect on the part that forms it"  (see p. 74), the author has been
led to disregard  altogether the discharge  of gonorrhoea, and to  con-
clude that, in no degree, and under no circumstances, is the inflamma-
tion  increased by its stimulus, or  relieved by arresting it.  This
doctrine, however, seems  scarcely consistent with experience.  It is
difficult to understand the effects of astringents in the early periods of
the disorder, except on the supposition that, by arresting the discharge,
they relieve the urethra from the stimulus of the virus, and thus take
away the  very  cause of  the inflammation.  Again,  the  distinction
between venereal gonorrhoeas and simple  purulent discharges, which
are not derived from infection, is to be  found less in the severity  of
the symptoms than in their obstinacy.  The urethra is often attacked
with inflammation as violent as  that  of gonorrhoea, in cases where
there has been no possibility of infection.  The discharge  may be  as
copious, and  exactly similar both in color and  appearance.  But  in
these cases the  inflammatory symptoms will in a few days sponta-
neously subside,  and the discharge will diminish with it; whereas the
inflammation and discharge  of  a  gonorrhoea  shall, under similar
circumstances, continue for weeks, or even months, without any visible
abatement.  Whence this difference, unless that in simple cases the
cause is temporary, and  hence the inflammation which  it has excited
soon exhausts itself; in  gonorrhoeas,  a poison is generated, which acts
as a perpetual stimulus, and constantly renews the excitement which
originally gave rise to the disorder.
  It does  not appear that the plan on which a gonorrhoea should be
treated differs from that which should be adopted in other inflamma-
tions of the urethra.  But it must  be remembered that inflammation
of mucous membranes  generally,  of Schneider's membrane, for in-
stance, or the inner membrane of the bladder, does not require, and is
not benefited by much reduction;  and  that, if the constitution be
rendered  irritable from weakness, these inflammations often become
aggravated and obstinate.   This rule, which is generally applicable to
mucous membranes, is more especially important in all inflammations
of the bladder and urethra, perhaps because depletion tends to change
the state of the urinary secretion, and  to render it alkaline  and irri-
tating.
  The duration and severity of a gonorrhcea depend much on the part
of the urethra which is attacked by it.  There is great variety in this
respect.  In most cases, the inflammation is confined to the neighbor-
hood of the glans; but in many, it involves also the membranous por-
tion, as  may be  shown,  not only by the  symptoms during life, but
also by dissections after death.  If the disease is limited  to the last
three inches of the urethra, it is seldom very violent or tedious;  if it
extends to the bulb and parts  adjacent, the symptoms are more obsti-
nate and distressing.  Except in very rare instances, the disease com-
mences  at the glans.  If it affects the membranous portion, it is by
the progessive extension of the inflammation which gradually creeps
up the urethra.   This extension seldom  occurs until the complaint 
124
GONORRHCEA.
has existed  for a fortnight or longer, and if the cure can be effected
within that time, may almost certainly be avoided.
  The true  principles on which the treatment should  be  conducted
will naturally follow from these considerations.
  If the patient be seen on the first access of the disorder, when the
discharge has only just appeared, and is small in quantity, before the
orifice of the urethra has become turgid, and the passage has become
sensible to the stimulus of the urine, the disease may often be entirely
arrested by astringent injections, or by internal medicines, which have
the property of acting as astringents on the urethra, such as the balsam
of copaiba, or cubebs.  But such a result can  only be obtained when
the inflammatory symptoms have scarcely commenced, and are in the
slightest possible degree.  After the expiration of twenty-four hours,
it is often too late, and generally so at the end of forty-eight hours.
When active inflammation  is present, the stoppage of  the discharge
can seldom be effected completely, and scarcely ever  permanently.  It
may be greatly diminished; but  this diminution rather aggravates
than relieves the inflammation, as it lessens a secretion  which has the
effect of unloading the distended vessels, and the  continuance of the
inflammation will in a short time inevitably reproduce  the discharge
as profusely as before.  It is to be  observed  that it  is  necessary, for
the success of this plan, that the discharge should be  entirely stopped.
If a single drop remains, it will go on to cause inflammation, and the
disease will hold its ordinary course.
  Should the malady be in such a state as to render this  mode of treat-
ment hopeless, it will be necessary to allow it to run its natural course.
A period will arrive when the urethra will become accustomed to the
virus, and the inflammation  will then spontaneously subside.  In the
mean time, the surgeon must endeavor to moderate its violence, by the
removal of  all stimulants which can be avoided.  The chief stimu-
lants  are the urine and  the discharge.   The urine must be rendered
mild, by neutralizing its acidity, and by copious dilution;  and the
discharge  must be moderated by astringent medicines, given in such
doses as will only slightly check the increase of the secretion, without
occasioning  any  immediate or sensible  diminution in its  quantity.
Everything  should be avoided which would  determine to the  parts
affected.   The diet should be light, and rather sparing, and no violent
exercise should be taken; but there is no advantage in rigid abstinence,
or absolute rest, or in any restrictions which would interfere with the
general health, or materially lower the general tone.
  However, should the inflammation extend to the parts surrounding
the urethra itself, or, as Mr.  Hunter expresses it, beyond the  specific
distance, this rule will not always apply.  If there is tenderness and
swelling of the perineum, or inflammation of the neck of the bladder,
a horizontal posture and a  careful regimen may be necessary.   Yet
even here, it is better that blood should be abstracted locally and not
generally, and that the diet should not be much reduced below the usual
standard of  health.
  When the inflammatory symptoms have nearly subsided; when the
ardor urinas and chordee have disappeared;  when the orifice of the 
TREATMENT.                      125
urethra has lost  its red and turgid aspect, and the discharge is  less
profuse and less purulent, astringents may again be given in full doses,
and will generally complete the cure.—G. G. B.]
   [Ricord.—Allow me to give the results of my personal experience.
   Gonorrhcea is  a disease, primarily and  almost always definitively,
local in its character.
   Complications  are sometimes developed in the  neighboring parts,
through continuity or contiguity of tissue; but sympathetic effects at
a distance are very much less frequent.
   The number and  gravity of supervening symptoms are in propor-
tion, not only to the intensity of the primary affection, but also to its
duration.
   Gonorrhoea does not immediately attain its maximum severity; nor
does it run through regular stages, nor last a limited time.
   In spite of Hunter's ideas to the contrary, we are too far removed
from a pure Stahlism, to coincide with the vulgar belief in the neces-
sity of suppuration,  and the need of letting the discharge  run on  un-
checked.  The abundance of the suppuration is in proportion to the
degree of the inflammation, and does not cause a diminution of the
latter.   The  pretended  danger of a rapid  cure, or of driving  in  the
discharge, is imaginary, and the contrary proposition may be proved,
viz:, the more rapid the cure, the more speedy security from complica-
tions.
   It results  from this proposition, that the treatment of gonorrhcea
should  aim to prevent its development; to diminish the  intensity of
its symptoms, when we have been  unable to stop it at the  outset;  and
finally,  in every case, to abridge its duration as much as possible.  It
is necessary, therefore, to divide treatment into abortive, palliative, and
curative.
   The  agents in the abortive  treatment  are direct or indirect.  They
may be employed alone or together.
   Whilst there is as yet no sign  of acute inflammation, on the first,
second,  third, or fourth  day, or even later, we may employ injections
of nitrate of silver, or use this salt in a  solid state, prescribing, at the
same time, cubebs or copaiba internally.   Nitrate of silver  is an excel-
lent and powerful modifier of inflamed  mucous membranes, but  it is
not without its inconveniences; it often excites much pain, and  the
artificial inflammation which it causes  is  sometimes so severe as to
occasion symptoms which, although transient, are  none the less  dis-
agreeable.  I have almost entirely renounced its use.
   If there already exist some degree of inflammation and pain, or these
symptoms appear under the influence of injections, we should abandon
their use, continuing meanwhile the internal remedies, aided by  diet
and other means, which we will presently indicate.
   As soon as the inflammatory stage is fully established, abortive treat-
ment is no  longer applicable, for it may injure, rather than benefit.
   In this case, we should employ the palliative treatment of the acute
stage, which  may be summed up as follows:—
  General repose  of the  patient, but above all, local repose  of the
affected part; the use of a suspensory bandage, when walking or in 
126
GONORRHOEA.
the upright position; strict diet, proportioned, however, to the strength
of the individual and the  severity of the disease; avoidance of excit-
ants of every kind, particularly, liquors, beer, asparagus, etc.; copious
cooling drinks, suited to the taste of the patient.
  Freedom of the intestinal canal, by means of enemata or  gentle
purgatives;  protracted warm baths, noticing,  however, their effect,
some  patients not supporting them well; local bathing, for the sake
of cleanliness, or for its sedative effect, bewaring, again, lest it occasion
congestion, or favor oedema;  lotions, fomentations, cataplasms, follow-
ing the same rules.
  Local  bloodletting, when the disease  is free from  general reaction;
venesection  in the  opposite  condition.   In the first case, giving the
preference to leeches, they should be applied as near as possible to the
diseased  parts, avoiding, in cases complicated with chancres, any slop-
ing parts within reach of the  pus, and in  every case, those regions
where lax cellular tissue favors <?edema, and exposes  the patient to the
severe symptoms of erysipelatous inflammation, and even to gangrene,
which often take place when  leeches are applied to the scrotum, penis,
eyelids, &c.
  When the  acute stage subsides, as  is shown by the diminution or
complete cessation  of pain  in micturition, much more than by the
absence of pain in  erections—which, as Hunter justly observes, may
continue to  be painful a long time after all running has stopped—we
should no  longer persist  in  antiphlogistic treatment, which, far from
curing, in most cases, as has been advanced, tends, on the contrary, to
make the disease pass into an indefinitely chronic stage.
  We should immediately abandon the use of general bathing, which
may not only keep up the disease in this  stage, but even cause its
return, when resumed too soon after a cure.
  A more  tonic regimen should gradually be employed, while anti-
blennorrhagic remedies, properly  so called, are prescribed.  Here, as
in the abortive treatment, two modes present  themselves: the direct
and indirect.
  I. Direct  treatment.—Direct or local  medication should rank first.
The indications which it should fulfil are: to isolate the diseased mu-
cous  membranes, by preventing their coming in  contact;  to oppose
the stay  and stagnation of morbid secretions in the  parts; and to dry
up the discharge.
   The first indication is not easily fulfilled in urethral gonorrhoea,
although I have attempted it with success in many cases, of which I
will hereafter speak. As to the other conditions of direct treatment,
they are specially fulfilled by the use of injections.
   Without seeking or absolutely rejecting a specific in injections, it
is very certain that, among the remedies employed in this form, there
are some which often have a most happy effect.  In this respect, nitrate
of silver has  been  ranked first, its action being so remarkable in  the
treatment of most of the  inflammations of mucous membranes.
   The formula to  which I formerly gave the preference, and which
may be  used in the abortive treatment,  is the same as proposed by
Prof. Serre, of Montpellier, after having witnessed my practice. 
TREATMENT.                       127
                   R.—Argenti nitratis gr. ij;
                       Aquas destillatffi §viij.—M.

  Injections of this liquid should be made with a glass syringe.
  The injections should  be cold, and they should not  be prevented
from  running the whole  length of the canal, in order that they may
reach the diseased part in every case.
  The number of injections a day should be limited; six are generally
sufficient, and  do not  fatigue  the canal.   If, after a day or two, the
running increase, and especially if it become a little bloody, the injec-
tions  are to  be suspended.  After which, the morbid secretion  soon
diminishes and dries up, or subsides to that degree of intensity which
it had at first.  In the first case, injections are no longer advantageous;
in the second, they must be resumed.   Sometimes, however, nitrate of
silver, of the strength above mentioned, has little effect on the progress
of the disease; in which case, its strength should be gradually increased
until  one of the results mentioned be produced.
  Dr. Carmichael, in England, in 1841, and Dr. Debeney, in France,
in 1843, proposed caustic injections, of a strength of twelve or fifteen
grains to the ounce, in all stages of gonorrhoea.  This method, strongly
opposed by my learned friend, Dr. Yenot,  of Bordeaux, often has a
happy effect  in  the abortive treatment.   However, I now prefer the
following injections:—

                   R.—Aquae rosae §vj;
                       Zinci sulphatis,
                       Plumbi acetatis, aa gr. xxx.—M.

   The following is another formula, which I have often  used with suc-
cess :—
                    R.—Aquae rosae ^vj ;
                        Zinci sulphatis gr. xv  ;
                        Plumbi acetatis gr. xxx;
                        Tinct. catechu,
                        Vini opii, aa 5j>—M.

 , The  mixture should be shaken before  using, and three injections
given daily, letting the fluid remain  in half a minute,  or a minute, if
there is not too great sensibility.
  It  is not necessary, however, to exclude other injections from our
practice;  we may, perhaps, direct their employment as  follows:—
  Injections of acetate of lead,  when nitrate of silver irritates, without
doing any good; of zinc, when these two  fail;  of tannin and wine,
when there is  atony and a relaxed state of the membrane; with the
addition of laudanum, when there is need of a sedative astringent; and,
finally, injections  of corrosive sublimate, iodine, iodide of  iron, and
even  the caustics, when it is necessary, as we shall see farther on, to
produce a more profound modification, or  perturbation of the  part.
Injections of chloroform have not succeeded in my hands.
  Injections have been reproached:—
  1. With exposing the patient  to repeated and dangerous  handling
of the parts.  This objection is ridiculous. 
128                      GONORRHCEA.
    2. They have been accused of driving in the contagious matter, and
 of prolonging the disease.  This effect is anything but proved.
    3. It has been thought that they often excite inflammation of the
 neck of the bladder, and engorgements of the epididymis.  Badly
 administered and highly concentrated, or made of unsuitable ingre-
 dients, they may produce this effect;  but, in this case, the fault is not
 in the remedy, but must be ascribed to those who have badly applied it.
    4. Finally, the most formidable and stubborn objection is the asser-
 tion, that injections are the most  common  cause of strictures of the
 urethra.
    In opposition to the ideas which men are prone to promulgate on
 this  subject, it may be said that  injections not only do not cause
 strictures in any case, but that, on the contrary, they anticipate them,
 when they promptly stop a gonorrhoea;  and that, even in certain cases
 of soft hypertrophy of the urethra, they may cure strictures dependent
 thereon.
    Those patients who have strictures after using injections, are those
 in whom the  running was  not stopped; and  it was  its persistence
 which caused an alteration of the tissues, as occurs in all inflammations
 which last too long.
   In short, the bad effects of injections pertain to their bad administra-
 tion or to their want of action.
   II. Indirect  treatment  should be  employed as soon as the use of
 injections is commenced.  In some cases even, when  the urethra is
 still too susceptible, or becomes irritable under  the influence of injec-
 tions, indirect treatment should, at  the outset or  subsequently, be
 employed alone.
   Indirect remedies may be enumerated in the following order, accord-
 ing to  their greater or  less degree of efficacy: copaiba, cubebs,  the
 turpentines,  purgatives,  diuretics, astringents, tonics, iodine, deriva-
 tives, diaphoretics, etc.
   Copaiba, to which Hunter seems to grant only the power of dimi-
 nishing the morbid  secretion, without having any marked influence
 on the inflammation which produces it, has, however, the latter effect
 to such a degree, when it is properly employed,  that we are forced, in
 spite of M. Jourdan's prejudices, to accord to it  a certain specific anti-
 blennorrhagic property.
   Copaiba acts on the stomach, the  intestines,  the  urinary passages,
 the skin, and, in some  rare cases, on the nervous centres.
   In the  stomach,  it may excite nausea, eructations,  retching, and,
 when not  tolerated,  vomiting;  or  it  may cause  irritation and true
 inflammation.  These various effects on the stomach are so much loss,
 and have no curative action on' the gonorrhcea.
   In the intestinal canal,  it may simply purge, or at times cause con-
stipation,  or  it may excite different degrees  of  inflammation.  It is.
however, in this part of the digestive organs  that the beneficial action
of copaiba takes place.   In some patients, its good effects are propor-
tioned to the alvine evacuations it excites, whilst  in others the contrary
is observed.  These different  conditions of success can only be deter-
mined a posteriori. 
TREATMENT.
129
  But copaiba produces its most powerful effect when it traverses the
urinary passages, which takes place only when it is tolerated by the
intestinal canal.  This effect is shown, by a  slight increase in the
secretion of the urine, whose odor, combining with that of the remedy,
undergoes a change; by an irritation, sometimes  considerable, of the
neck of the bladder, which excites frequent desire to urinate; and,
finally, by an  increase of  the burning in the urethra during  micturi-
tion.   Here, in its effect on the  urethra, we  recognize the almost
specific action of balsam of copaiba;  and we may assert that it is as
powerful in the treatment of urethral gonorrhoea in the two sexes as
it is inert in the other varieties of this affection.
  In proof of this statement, I will report the following case, which I
have published in the third number of my Iconographie de VMpital des
veneriens:—
  Accidental division of the urethra ;  Urethral gonorrhoea ; Urethroplastic
operation.—T----, aged 26, a shoemaker, entered ward No. 3, June
16, 1840.
  This patient, at the age of seven, in one of those odd  caprices that
have given rise to so  many curious accidents connected with the
genital organs, took it into his head  to tie a thread round his  penis.
This thread, drawn tight, a little in front of the  scrotum, produced, the
following day, considerable swelling  of the tissues, beneath  which it
soon  disappeared, cutting its way  through the  skin.  To the general
tumefaction of the parts, and the section* of the integument, retention
of urine was added, which the patient declares was complete during a
period of fourteen days.
  At this time, that is to say on the  fourteenth day, the urethra was
in turn divided  by the thread, and a large quantity of urine escaped
through the accidental opening which was made.
  It  was only then, if we may believe the patient, that his parents,
who, up to that  time, were ignorant of his state, called  in a physician,
in consequence of the grave symptoms which supervened, and of which
he  can give no clear account.  We will not  describe in detail the
treatment which the patient received  under these circumstances; and
we  will only  say that he  recollects  perfectly  that the thread could
never be found, in spite of all the care with which the physician looked
after  it.  However, at the end of six weeks he was cured,  but still
retained the vice of conformation  which he had  acquired, and with
which he presents himself to our observation.
  The spongy portion of the urethra is now divided through its whole
thickness, a little in front of the scrotum, and the canal  is thus cut into
two parts; the one connected with the bladder,  the other with the
penis.  The two accidental orifices resulting from this division, at the
distance of about  an inch from  each  other,  are slightly  swollen,
directed obliquely downwards, and present an eversion of the mucous
membrane.  The tissue lying between and around them consists of a
deep and hard cicatrix, which forms  a ring or circle, constricting the
yard at the  same point  in its whole circumference.  Partly in conse
quence of congenital malformation,  but especially from the former 
130
GONORRHCEA.
inflammation,  a phimosis exists, which  entirely prevents the glans
from being uncovered.
  His urine is discharged in a perfectly normal stream, and is perhaps
a little inclined to curve towards the pubis.   The anterior portion of
the urethra does not appear to participate as much in the turgescence
of erection as in the normal state, and the glans is' certainly less florid.
This portion also takes no part in voluptuous  sensations, which are
limited to the posterior portion of the canal; so  that the fossa navicu-
laris, in this patient, is not the goal or rendezvous of urethral sympa-
thies.  Ejaculation  is performed in the same way as the emission of
urine; and the semen, which is projected with much  less force than in
the ordinary state, does not  pass through the anterior portion of the
canal.
  The  patient was  in this state, when, the  first of June, 1849, eight
days after having intercourse, a gonorrhoeal discharge appeared.   The
disease began in the vesical portion of the urethra,  and it was only
four days later that the external portion  became in turn affected;  the
discharge then flowed from the orifice of  the vesical portion, and from
the two orifices of the external portion (the meatus urinarius and the
accidental opening).
  June 17th. The inflammation is everywhere very  intense; the dis-
charge is very abundant, strongly purulent and greenish; however, in
spite of these decided symptoms of extreme severity in the  disease,
the vesical portion of the canal, which alone is traversed by the urine,
is the only  seat of pain during the  emission of this  fluid, and  the
external portion is slightly sensitive only on pressure.  Erections are
not at all  painful, the canal being divided in the most favorable  part
for  preventing the formation of what is usually called " the cord;" the
result of  a  deficient  lengthening  of the canal, rendered rigid by
inflammation, which is observed in gonorrhcea  attended by chordee.
The patient  is ordered a light diet, a cooling ptisan, and a bath.'
  19th.  The acute stage has almost entirely yielded  to repose and an-
tiphlogistic regimen. There still remains a little pain in passing water.
Six drachms of cubebs are ordered in three doses; continue the same
regimen;  suspend the baths.
  21st.  The morbid  sensation  has considerably  diminished in  the
vesical portion of the urethra, whilst it has undergone no modification
in the external portion.
  2±th. The running has entirely stopped in the vesical portion; the
cubebs is continued; the diet increased by one-half.
  July 1st.  The cubebs is omitted; there has been no trace of a  dis-
charge in the vesical portion.   The condition of the external portion
does not appear modified; the same diet  is continued.
  6th.  The morbid  discharge  has  reappeared in that portion of the
urethra in which it stopped; and this is perhaps explained by the fact
that, during the administration of the cubebs, the abnormal orifices of
the canal were kept separated; whilst, after the cure of the vesical
portion, the pus, furnished by the external portion, was allowed to
come in contact with the orifice of the sound portion of the canal. 
TREATMENT.                      131
 _ 8th.  The previous treatment is resumed, and six drachms of cubebs
given; the regimen as before.
  16th. The  gonorrhoeal discharge is again dried  up in the vesical
portion of the urethra; the treatment and regimen  are continued.
  17th. A solution of nitrate of  silver (a grain and  a half of the crys-
tallized nitrate to six  ounces of water), is injected into  the  external
portion of the  urethra, in order to cure the discharge of which it is
the seat; the same treatment and regimen.
  20th. Under the influence  of the injections of nitrate  of silver,  the
gonorrhoeal discharge from  the external portion of the urethra  has
almost entirely disappeared.   Treatment and regimen as before.
  22c?. There is no trace of a discharge  remaining  in any part of  the
canal; all treatment is stopped, but the regimen is continued.
  26^A. The cure of the gonorrhcea is complete; there is not the least
morbid secretion.  Desiring to allow the patient a few days' rest before
performing the urethro-plastic operation, that his state requires, he is
allowed to go out and arrange some private business.
  Although he promised to return sooner, T— was not able to come
back to the hospital till October, 1840.
  The preceding observation is interesting as regards external treat-
ment,  and the action of antiblennorrhagics.   The state of the patient
presented a fine opportunity of studying the mode of  action of these
remedies, which are  almost specifics  in urethral gonorrhoea, but which
have scarcely any effect in other  varieties of gonorrhoea.   We were
able to convince ourselves in this case, in the clearest manner possible,
that antiblennorrhagics act especially in virtue of the peculiar modifi-
cation which they undergo in passing through the renal filter, to be
 afterwards transported by the urine, and applied locally to the diseased
 mucous membranes, which  this  fluid traverses;   and they are thus
 applied, with their  elements better combined, or  with  curative pro-
 perties, which  vital chemistry, and the mechanism of certain functions,
 alone  have the secret  of extracting  and applying.  Indeed, it will be
 recollected that twice, in the case of T—, cubebs  exerted a curative
 action only on that  portion of the urethra which the medicated urine
 traversed; whilst that part, which was foreign to the discharge of this
 fluid,  underwent no modification.
   I do not, however, deny the general action of the balsams, as I have
 been charged with doing; I admit, as  everybody does, that they may
communicate certain properties  to the blood, and modify certain secre-
 tions.  I am equally convinced of their revulsive  action.  But expe-
 rience has taught me, as well as others, that this is their most feeble
 and uncertain  mode of action, as  may be seen in  the above case, by
 the persistence of the gonorrhoea  in  the  anterior portion of T—'s
 urethra; and as may be seen every day in the treatment of balanitis,
 of  discharges from  the vulva, vagina, or  uterus, and. in gonorrhceal
 ophthalmia, where they produce no  more effect.  Under some circum-
 stances, more or less acute irritation of the digestive organs is excited,
 and vomiting,  or oftener diarrhoea, induced;  in such  cases, they may
 modify or even suppress certain runnings, without communicating, at
 least in an appreciable degree, any of their elements to the urine;  but, 
132
GONORRHOEA.
experience teaches, that in these cases the  suppression of the disease
is only temporary, and that it reappears  as soon as we  suspend the
use of the remedies, which have acted only in the general manner of
revulsives, without any specific action.  It  may be added that if, with
intention of maintaining the cure, the dose of these drugs be increased,
so as to surpass  the safe bounds of revulsive action, and if we thus
produce a true inflammatory state of the gastro-intestinal mucous mem-
brane, then again the revulsive action stops, and the gonorrhoea reap-
pears ; but this time it is more intense and obstinate, since the trouble
produced in the digestive  organs  now favors the  disease which we
wish to  combat,  and deprives us  of the use of an  internal remedy,
which might have been more wisely administered.
   On the other hand, when the balsams  taken internally exert their
action on the skin, and produce eruptions, commonly no revulsive ac-
tion is observed, and the gonorrhoea for which they were administered
continues the same as before their  use, or is even  aggravated,  and
almost always forces us to suspend them, until the  eruption has  dis-
appeared.
   My honorable colleague, the late Dr. Cullerier, convinced, as I was,
of the little confidence to be placed in the general and revulsive action
of copaiba and cubebs, and  certain that there must be something pecu-
liar in the action of these  agents on diseased mucous membranes, made
experiments for several years, on their direct action, when applied in
substance to the mucous membranes, by means of injections or other-
wise; and, contrary to the opinion advanced by some able experimenters,
but who are a little too hasty in their  conclusions, he found  that the
effect was inappreciable, or injurious.  I will also add, in support of
these experiments, that I have obtained no better result from  the admi-
nistration of copaiba and cubebs by the mouth in reputed gonorrhceal
discharges from the lower portion of the rectum; and this could easily
have been foreseen, since the effect must be very nearly the same as in
the  experiments of Dr. C, for a considerable quantity of these sub-
stances frequently passes through the  digestive  tube, without under-
going any alteration, and may thus be  justly considered as  applied
locally to the diseased parts.
   Hence, we must rely on injections and appropriate local applications
in the treatment  of all varieties  of gonorrhcea,  other than  urethral
gonorrhcea; and in the latter, we cure the sooner and the more readily
in proportion as we associate with  the internal treatment, suitably
adapted to produce an action on the urinary passages, a local treatment,
in which the use of nitrate of silver should rank first.
   I have also thought it interesting to add to the preceding observation
the  two following  recent cases, which I have communicated to the
Academy of Medicine.
   Gonorrhoea in a  urethra divided in its  middle portion, in front of the
penoscrotal angle.—P----,  aged 24, entered the Hopital du Midi. Feb.
2, 1849.                                        *           '
   When seven' years old, this patient took the singular fancy to stop
his water, by strangulating his penis with  a  tightly drawn cord; the
cord was removed  at the end of several hours; but the constriction had 
TREATMENT.
133
lasted long enough to deeply mortify the tissues, including the urethra,
and to occasion the lesion, which we proceed to describe.
  At the junction of the posterior with the middle third of the penis,
there exists a circular constriction, the result of compression of this
organ.  At this point, the skin presents a circular, furrowed  cicatrix,
about two lines in depth; the portion of the yard anterior to the con-
striction has attained its normal development.   The urethral canal,
opened in front of this constriction, presents a clearly defined circular
orifice, through which a director can be introduced.   Posterior to the
cicatrix, the second portion  of the urethra  opens by a more  everted,
uneven orifice than the preceding; has a very irregular border, and is
capable of admitting a catheter of ordinary caliber.  All the  urine
comes out of this opening.
  Erections are nearly the same  as in the normal state. A month ago,
P----contracted an acute gonorrhoea, which had not been treated until
his admission to the hospital.
  On entering the Hopital du Midi  (Feb. 2), the disease occupied the
two portions of the canal; the abundant discharge was of a greenish
yellow color; the posterior portion of the canal was the seat of tolera-
bly acute pain, during and after the emission of urine; at night there
were erections, attended with scarcely any pain.
  Feb. 3. The patient is ordered an emulsion of copaiba.  In order to
appreciate exactly the effect of the remedy on each part of the canal, I
carefully plug up with diachylon the orifice in front of  the stricture;
though it is almost a superfluous precaution, since all the urine comes
out of the posterior opening; the urine thus charged with the medi-
cinal element, will affect only that portion of the urethra which  is be-
hind the solution of continuity.
   6th. The discharge has much diminished, and changed its color and
character in this  portion; pressure of the fingers produces a drop of
whitish muco-pus, suspended in  a  clear adhesive fluid;  the pain has
ceased.
  8th. The discharge has completely disappeared in the posterior por-
tion.   I now direct the patient, who continues the use of the copaiba,
the moment he has passed his urine, to inject it from behind forwards
(through the artificial opening) into the anterior portion, which has
undergone no modification.
  12^. There is already a marked improvement; the  nature of the
discharge has changed;  it is of a yellowish-white color and much less
abundant.
  15th. The quantity and color of the discharge are still farther modi-
fied ; three-quarters of an hour after injecting, on squeezing the canal,
we obtain with difficulty a drop  of very clear muco-pus,  at the orifice
of the natural meatus.
  16^. The discharge is cured throughout the whole canal.
  I met with the second case in my private practice.
  Accidental hypospadias; gonorrhoea cured successively in the  two por-
tions of the canal.—M----was affected at the same time with gonor-
rhcea and  a rupture of the urethra, which  produced an accidental
hypospadias in the middle portion of the penis.   As in the preceding 
134
GONORRHOEA.
observation, the mortification  of the tissues, and consequent rupture
of the urethra,  was the result of constriction exercised by a cord, and
it was at the same age, of seven years, that the patient inflicted on him-
self this injury.
  The urine escaped by the artificial meatus; but the patient could
make it pass through the whole length of the canal, by applying the
anterior portion of the penis to the posterior, and maintaining the
longitudinal axis of the organ, so as to stop up the traumatic orifice.
Copaiba was given internally; the gonorrhoea stopped, in a few days,
in the posterior part of the urethra, but it  continued in the  anterior
part, through which the urine,  charged with the medicinal elements of
the copaiba, was not  allowed to run.
  No change was made in the treatment, however, for three days.  The
cure of the posterior part  of  the urethra  being  then perfectly esta-
blished, the internal administration of the copaiba was continued, but
now the patient made the urine run through the whole extent of the
urethra, by taking the precaution above indicated; by this  method,
the copaiba-bearing fluid cured  the anterior portion of  the canal, but
in double the time which was required for the cure of the posterior part.
  My learned colleague,  Dr. Hardy, has presented to the Society of
Physicians of the Hospitals of Paris, some cases of the cure of vaginal
gonorrhoea  by injections into  the vagina of  urine charged  with
copaiba.  I have myself thus succeeded in  some cases of balanitis.
  But when  I  have  endeavored to mix the copaiba with the urine
after its emission, and then inject it, I have always failed.
  I have instituted some researches, not yet completed,  to ascertain if
the medicated urine,  prepared  by the kidneys, cannot be imitated, but
I have as yet obtained no very satisfactory  result.
  In the  cold  and wet weather  of spring and autumn,  copaiba often
determines cutaneous eruptions, which, in  order of frequency, come
under roseola, urticaria, or simple erythema.  These eruptions appear
especially when the digestive organs are disordered.   They are gene-
rally attended with severe itching, and rarely last beyond  a week, when,
recognizing the cause to which they are due, we suspend  the treatment.
This action of copaiba upon  the skin, while it  torments the patient,
not only has no beneficial  action on  the  gonorrhoea, but it is not
uncommon to see patients in whom the running, after being dried up,
reappears  as soon  as a cutaneous eruption  shows  itself.  After these
practical observations, which  may be  repeated  every day, we must
beware  of adopting the opinion recently advanced in the Dictionary of
Practical Medicine and Surgery, which states that the action of copaiba
on the skin, is not a contra-indication to its use.
  I cannot speak of the action of copaiba on the skin without point-
ing  out a serious mistake made by M. A.  Cazenave, in his Traite des
Syphilides.  This pathologist considers the exanthemata produced by
copaiba and cubebs as true syphilitic  symptoms, from the  sole fact
that  a gonorrhcea  preceded them!  But for what  are these remedies
given?  And is the existence of  a gonorrhoea necessary that they
should produce such effects ?
  The rarest of all the effects of copaiba is doubtless its action upon 
TREATMENT.
185
the nervous centres.  And yet, I have had the opportunity of observ-
ing patients in  whom excessive doses  of this  drug, or its untimely
administration, produced alarming symptoms of congestion, and excita-
tion of the spinal marrow and brain.  In  the case of a woman, it
caused a temporary hemiplegia, which disappeared as soon as a lively
rubeolar eruption showed itself; whilst in another female, its employ-
ment was followed by violent convulsions, whose crisis was also an
acute exanthema.
   Copaiba is applied locally by means of dressings, injections, or sup-
positories.   It is given internally by the stomach  or rectum.
   Its direct application is without effect or injurious.  Its best mode
of administration is by the stomach; it is ten times more powerful, when
given in this way, than by the rectum, and it should be given by the
large intestine only when the stomach cannot tolerate it.
   The purer, and more free from adulteration copaiba is, the better it
acts.  All the pharmaceutical preparations, whose object is to solidify
it and remove its taste or smell, are liable to impair its efficacy.
   The stomach  may be  made to bear it,  by combining it with anti-
spasmodics, opiates, tonics, &c.   Acidulated  drinks answer very well
for this purpose, as lemonade and Seltzer water.
   The capsules,  in which it is now given, constitute a true advance in
pharmacy.
   When copaiba purges too powerfully, without  good result, it must
be combined with astringents;  or when it has  the opposite effect, its
action must be  increased by purgatives.  In the same manner, also,
when its action on the urinary passages  is not decided enough, diure-
tics must be given as  adjuvants.
   It is given by the rectum, in small enemata, or in the form of a sup-
pository.   Some persons  retain more easily capsules introduced into
the intestine above the sphincter, as proposed by Dr. Ratier, the skilful
collaborator with Cullerier.
   We do not obtain the happiest results by commencing with minute
doses.  From one  to  three drachms, and even  eight drachms and
upwards, may be given daily, according to the patient's susceptibility.
When copaiba has produced its effect, its use should not suddenly be
suspended; we should finish off with decreasing doses.
   After copaiba, and perhaps of equal importance as an anti-blennor-
rhagic, we must  rank cubebs.  The latter  is less nauseating than the
former, but it is more irritating, and causes constipation more fre-
quently than diarrhoea.   It imparts much less odor to the urine, and
its action on the skin is infinitely more rare.
   Since it is cheaper, and more easily obtained pure in commerce, it
generally deserves the preference; regard being had, however, to some
of its properties, which we have  just mentioned, and which often find
their application.
  The dose is from four to eight, or even  fifteen drachms a day. It
may be given, like copaiba, with which it is often  united, under many
pharmaceutical forms; the most  simple is in powder; the most agree-
able aud convenient is in capsules.
  The turpentines, and especially Venice turpentine, are much less 
136                      GONORRHOEA.
powerful, spite of what has been  said  of them latterly.  Purgatives,
at most, only serve to fulfil certain indications; the same is  true  of
diuretics,  on which we no longer rely, as Tode and his  followers did.
As to astringents, tonics, and iodine, which MM. Richond and Henry
have so highly recommended;  derivatives to the skin, blisters, cold
baths, vapor baths, etc.;  we should consider them  only as purely
accessory  means of treatment, and of very little efficacy.
   Since Hunter  says  nothing of  balanitis, or external  gonorrhcea, I
may be allowed a few words on the subject.
   The best treatment of this form of gonorrhoea consists in the super-
ficial cauterization of  the  affected part, with stick nitrate of silver;
this is to be passed rapidly over the surface, so as to whiten it, without
giving the caustic time to penetrate deeply.  Having done this, if. the
glans can  be uncovered, a pledget of  dry lint is placed between it and
the prepuce, and  renewed  twice a day.  When the balanitis occurs
without any erosions, simple lotions of lead water, and  the interposi-
tion of dry lint, are sufficient.   When there is more or less phimosis,
cauterization, by  passing the lapis infernalis  between the glans and
its envelope, and afterwards  injecting  Goulard's  extract, gives the
happiest results.   I generally use lotions or injections between the
glans and the prepuce, twice a day, of the following:—
                  R.—Aquae destillat. %vj ;
                      Argent, nitrat. gr. xxx.—M.

   When other applications, as emollients, antiphlogistics, and reputed
specifics fail, or prolong the disease, you obtain, by this means, the
most rapid cure.   More or less inflammation is not a  counter-indica-
tion ; but  in cases of excessive inflammation, abstraction  of blood may
be added to the treatment; and it  is only in cases of threatening gan-
grene  that we should  operate  for the acute phimosis, which  may
complicate balanitis.
   In woman, gonorrhoea of the vulva  is  the  most easily cured.  It
yields to the same means as balanitis.   When  the vagina is affected,
the acute  stage requires antiphlogistics, especially the use of emollient
and sedative injections.  But as soon as this stage subsides, or when
the chronic stage  precedes  or follows  it, the method which has given
the most happy results, and which I was the first to notice favorably,
though it  has been copied by others, is  the use of nitrate  of silver in
a  solid  or liquid  form.  In the  first  case, the  parts are exposed by
means of  my bivalve  speculum;  and,  commencing with the  deeper
regions, the nitrate of silver is passed over the whole surface of the
vaginal parietes as the instrument is  withdrawn.  After this applica-
tion of caustic, the walls  of the  vagina are  kept separated by dry
charpie, as in the treatment of balanitis.  This cauterization is followed
the day after, by  resolvent or astringent injections, repeated three or
four times a day.   The application of the solid nitrate succeeds  espe-
cially when the mucous follicles are much affected, in that form which
I have designated under the name of psorelytrie.  It should be repeated
after an interval of three or four days, if the disease remains in statu
quo, or be abandoned, if the discharge is aggravated or  dries up.  In 
TREATMENT.                       137
other cases, it is sufficient to inject, two  or three times a day, a solu-
tion of crystallized nitrate of silver, containing fifteen to thirty grains
to three ounces of distilled water.
   In all cases, where injections are indicated, the action of the fluid is
much more efficacious when it is kept in contact with the diseased tis-
sues by means of pledgets soaked in it.  Again, isolating the walls of
the vagina by the introduction of charpie or carded cotton is  often
successful.
   When the disease  has involved the uterus, the above means may
still act  through continuity or contiguity of tissue;  but, it must  be
confessed, they are more frequently powerless.  Much may be hoped,
in this case, from cauterizing the neck and its cavity  by the introduc-
tion, with all necessary care, of a stick of nitrate of silver.  Injections,
also, with a solution of this salt, may be  made of the strength that I
have mentioned.
   Nitrate of silver, suitably employed  in these cases, causes no  more
unpleasant  symptoms than  any other  method; and  those  who  have
blamed it, have badly read and observed, or imperfectly understood.
Uterine injections, which M. Yidal invented about the same time as
myself, produce, in some cases, very alarming nervous hysteric pheno-
mena, which I pointed out in a memoir, in 1832.   They must  there-
fore be employed with excessive caution; and perhaps it would always
be preferable to insert the medicated liquids, by means of a small
sponge, attached to a piece of whalebone.
   What I said of the treatment of urethral gonorrhoea in the male, is
true of the same disease in the female; and copaiba and cubebs are
here again efficacious.
   I will only add a few words to what  Hunter says of  the constitu-
tional treatment of gonorrhcea, so far as regards mercury.   It is almost
always injurious, employed  as a constitutional remedy, and  a fortiori,
injurious as a local application.  The half treatment of M. Lagneau is
not rational,1 and recourse  should be had to  this class of remedies
only when other indications present themselves, and demand constitu-
tional remedies, as the coexistence of an  indurated  chancre,  or a per-
sistent engorgement, to which mercury may be locally applied as a
resolvent.—Ricord.]

   [EnrroR.—In the treatment of gonorrhoea, it is often exceedingly difficult
to make the stomach tolerate its  chief  remedial agent, copaiba.   Capsules
are far from being  sufficient  in  the majority of  cases.   They  frequently
nauseate the patient, when taken in sufficient numbers, and  their contents
are often impure.  That  form of copaiba which  is  applicable to the largest
number of cases, I believe to be copaiba solidified by magnesia, especially
when combined with cubebs.  Copaiba and cubebs  together, are more  effica-

  1 M. Lagneau  regards gonorrhoea as a "superficial effect of the venereal virus,"
(see page 56), and after the discharge has stopped, administers " four grains of mer-
cury daily for at least a fortnight."  (Diet, de M6d., Art. Blennobrhagie.) Of course,
this demi-treatment will be used only by those who believe in the existence of a demi-
syphilitic disease.—Ed. 
138                        GONORRHCEA.
cious than either alone, and are better supported by the stomach.  I am in
the habit of using the following formula, in large doses :—
                        ty.—Copaiba §ij;
                            Pulv. cubebae §j;
                            Aluminis 3iss;
                            Magnesiae q. s.
  To be taken in boluses, in from three to six days, according as the stomach
is able to  bear it.   The alum is  added as an astringent.  Its  place may be
supplied by a cathartic, as  rhubarb, or a tonic, as carbonate of iron, to meet
certain indications.   Copaiba thus solidified is  nearly tasteless, can be con-
veniently taken in large doses, and is -borne by the stomach remarkably well.
This formula is  essentially the same as those recommended by Yelpeau,
Yidal, Maisonneuve, etc.  M. Yelpeau, especially, relies entirely on large
doses of copaiba and cubebs, combined  and solidified  by magnesia, in the
treatment of the early stages of gonorrhoea.
   The most convenient way of taking cubebs alone  is in the wafer-paper, or
pains a chanter, which can now be purchased of any of  our chief druggists.
   With regard to the question to which stage  of  gonorrhoea copaiba and
cubebs are particularly applicable, and whether  they are contra-indicated by
a high degree of inflammation, the opinions of  authorities have undergone a
remarkable change.  It was formerly thought, that they should be used only
after the discharge has become chronic, and in small doses ;  but this opinion
is now proved to be incorrect.   They are powerful remedies in acute gonor-
rhoea,  and may even be administered in large doses; but they have very little
efficacy in gleet.
   Whether they are contra-indicated in cases of excessive inflammation, has
not been so satisfactorily settled.  Many surgeons abstain from their use till
the more inflammatory symptoms have subsided, for fear of producing com-
plications, swelled testicle, &c;  but others, like M. Yelpeau, do not fear to
use them in any stage of an ordinary case;  and others, still, within the last
half century, have gone  so far as  to consider them peculiarly applicable to
the high degree of inflammation and the complications  which often  occur in
gonorrhcea.  Among the latter  may be mentioned, Ansiaux, Ribes, Laennec,
Delpech, and Trousseau.
   This, and many other points connected with the treatment of this affection,
demand farther  investigation;  and  it belongs to  those surgeons who are
 suitably situated for the purpose, to make the necessary careful analyses of
 cases, to ascertain what are the exact indications  for each of the numerous
 modes of treatment, that compose the therapeutics of gonorrhoea.—Editor.] 
TREATMENT OF OCCASIONAL SYMPTOMS.         139
                      CHAPTER  VII.

  OF THE TREATMENT OF OCCASIONAL SYMPTOMS OF THE
                            GONORRHCEA.

   As the following symptoms are'only occasional consequences of a
 venereal gonorrhoea, being  the effects of an irritation on the urethra,
 and therefore not venereal,  they are to be treated in the same manner
 as if they had arisen from any other cause.

                 § 1. Of the Bleeding from the Urethra.

   It has been already observed, that when the inflammation is violent,
 or spreads along the urethra, there is frequently a discharge of blood
 from the vessels of that part.  In such bleeding, the balsam capivi,
 given internally, has been of service; and it may be supposed that all
 the  turpentines will be  equally useful.  I  have not found any good
 effects  from  astringent injections, and in some  cases have suspected
 that they have been the cause of this complaint.  They always go off
 in the usual time of the cure of the gonorrhoea.1

                  § 2.  Of preventing Painful  Erections.

   Opium, given internally, appears to have  great  effects in preventing
 painful erections in many cases.   Twenty drops of tinctura  thebaica,
 taken at bedtime, have procured ease for a  whole night.   The  cicuta
 likewise seems to have some powers in this way.

                  § 3.  Of the Treatment of the Chordee.

  In the beginning of this complaint bleeding from the arm is often of
 service;  but it is more immediately useful  to take away blood from

  1 Bleeding from the urethra in gonorrhoea is beneficial, and should very seldom be
 repressed.  If, however, the quantity which is lost is very excessive, and  it becomes
 necessary to check it, the application of cold, in the form of a bladder filled with ice,
 to the perineum, wiU be found by much the most effectual remedy.—G. G. B.
  [Bleeding from the urethra takes place by exhalation, or is a consequence of lacerations
 of the canal, which often occur in gonorrhoea attended with chordee.   It  may some-
 times be beneficial.  Contrary to what Hunter says, copaiba and the turpentines have
 little effect in repressing it, and may even be injurious.
  When the loss of blood is considerable, we must endeavor to  stop it.  Repose, cold
injections, and ice to the neighboring parts, often succeed;  but when it is due to a
ruptured vessel, which is often the case when patients try to subdue their chordee by
violently straightening the curved penis,  we are sometimes obliged to have recourse
to compression.  This is exercised by introducing a  sound into the urethra; and if
the bleeding still continue, a circular bandage around  the anterior portion of the yard,
or a pad to the perineum, may be  applied externally.—Ricoed.] 
140                       GONORRHCEA.
the part itself by leeches, for we often find by a vessel giving way in
the urethra, and a considerable  hemorrhage ensuing, that the  patient
is greatly relieved.   Relief will often be  obtained by exposing the
penis to the steam of hot water.   Poultices have likewise beneficial
effects, and both fomentations and poultices will often be assisted in
removing inflammation  by the addition of camphor.   Opium given
internally, is of singular service, and if it be joined with camphor the
effect will be  still greater; but opium in  such cases  acts  rather by
lessening the pain than by removing the inflammation, though  by pre-
venting erections it may be said to obviate  the immediate cause of the
complaint.1
  When the chordee continues after all other symptoms are gone, little,
or nothing, in the way of evacuation, seems to be necessary, the inflam-
mation being subdued, and a consequence of it only remaining, which
will cease gradually by the absorption of the extravasated coagulable
lymph.   Therefore bleeding in  this case can be of no use.  Mercurial
ointment applied to the parts will promote the absorption of the extra-
vasated coagulated lymph, for experience has shown that  mercury has
considerable powers in exciting absorption.   The friction itself also will
be of use.  In one case considerable benefit seemed to result from giving
the cicuta, after the common methods of cure had been tried.  Electri-
city may be of service.  This symptom is indeed often longer in going
off than either the running or pain; but no bad consequences arise from
it.  Its declension is gradual and uniform, as happens in most conse-
quences of  inflammation.
  In relieving the chordee, or the remains of it, which appear to arise
from spasm, I have  known the bark of great service.  Evacuations,
whether from the part or from the constitution, generally do harm.

§ 4. Of the  Treatment of the Suppuration of the Glands of the Urethra.

  Suppurations in the glands of the urethra are to be treated as chancres.
Therefore mercury ought to be given, as will be explained hereafter.
  Should suppuration take place in Cowper's glands, it demands more
attention.   The abscess must be opened freely and early, as the matter,
if confined, may pake its way either into the  scrotum or urethra,
whence would arise bad consequences.  Here also mercury must be
given, and  perhaps as freely as in a  bubo.   In short, the treatment
should be the same as in a venereal ulcer;  and in this respect it will
differ from the treatment of those abscesses which arise in  consequence
of stricture.2

  1  I am entirely of Hunter's opinion. Camphor is the most powerful sedative  in
erections, in spite of what some modern theorists have written on the subject.  It
should be added, that experience, which  is better than any theories or arguments,
teaches that opium is its best adjuvant.  But  they do not always succeed.
  Dr. Sistach  has lately submitted to the Academy of Medicine a mode of treating
erections, by compressing the prepuce in front of the glans.  This method is far from
succeeding in every case.—Ricord.
  2 Experience does not confirm this doctrine. Suppurations in the glands of the ure-
thra are not very uncommon in gonorrhoea, yet they heal readily without the use of
mercury; nor are they ever followed by secondary symptoms.—G. G.  B.
  [I am entirely of Mr. Babington's opinion.—Ricobd.] 
              TREATMENT OF SWELLED TESTICLE.           141


  § 5. Of the Treatment of the Affection of the Bladder from Gonorrhoea.

  When the disease extends as far as the bladder, it produces a most
troublesome complaint, from which, however, bad consequences seldom
arise.  But I suspect  that  it sometimes has laid  the groundwork of
future irritation in that part, which has proved very troublesome and
even dangerous.
  Opiate clysters, if nothing in the constitution forbid the use of them,
procure considerable temporary relief.  The warm bath is of service,
although not always; and bleeding freely, if the patient is of a full habit,
often does good.  Leeches also, applied to the perineum, have good
effects. But in many constitutions bleeding will rather do harm; and
we should be cautious in making use of this evacuation, for it has been
already observed that many of these cases are rather from sympathy
than inflammation.  As this affection of the bladder often continues for
a considerable time, producing other sympathies  in the  neighboring
parts, and is not in the least mitigated by the methods commonly used,
I would recommend the following trials to be made use of in such cases.
An opiate plaster to be applied to the pubes, or the small of the back,
where the nerves of the bladder take their origin;  a small  blister on
the perineum, which is of  service in irritations of the bladder arising
from other causes.1

             § 6. Of the Treatment of the Swelled Testicle.

  When  the testicle  sympathizes either with the urethra or bladder,
and is inflamed, rest is the best remedy.  The horizontal position of
the body is the easiest, as such a position is the best for a free, circula-
tion.  If  the patient cannot submit to a horizontal position,  it is abso-
lutely necessary to have the testicle well suspended.  Indeed, the patient
will be happy in having recourse to  that expedient as soon as he is ac-
quainted with the ease which it affords.
  In this complaint, perhaps, no particular method of cure can be laid
down.  It is to be treated as inflammation in general, by bleeding and
purging, if the constitution requires them, and by fomentation and
poultices.   Bleeding with leeches has often been of service.   This we
cannot well account for, as the vessels of the scrotum  have but little
connection with those of the testicle.
  As I do not look upon  the  swelling of the testicle to be venereal,
mercurials, in my opinion, can be of no service in these cases while the
inflammation continues; but they are useful when that is gone and the
induration only remains.2

  1 Irritation at the neck of the bladder is not uncommon in urethral gonorrhcea. This
irritation is accompanied by spasm of the bladder, and by a discharge which is often
bloody, through a process analogous to that of hemorrhoids.  It is subdued especially
by small, cold, opiated enemata.—Ricord.
  2 Though mercurials are not required for the sake of counteracting the venereal virus,
yet experience shows that calomel is of the greatest service, even in the acute stage of
inflammation of the testicle. It is probable that it acts here, as in many other cases
of adhesive inflammation, by controlling the capillary circulation of the inflamed part.
It should always be  combined with purgatives, and generally with local bleeding.—
G. G. B. 
142                      GONORRHCEA.
  Yomits have been recommended in such cases, and are sometimes
of service.  I  have known  a vomit to remove the swelling almost
instantaneously.  The effects of the vomit most probably arise from
the sympathy between  the stomach and the testicle.  Opiates are of
service, as  they are  in  most irritations of those parts.   When such
swellings suppurate, which they seldom do, they require only to be
treated as common suppurations, and mercury need not be given.
  In the history of this disease, I observed, and, indeed, it has been
observed by most writers, that, when a swelling comes upon the testi-
cle in consequence of a gonorrhoea, the running ceases, or, when  the
running ceases, the testicle swells; but which is the cause, or which is
the effect, has not yet been  ascertained.   It has been  also  observed
that when the running returns, the testicle then shows the first symp-
toms of recovery; so that, the lesticle having lost its sympathizing
action, the action is restored to the urethra. And here, also, it has  not
yet been ascertained which is the cause or which is the effect; but,
from a supposition that the cessation of the discharge  in the urethra
is the cause of the swelling, it has been attributed to the mode of treat-
ment of that irritation, and by some to injections.
  It has been advised by many, and attempted by some, to procure a
return of the running; but the methods used have hardly been founded
upon  any sound principle.   Mr. Bromfield appears to have been  the
first who recommended a treatment suitable to this theory, which was
to irritate  the urethra to suppuration again, by introducing bougies.
I have not seen that benefit  that could have been wished, or that  the
first idea might induce us to expect, from this practice.  Some have
gone farther, by recommending the introduction of venereal  matter
into the urethra; but this appears to be only conceit, and is founded
upon a supposition that such swellings arise only from venereal irrita-
tions.   But I have already observed that they are produced by other
causes.
  It is generally a long time before the swelling of the testicle entirely
subsides, although it does so more quickly at first than swellings of
this part arising from other causes.  Before it becomes less, it gene-
rally becomes softer, commonly on the anterior surface; and by degrees
the whole becomes perhaps softer than natural, and then it diminishes.
It is still much longer (sometimes even years) before the epididymis
returns to its natural state; sometimes it is never reduced to its natural
size and softness.  However, this is of no great consequence, as no
inconvenience results from a  continuance of the hardness simply,
though sometimes, perhaps, such testicles  are rendered totally useless.
I never had an opportunity of examining the testicle of one that was
known to have this complaint, but have examined testicles where the
epididymis has had the same  external feel, and where the canal of the
vas deferens  has been  obliterated.  But  this, I suspect, too  seldom
happens, for there are people who have both testicles swelled, and, not-
withstanding, discharge their semen as before.1

  1 The hardness which is left after inflammation of the testicle, does not appear, in
most instances, to interfere with its functions.  The obliteration  of the vas  deferens
is not a frequent occurrence; and the induration which often remains in the epididy- 
TREATMENT  OF  SWELLED  TESTICLE.          143
  It is in this stage of the complaint that resolvents may be of service,
such as  mercurial friction  joined with camphor.  Likewise, we may
usefully  apply fumigations with aromatic herbs, in order to stimulate
the absorbents to take up the superfluous matter. Electricity has been
in some  cases of singular service.
   [Ricord.—The  treatment of epididymitis can, perhaps, be  more
methodically laid  down than that of any  other of the affections  of
which we treat.
   Yenesection, when  there is constitutional reaction.   Application of
leeches over the course of the inguinal canal  and  to the perineum,
when the inflammatory symptoms are entirely local.
   If there be an effusion into the tunica vaginalis, it must be drawn
off, in whatever stage of the disease it occur.  In cases of true orchitis,
where the body of the testicle is involved, and the pain is very severe,
owing to the constriction exercised by the tunica albuginea, we may
do what J. L. Petit did, make incisions into the body of the testicle.
These incisions have recently been employed in  many cases of epididy-
mitis, which were thought to be only cases of parenchymatous orchitis,
so called.1  It is evident that a  highly swollen  epididymis, compress-
ing the  testicle, by stretching  the tunica albuginea over it, also gives
rise to symptoms of strangulation, which may be removed by incisions,
which are, moreover, harmless.   Professor Yelpeau, myself, and others,
had already used this method, but without abusmg it, as has since been
done.
   After reducing the  inflammatory reaction by antiphlogistics, and
drawing off  any effusion into the tunica vaginalis, if the cord be  not
too m.uch swollen, nor the sub-scrotal cellular tissue the seat of phleg-
monous inflammation;  and, with stronger reason, when no abscess has
formed, and  there is no tendency to suppuration, then the best treat-
ment is by compression, which was first used by M. Fricke, of  Ham-
burg.   This is applied by means  of small  strips  of emplastrum de
Yigo cum mercurio, arranged circularly around the affected organ, by
commencing with one turn round the origin of the cord, and descend-
ing as far as the lower  portion of the testicle.  Having done this, the
bottom  of it is compressed  by means of small strips, closely applied
from below upwards, in a criss-cross manner, so as  to make a kind of
basket,  which completes the dressing.
   It is  a  requisite for  success that the compression, thus accurately
applied, shall, in the course of half an hour or  an hour after its appli-
cation, give a sense of  relief, such as has followed no other means em-

mis, is usually from deposition in the cellular membrane  which connects its convolu-
tions, or mere thickening of the membranes which invest it; and though it is not
 uncommon that some of the vasa efferentia should be totally obstructed, and converted
into solid cords, yet, unless  the whole of these vessels should be thus changed, such
 an occurrence is of little consequence, as those which still remain pervious will be suf-
 ficient to  carry the semen, as before, into the vas deferens.—G. G. B.
   Several dissections have given me the same results.—Ricord.
   1 In the affection of the scrotal organs attending gonorrhoea, M. Vidal admits three
 varieties, according to the  part which is chiefly involved, viz: inflammation of the
 epididymis, or epididymitis; inflammation  of the tunica vaginalis, or vaginalitis ; and
 inflammation of the parenchyma of the testicle, or parenchymatous orchitis. M. Vidal's
 treatment by incisions is especiaUy applicable to the last variety.—Ed. 
144
GONORRHCEA.
ployed.  When  the contrary is the case, and the pain increases, the
dressing should be speedily removed, to avoid unpleasant symptoms.
  When patients can bear compression, care should be taken to renew
it as fast  as the  affected organ decreases in size under  its influence.
H this indication be not carefully fulfilled, disagreeable reaction will
speedily follow.
  When compression  cannot be used  on account of the above-men-
tioned contraindications, while we  carry  out other treatment, we may
derive great advantage from the local  application of mercurial  oint-
ments, together with emollient fomentations and cataplasms.
  Leeches applied repeatedly in small numbers, according to Lisfranc's
method, are of great assistance; as is also calomel taken  internally.
  Experience has taught  me that  it is not only useless to recall the
discharge from the urethra, but that it is often dangerous;  and that
we cannot count on a complete cure of the epididymitis until the dis-
charge has  entirely  stopped.
  But if Bromfield's method be dangerous, there is still more risk in
introducing fresh venereal pus into the  urethra; for, in taking venereal
pus, whose  nature has not been previously ascertained by inoculation,
we should run the risk of giving syphilis to a patient who has only  a
simple gonorrhcea.—RlCORD.]

  [Editor.—M. Yelpeaa first proposed to evacuate  the effusion into the
tunica vaginalis in this affection by incision with the point of a lancet.  The
lower and posterior part of the tumor, where the testicle is usually situated,
is grasped by the left hand of the operator, while, with his right, he plunges
a lancet perpendicularly into the bulging mass of the fluid above and in front.
One or more incisions are made, which are  usually followed by a jet of serum,
or a few drops of blood.  Lotions of acetate of lead are applied, and the
operation repeated, if the effusion again accumulates.
  The  credit of reviving the practice of incising the body of the testicle,
which was first proposed by J. L. Petit, is  certainly due to M. Yidal (de
Cassis).  This surgeon first practised it only in case the body of the testicle
was involved; but, finding the operation perfectly free from danger, he ex-
tended it to  cases of simple epididymitis.  It is performed in the same way
as M. Yelpeau's incisions of the tunica vaginalis, except that the knife is
made to pass through the tunica vaginalis,  and incise the tunica albuginea to
the extent of half or three-fourths of an  inch.  In  spite of the prejudices
against this  operation, M. Yidal says that he has performed it four hundred
times without any bad result; and that it is  always harmless if the incisions
are confined to three-fourths of an inch  in  length.  Its  effects  are in the
highest  degree  satisfactory.   It  removes the  strangulation,  relieves the
excessive pain, and acts as  a powerful antiphlogistic in reducing the swell-
ing-] 
TREATMENT OF SWELLED TESTICLE.
145
  § 7. Of the Decline and Termination of the Symptoms of Gonorrhcea.

  The decline of the disease is generally known by an abatement of
some or all of the above-mentioned symptoms.  The pain in the part
becomes less, or terminates in an itching similar to what is felt in the
beginning of many gonorrhoeas, and at last entirely  goes  off.  The
sense  of weariness about the loins, hips, testicles, and scrotum, is no
longer felt;  and the transparent cherry-like appearance of  the glans
penis  gradually disappears.  These are the most  certain signs of an
abatement of the disease.
  The running becomes less; or, if it does not diminish, becomes first
whiter, then of a paler color, and gradually acquires a more slimy and
ropy consistence, which has always been considered as the  most  cer-
tain sign of an approaching cure.  When  the running becomes more
slimy, it is then changed from matter to the natural fluid which lubri-
cates the passage, and also to that  fluid which appears to be prepara-
tory to coition.  But it is  often very inconstant  in its  appearances,.
arising  frequently from  different  modes  of living, exercise, or other
causes.
  It often happens that all the  symptoms shall totally disappear, and
the patients shall think themselves cured, and yet the same symptoms
shall come upon them anew; commonly, indeed, milder than at first,
though in some cases as violent, or even more violent; and  this takes
place  sometimes at a considerable distance of time.   I have known
the symptoms return a month  after every appearance of the disease
has been  removed.  However, in  such cases they seldom  last long.
How  far this second attack is to be looked upon as truly venereal, has
not as yet been ascertained. Nothing can prove  it absolutely to be
venereal but the circumstance of having given it to a sound person.
What may be the case with those in whom it has returned  soon after
the going off of the symptoms, I will not pretend to say; but I should
very much suspect  that,  where the patient has continued well for a
month, a return cannot be  venereal.  This is only conjecture; and if
we were to reason upon it we might easily reason ourselves  into a
belief of its being venereal; for if the parts can fall back again into
one mode of action, that of inflammation and suppuration, there can
be no reason why they should not fall back again into  the specific
mode of action.  However, as the  common effect of irritation is sup-
puration, and as the specific suppuration requires a peculiar  irritation,
it is easier to conceive that the  parts may fall into the common mode
of action  than into both.  It is possible, however, that in such cases
the venereal action  may be only suspended, similar to what happens
between the contamination  and complete appearance of the disease.
  In  women, returns of the symptoms are more frequent than in men,
particularly of the discharge;  which being similar to  the fluor albus,
and frequently taken for that  disease, gives  less suspicion, although
they are perhaps equally virulent as those in men.
  The distinction between a gonorrhcea and a gleet is not  yet ascer-
tained ;  for  the  inflammation  subsiding, the pain going off, and the
       10 
146                      GONORRHCEA.
matter altering, are no proofs that the poison is destroyed.  It is no
more necessary that there should be a continuance of the inflammation
to produce the specific poison than that there should be a continuance
of the inflammation to produce the gleet, as will appear evident from
two cases before related.1
  The first of these cases shows that the inflammation is not necessary
to the  existence  of the  venereal  poison; and, on  the contrary, the
inflammation may exist  after the matter  discharged has ceased to be
venereal.   I have known cases where the infiammation and discharge
have continued for twelve months, and  with considerable violence;
in the mean time a free intercourse with women has not communicated
the disease.  However, this is not an absolute proof that there is no
virus in the discharge.
  [Ricord.—A distinction between gonorrhcea and  gleet, which Hun-
ter would establish, is far from being admitted, in the  same sense, by
all writers on venereal.
  As has been seen, Hunter, believing gonorrhoea virulent, thinks the
principal difference between it  and gleet, laying  aside  the  greater
mildness of the symptoms in  the latter, consists in  the entire absence
of any virus  in true  gleet; but the reasons which he gives  are  far
from convincing  himself of  the  justness of this  distinction.  The
presence or absence of a contagious property, can lead to no decided
conclusion  on this point.
  Gleet is  to gonorrhoea what the chronic stage, in  inflammations in
general, is  to the acute stage.  A virulent cause  has no more to do
with one than with the other; there is only a difference of intensity
in the  morbid  state, whence  result differences in the symptoms, and
especially in the secretion, which is more or less purulent in the acute
stage, and more or less mucous in the chronic.
  By thus  subjecting gleet to the general laws of catarrhal inflamma-
tions, we can explain, without any need of hypotheses, its liability to
aggravations, to intermissions, and to  fresh attacks.  We discover a
reason for the contagious or innocuous character of the morbid secre-
tion, without being forced to admit the presence or  absence of a virus.
And whilst we emerge from  the uncertainty in which  Hunter leaves
us, as well as if we adopt the  rational doctrine of B. Bell, we arrive at
the certain conclusion,  that the more purulent the secretion is, the
more it may act as a contagious principle,  in #virtue of its  irritant
properties; and that,  on the contrary, it has  no effect  when it passes
into the  mucous  stage.   It is evident that a running,  which  has  be-
come innocuous,  as last supposed, may become again  contagious, on
returning to the acute stage;  and we can thus account  for those cases
which  Hunter  vainly endeavors to explain, and for the too guarded
opinion of Wathely, who believes that a purely mucous  discharge is
still contagious.]
Vide pages 76 and 77. 
SEQUELAE.
147
                    CHAPTER VIII.

OBSERVATIONS ON THE SYMPTOMS WHICH OFTEN REMAIN
              AFTER THE DISEASE IS SUBDUED.

  It often happens, after the virus is destroyed, and the venereal inflam-
mation removed, that some one, two, or  more of the symptoms shall
continue, and perhaps prove more obstinate than the original disease
itself.  Some of these symptoms shall continue through life, and even
new ones shall  sometimes arise  as  soon as the first have subsided.
All these symptoms are commonly imputed by the patients themselves,
and what is still worse, by some of the profession, to the original
disease having been ill treated.  But certainly, so far as we are yet
acquainted with the disease and method  of cure, this is not true;  for
the methods of treatment, though numerous, may be said to be very
similar; and we shall find  these symptoms not to be consequences of
any one mode of treatment, but that they happen indiscriminately
after  them  all.   Yet I can  conceive that many constitutions and
particular parts  often require one mode of treatment in preference to
another, and probably require modes that we are not as yet acquainted
with; but if these peculiarities of constitution  or of parts are not yet
known, which must often  be the case, the practitioner is not to be
rashly accused of ignorance.
  In the Introduction, I observed that the venereal disease is capable
of calling into action  such susceptibilities as are  remarkably strong,
and peculiar  to certain constitutions and countries; and that, as the
scrofula is predominant  in this country,  some of the effects of  gonor-
rhoea may partake of a scrofulous nature.
  The symptoms which  continue after the virus is gone  do not owe
their continuance to the specific qualities of the virus, but  to its effects
upon  the parts, such as  inflammation, and its  consequences; for the
same  degree of inflammation,  arising from  any other cause,  would
leave most of the same effects.  But I suspect that the continuance of
the discharge called a gleet is  an exception  to this; for we find that
it is often cured by the same mode of action which would  produce the
other symptoms, that is,  inflammation; and we find in general that a
discharge brought  on by violence  of no specific  kind does not last
longer than the  violence, even although the cause has been continued
for some time, as is often the case during the use of bougies.1

  1 Ricord.—Because a discharge, which was produced by a mechanical irritant, as a
bougie, for example, soon subsides after the removal of the cause, we are not forced
to admit the presence of a specific cause, when the running continues for a longer time,
independently of any mechanical irritation.   Many other things are necessary besides
the action of syphilitic virus, for a catarrhal inflammation to arise and  run its course. 
148
GONORRHCEA.
     The first of the continued symptoms may be reckoned the remains
  of the disagreeable sensations excited by the original disease.
     The second, the discharge called a gleet.
     The third, the chordee.
     The fourth, the irritable state of the bladder.
     The fifth, the increase and hardness of the epididymis.

    § 1. Of the Remains of the Disagreeable Sensations  excited  by the
                           Original Disease.

    The disagreeable sensations which continue in the urethra and glans
  occur most frequently when the bladder has  sympathized with the
  urethra during the disease; for then there are often the remains of the
  old shooting pains in the glans, or on its surface, which take their rise
  from the bladder.  These, however, commonly go  off", seldom  being
  the forerunners of any  bad symptoms,  and therefore are not  to be
  considered as part of the disease, but merely a  consequence; yet they
  are often very troublesome and teazing  to the patient,  keeping his
  mind in doubt whether he is cured or not, which makes him frequently
  become the dupe of ignorant or designing men.
   As  these remaining sensations vary  considerably in their nature,
  perhaps no one method of treatment will always be proper.  I have
  known a bougie, introduced a few times, take off entirely the disagree-
  able sensation in  the  urethra;  and I have known  it  to do no  good.
  Gentle irritating  injections, used occasionally, will  often  alleviate in
  some  degree  those complaints.  A grain of corrosive sublimate  to
 eight ounces of water makes a good injection for this purpose; but all
 such applications are in general no more than palliatives.
   I have known the use of hemlock relieve the  symptoms very much,
 and in some cases entirely cure them; while in  many others it has
 not had the least effect.
   A blister  applied  to the  perineum will entirely cure some of the
 remaining symptoms, even when they extend towards  the bladder, as
 will be explained  hereafter;  indeed, it  appears to  have  more  effect
 than any other remedy.   A blister to the small of the back will also
 give relief, but not so effectually as when  applied to  the perineum.
   The following cases are remarkable instances of this.  A Portuguese
 gentleman, about  twenty-five years of age, had  contracted a venereal
 gonorrhoea, of which he was cured;  but  two years after, many of the
 symptoms still continued, and even with considerable violence   The
 symptoms were the  following:  a frequency in making  water,  and
 when the inclination came on he could  not retain  it a moment; a

 The nasal mucous membrane is excited for a time by snuff; its sensibility and its
 secretion are increased; but there are  other requisites for a regular coryza to take
 p ace, and these are assuredly not the presence of a specific cause.  The same is true
 ot gonorrhoea ; without the necessary predisposing cause, the exciting cause whatever
 it may  be, has no effect.  Take, as a proof, those persons, who run every risk of
 contagion with impunity; whilst in others, who have the necessary pred'sposifion
 the simplest cause : the catamenial flow, leucorrhcea, the introduction^ oa.bougieor
 an irritating injec ion as m Swediaur's experiment, are sufficient to excite a discharee
identical with that of the most perfect gonorrhoea.—Ricord.              aiscnarge, 
SEQUELS.
149
straining, and pain in the bladder after voiding it;  a constant pain in
the region of the bladder; a shooting pain in the urethra, which ex-
tended often to the anus; strange sensations in the perineum; a sense
of weariness in the testicles; and if he at any time pressed his thighs
close together the pain or sensation in  the perineum was excited.  It
was supposed at Lisbon  that he had the stone, and he came over to
London for a cure of that disease.  He was examined, but no stone
was found.  He was ordered to wash the external parts every morning
with cold water, which he did for a fortnight, but found no benefit.
I  was consulted, and informed of all the above-mentioned circum-
stances.  As a staff had  been passed, there could be no stricture;
however, I thought it was possible there might be a diseased prostate
gland, and therefore examined him by the anus, but found that gland
of its natural size and firmness.  As there was no visible alteration of
structure  anywhere  to be found, I looked upon the disease as only
a  wrong action of the parts, and therefore ordered a blister to be
applied to the  perineum, which being kept open only a few days all
the symptoms were entirely removed.  He retained his water as usual;
all the disagreeable sensations went off; and the blistered part was
allowed to  heal.  About a fortnight after, he got a fresh venereal
gonorrhcea, which alarmed him very much, as he was afraid it might
bring back all his former symptoms, which, however, did not return,
and he was soon cured of the gonorrhoea.   He stayed in London some
time after, without any relapse.
   Another case was that of a gentleman's servant in the country.   He
had, from a venereal cause, a disagreeable  sensation whenever he
made water, also  a running, and some  degree of chordee;  which
symptoms he  had labored  under for  a  considerable  time.  He had
 gone through  a course of mercury, which lasted  two months, on  a
 supposition  that  the venereal  virus  had not  been  destroyed, but
 without benefit.  He had after that been bled, used powders of gum
 Arabic and tragacanth,  and taken calomel in small  doses, with no
 better success.  He then had recourse to injections and bougies of all
 kinds, but with no  better success.   On the ground of the symptoms
 not being venereal, but only wrong actions of the  parts, a blister was
 applied upon  the perineum, repeated  and kept open six days, upon
 which  the symptoms totally disappeared, and  had not  recurred  a
 twelvemonth afterwards.
    This practice is not only of service where there has been a preceding
 gonorrhcea, but I have found it remove, almost immediately, suppres-
 sions of urine from other causes, when the turpentines and opium,
 both by the mouth and anus, had proved ineffectual, and when the
 catheter had been  necessarily introduced twice a day to draw off the
 water. But of this  more fully hereafter.
    Electricity has been found to be of service in some cases, and there-
fore may be tried either  in  the  first instance, or when other means
 have failed.                                        .         ,.
    [Ricord.—Continuance of the pain, after  the cessation ot a  dis-
 charge, should render patients more guarded than usual, since, under
 such circumstances, a relapse is very easily brought on. 
150                          GLEET.
  In some cases, the persistence of the pain constitutes a true nervous
affection, a urethralgia, which may be continuous, irregular, or deci-
dedly intermittent.
  To the therapeutic  agents mentioned  by Hunter, the following
should  especially be added:  small cold opiated enemata;  frictions
with laudanum, or extract  of belladonna  over the  course of the
urethra; passing these substances into the canal by means of a bougie,
and, above  all, following the  advice  of Professor Lallemand,  of
Montpelier, superficial cauterization of the canal with his instrument.
  I have often succeeded in obstinate cases,  by  using a blister,
sprinkled with morphia, and  by giving sulphate of quinia, combined
with camphor, when there was any appearance of intermittence.—
Ricord.]

  [Editor.—M. Yidal states that he has succeeded in obtaining speedy and
complete relief in these neuralgic pains in the urethra following gonorrhoea,
by a very simple means, viz.: compression of the penis.  This is exercised
by means of strips of sticking-plaster, half an inch wide, and just long enough
to encircle the organ. They are first applied to the glans, and then con-
tinued up to the scrotum, each strip overlapping the preceding one.  They
should be applied as tight as possible, without interfering with the passage
of the water, and should  be continued after  the pain has ceased, in order to
prevent a relapse.  This method is chiefly applicable to those cases in which
the pain is situated in the spongy portion of the urethra.
  M. Civiale states that one of the most efficacious remedies in this affection
is the introduction into the canal of a soft bougie, of medium size, and leaving
it there five or ten minutes.  This should be repeated every day.
  Many of these cases are dependent on the  mental state of the patient, and
require mental rather than physical treatment.]

                          § 2. Of a Gleet.

  Whatever method has been had recourse to in the  cure of the vene-
real inflammation, whether injections have been used  or internal medi-
cines (mercurials, purgatives, or astringents), it often  happens that the
formation of pus shall continue, and prove more tedious and  difficult
of cure than the original  disease.  For, as I have already observed,
the venereal inflammation is  of such a nature as to go off itself, or to
wear itself out; or, in other  words, it is such an action of the living
powers as can  subsist only for a certain time.  But this is not the case
with a gleet, which seems  to take its rise from a habit of action which
the parts have contracted; and, as they have  no disposition to lay
aside this action, it of course is continued; for we find in those gonor-
rhoeas which last long,  and are tedious in their cure,  that this habit is
more rooted than in those which go off soon.
   This disease, however, has  not always the disposition to continue,
for it often appears to stop of itself, even after every  method has been
ineffectually used.  It  is  most probable that  this arises from some 
GLEET.
151
accidental  changes in the constitution, not at all depending upon the
nature of the disease itself.
  I have suspected that there was something scrofulous in some gleets.
We find frequently that a derangement of the natural actions of a part
will  be the cause of that part falling into some new disease to which
there may  be a strong tendency in the constitution.  We find that a
cold falling on the eyes produces a scrofulous weakness in those parts,
with a considerable discharge.  There are often scrofulous swellings
in the tonsils from the same cause.
  This opinion  of the  nature of  some gleets is strengthened  by the
methods of cure;  for we find that the sea-bath cures more  gleets than
the common cold  bath, or any other mode of bathing.   I have never
yet tried the internal use of those medicines which are generally given
in the scrofula; but I have found sea-water, diluted and used as an
injection, cure some gleets,  though it is not always effectual.
  A  gleet is generally understood  to arise from  a weakness; this
certainly gives us  no idea of the disease, and indeed  there  is none
which can be annexed to the expression.  By mechanical weakness,
is understood the inability to perform some action or sustain some
force.   By animal weakness the same is understood.  But when the
expression is applied to the animal's performing  an uncommon or an
additional  action, I do not perfectly understand it.
  Upon this idea of weakness depended, in a great  measure, the usual
method of cure; but we shall find that the treatment founded on this
idea is so far from answering in all  cases that it often does harm, and
that a contrary practice is successful.
  A gleet  differs from a gonorrhoea: first, in this, that though a conse-
quence of it, it is perfectly innocent with respect to infection; secondly,
when it is a true gleet, it is generally different in some of the consti-
tuent parts of the discharge, which consists of globular bodies, floating
or wrapt in a slimy mucus, instead of a serum.   But the urethra is so
circumstanced as easily to fall  back into  the formation of pus; and
this commonly happens upon the least increase of  exercise, eating or
drinking indigestible food, or anything which increases the circulation
or heats the patient.  The virus, however, I believe, does not  return;
but  of this I am  not certain, for there are  cases that  make  it  very
doubtful;  as was before observed.
  I am inclined to suspect that a gleet arises from the  surface of the
urethra only, and not from the glands; for I have observed, in several
instances, that when the passage has just been cleared, either by the
discharge of urine or by the  use of an injection, a lascivious idea has
caused the natural slime to flow very pure, which I do suppose would
not  have  happened if  the parts secreting the liquor had  assisted in
forming the gleet.1

  1 Added: " A gentleman has a gleet, occasionally attended  with pain in making
water ; it is brought on by sitting in a postchaise, if he sits on  the cushion,  but not if
he sits on a hard seat; in never comes on after riding on  horseback, but he believes
that riding upon a padded saddle would produce it."—Home.
  [Pathological anatomy has taught me, contrary to the idea which Hunter advances,
that the same elements of the mucous  membranes are affected  in the chronic stage or
gleet, and in the acute stage or gonorrhcea.—Ricord.] 
152
GLEET.
   A gleet is supposed to be an attendant upon what we call a relaxed
constitution; but I can hardly say that I have observed this to be the
case; at least, I have  seen instances where  I should have expected
such a termination of a gonorrhoea, if this had been a general cause,
but did not find it; and I have seen it in strong constitutions, at least
in appearance, in every other respect.   Gleets do not in all cases arise
from preceding gonorrhoeas, but sometimes from other diseases of the
urethra.  A stricture  in the  urethra is, I  believe, almost always
attended  with a gleet.  It  sometimes arises from a disease  in the
prostate gland.
   When a gleet does not arise from  any evident cause, nor can  be
supposed  to be a return of a former gleet in consequence of a gonor-
rhoea, a stricture or diseased prostate  gland is to  be suspected; and
inquiry should  be made into the circumstances  of making water,
whether the stream is smaller than common, whether there be any
difficulty  in voiding it, and whether  the calls to make it are frequent.
If there should be such symptoms, a bougie,  of a size rather less than
common,  ought  to be used,  which,  if there is a  stricture, will stop
when it reaches it; and if it passes on to the bladder with tolerable
ease, the disease is probably in the  prostate  gland, which should  be
next examined.   But  more  fully of both  these complaints  here-
after.1
   [G. G. B.—A  gleet may arise from  any source  of  irritation in any
part of the urinary passages, or  even  in the neighborhood.  Hemor-
rhoids are a frequent cause, and, in children, worms in the intestines.
In like manner it may be occasioned by a calculus, or by other disease
in the bladder or kidneys, and still more commonly, as the author has
stated, by stricture in  the urethra.  But perhaps  the most common
cause, if we except stricture, is some derangement in the secretion of
the urine, by which that fluid is rendered too acid  or alkaline, and is
converted into a perpetual source of irritation, occasioning  various
derangements of the  urinary organs, and none, at least in those who
have suffered from gonorrhoea, more frequently than  gleet.
   The cure of a gleet depends chiefly on the discovery, and the removal
of the causes which excite it.  While  these continue, the effect of any
remedies which  are calculated to act directly on the discharge is gene-
rally inadequate, and at the best temporary.   When the source of  ir-
ritation, whatever it may be, is taken away, there is seldom much diffi-
culty in repressing the excessive secretion from the urethra.
   The same remark  applies to leucorrhcea in women.  This is very
generally kept up by some  uterine derangement,  as  amenorrbcea,  or
irritability of the os uteri.   While this derangement subsists, no reme-
dies are effectual;  but if it is first corrected by appropriate treatment,
the discharge may usually be arrested, without great difficulty, by a
little perseverance in the use of the commonest astringents.]

  "The passage of a bougie, with tolerable ease into the bladder, does not indicate a
probable disease of  the prostate as the cause of the continuance  of the discharge, as
Hunter asserts.—Ricord,                                          6 ' 
TREATMENT.
153
         § 3.  Of the Cure of Gleets—constitutionally—locally.

  As this discharge has no specific quality, but depends upon the con-
stitution of the patient or nature of the parts themselves, there can be
no certain or fixed method of cure;  and as it  is very difficult to find
out the  true  nature of different constitutions  or of parts, it becomes
equally difficult to prescribe with certainty the medicines that will
best suit this disease; for so great is the variety in constitutions, that
what in one case proves a cure will in another aggravate the complaint.
  There are two ways of attempting the cure of this complaint; con-
stitutionally, or locally.
  Medicines, taken into the  constitution with a view to the cure of
gleet, may be supposed to act in three ways; as specifics,1 strengtheners,
and astringents.
  The specific power of internal medicines upon those parts is not very
great; however, we find that some of them, such as the balsams, tur-
pentines, and  cantharides, are of use,  especially in slight  cases.  I
think I have been able to ascertain this fact, that when the balsams,
turpentines, or cantharides are of service, they are almost immediately
so; therefore, if upon trial they are not found to lessen, or totally re-
move the gleet in five or six days, I have never  continued them longer.
And  even where  they have either  lessened or totally removed the
gleet in that time, it will often recur upon leaving them off, and there-
fore they should be continued for some time after the symptoms have
disappeared.   I have known cases where the gleet has disappeared
immediately upon  the  use  of the balsam capivi, and  recurred upon
the omission of it;  and  I have also seen where that medicine has kept
it off for more than a month, and yet it  has recurred immediately upon
laying  it aside, and  stopped again as quickly when the patient has
returned to  it.  In such cases  the other methods of cure should be
tried.   The balsams may either be given  alone, or mixed  with other
substances, so as to make them less disagreeable.2
  The general strengtheners of the habit need  only be given when the
parts act merely as parts  of that habit.  The whole being disposed to
act properly,  these parts are also disposed to act in the same way. By
general strengtheners are here meant the cold bath, the sea bath, the
bark, and steel. Astringents taken into the constitution, have no great
powers; and  if they had, they might be very improper, as anything
that could act with powers in the constitution equal to what would be
necessary here,  might very much affect many natural operations in the
animal economy.  The astringent gums and salt of steel are commonly
given.
  The  second  mode of cure is by local applications.  These  may be
divided into four, which are: specifics, astringents, irritating medicines,
and such as act by derivation.

  1  It may be necessary to  remark here, that by specific I do not mean a specific for
the  disease, but only such medicines as act specifically on the parts concerned, as the
turpentines, cantharides, &c.
  2  Added: " I believe that the balsam of capivi cures a gleet more permanently than
injections, its action being specifically upon the parts."—Home. 
154                         GLEET.
  The specifics, applied locally, we may reasonably suppose will have
greater effects than when given internally, because they may be applied
stronger than can safely be  thrown into the circulation.   Of this, I
think I have had experience.
  The astringents commonly used are the decoction of the bark, white
vitriol, alum, and preparations  of lead.  The aqua vitriolica ccerulea
of the London Dispensatory, diluted with eight  times its quantity of
water, makes a very good astringent injection. The same observations
that I made on the specifics are applicable to the astringents; I believe
that they act nearly in the  same  manner, and have the same effect.
What their mode of action is it is difficult  to say.
  When  either  of these methods has been used, and has had the de-
sired  effect, it should  be continued for a  considerable time after the
symptoms have  disappeared; and  the  time must be  in proportion to
the duration of the complaint, or the frequency of its returns.  If it
has been of long standing, we may be sure that the disposition to such
a complaint is strong;  and  if  it has returned frequently, upon the least
increase of circulation, we may expect the same thing to happen again.
Therefore, to correct the bad habit, it is necessary to continue the medi-
cines  a considerable time.
  Irritating applications are either injections or bougies, simple, or
medicated with irritating medicines.  Yiolent exercise may be  con-
sidered as having the same effect.   Such application  should never be
used till the other methods have been fully tried and found unsuccess-
ful.   They differ from the foregoing by producing at first a greater
discharge than that which they are intended to cure; and the increased
discharge may or may not  continue as long as the application is used.
It becomes, therefore, necessary to inquire how long they are to be used
to produce a cure of the gleet.  That time will generally be in  pro-
portion to the violence used, and the nature of the parts which form the
matter, and according to the disposition being strong or weak, joined to
its duration, and  the greater or less irritability of the parts.  If the
parts are either weak or irritable, or both, an irritating injection should
not be used; if strong, and not irritable, it may be used with safety.
In this last case, if it is an  injection that stimulates very considerably,
perhaps it may be sufficient to use it twice or thrice a day.  I knew a
gentleman who threw into  the urethra,  for  a gleet of  two years' stand-
ing, Goulard's extract of lead, undiluted, which produced a most violent
inflammation; but when the inflammation went off, the gleet was cured.
Two  grains of corrosive sublimate to eight ounces of water are a very
good  irritating injection.
   If  it is a gleet  of long standing, it may require a week  or more to
remove it, even with an irritating injection; and if the injection is less
irritating, so as to give but little pain, and to increase the discharge in
a small degree, it may require a fortnight.  But one precaution is very
necessary respecting the use of irritating injections;  it should  be  first
known, if possible,  that they will do no harm.  To know this may be
difficult in many cases; but the nature of the parts is  to be ascertained
as nearly as possible;  that is, whether they had ever been hurt before
by such treatment; whether they are so susceptible of irritation as that 
TREATMENT.
155
the irritation may be expected to run along  the urethra and produce
symptoms in the bladder, for in such cases irritating applications do not
answer, but, on the contrary, often produce worse disorders than those
they were meant to cure.
  Bougies maybe classed with the irritating  applications, and in many
cases they act very violently as such.  They appear to be more effica-
cious than injections, but they require longer time to produce their full
effect.  A simple, or unmedicated bougie, is, in general, sufficient for
the cure of a gleet, and requires a  month  or six weeks' application
before  the cure can be depended upon.   If bougies are made to stimu-
late otherwise than as extraneous bodies, then a shorter time will gene-
rally be sufficient.  Probably the best mode of medicating them would
be by mixing a little turpentine, or a little camphor with the composi-
tion, so as to  act specifically on the parts;  but great care should be
taken not to irritate too much.
  The size of the bougie should be smaller than the common, and need
only be five  or six inches long, as it seldom happens that a greater ex-
tent  of the urethra has a disposition to gleet; but no harm will arise
from passing a bougie of the common length  through the whole extent
of the  urethra.
  In the cure of a gleet, attempted by  means of the bougie, we have
no certain rules to direct us when it should be left off, as the discharge
will  often continue as long as the bougie is used.  If, upon leaving off
the bougie, after the use of it for several  weeks, the running ceases, then
we may hope there is a  cure performed; but if it should not be in the
least diminished, it is  more than probable that bougies will not effect a
cure, and therefore it is hardly necessary to have recourse to them
again.   Yet, if the gleet is in part diminished, it will be right to begin
again, and probably it may be proper to increase the irritating quality
of the bougie, in order  to suit it to the diminished irritability of the
parts.
   The fourth mode of cure is by sympathy, or by producing an irrita-
tion in another part of the body, which shall destroy the mode of action
in the urethra.
  I knew a case of obstinate gleet attended with very disagreeable sen-
sations in the urethra, especially at the  time of making water, removed
entirely by two chancres appearing upon the glans.  The patient had
taken all the medicines  commonly recommended, and had applied the
bougie without effect.
  A gentleman informed me that he had cured two persons of gleets
by aPPtymg a blister to the under side of the urethra; and I have
known several old gleets, after having baffled all common attempts,
cured by electricity.   All these different methods of cure alter the dis-
position of the part.
  In whatever way the cure is attempted, rest or quietness in most cases
is of great consequence; for, as  I have observed, exercise  is often  a
cause, not only of its continuance, but of its increase and return.  But
this  idea is not to be too rigidly adhered to, especially in cases which
have been treated unsuccessfully, as I have known some that have got 
156
GLEET.
immediately well by riding on horseback after long disuse of that ex-
ercise.
  Regularity and moderation in diet should be  particularly attended
to; for irregularities of this kind either hinder the cure or bring on a
return of the disease.
  Intercourse with women often causes  a return, or increase of gleet,
and in such cases it gives suspicion of a  fresh infection; but the differ-
ence between this and a fresh infection is, that here the return will fol-
low the connection so close as to be almost immediate, and that circum-
stance, joined with the other symptoms,  will in general ascertain the
nature of the discharge.
  The cure of the gleet in women is nearly the same as in men, except
in the use of what I have called specifics to the parts; for as the gleet
in women is principally from the vagina, I believe that this part is not
more affected by the turpentines than other parts are; but as the vagina
is less irritable than the urethra in men, the astringents which are ap-
plied to it may be considerably stronger.  Neither can we use the bougie
in cases of gleet in the vagina; and when the gleet  is only from the
urethra, I imagine it is hardly ever attended to in women.
  [Ricord.—Nothing  is more  common than the persistence of a dis-
charge in the chronic stage, or, in other words, a gleet.  It appears in
some patients as a slight, but constant oozing of mucus, and  in others,
in the form of a drop, which is observed especially in the morning, and
is commonly called the goutte militaire.
  Besides those  remedies, of which we have already spoken,  and those
which Hunter mentions, allow me to add some others, which my daily
practice authorizes me to recommend.
  Injections.—Todine is often successful in obstinate cases, after the
pathological changes in the membrane have passed off;  especially in
that state of things, which Hunter understood so well, where scrofula
seems to constitute part of  the disease,  or keep it up.  In  that case,
injections are made of one drop of tincture of iodine to an ounce of
distilled water.   The quantity of the  tincture is increased,  following
the rules which I have laid down before, until the discharge is stopped,
or its increase under the  treatment compels us to suspend  the injec-
tions.
  Under the same  circumstances, in  a  number of obstinate cases, I
have employed successfully a solution of the proto-iodide of iron, com-
mencing with a grain to an ounce of distilled water.
  Meshes.—A new mode of  treatment has  also yielded me numerous
favorable results. I have elsewhere laid down the rule that one of the
first requisites for the cure of inflammation of the mucous membranes
is to isolate them, and prevent their walls coming in contact.  In ure-
thral gonorrhoea, this is of more importance than protecting the walls
of the urethra from contact with the urine.  But the disadvantages re-
sulting from the painful introduction of foreign bodies in the acute stage
surpass the benefit derived, but they cease to exist in the chronic stage;
and, when other  means have failed, I often employ with success a mesh
of dry linen, introduced into the canal  by means of  an India rubber
canula and a stylet.  This mesh is left in place until the next emission 
TREATMENT.
157
of urine, when it is renewed, and is repeated in the same way up to
the time of cure, which takes place in seven or eight days, or later.
  These meshes, which I use at first in a dry state, may also be smeared
with medicinal  substances.  You may also supply their place, as M.
Crespiat does, with little cylindrical bags of gold-beater's skin, which
are first introduced empty, by means of a stylet placed within, and
afterwards distended with air or water.
  Bougies and Sounds.—Bougies and sounds often cure cases of gleet
which are refractory under  every other mode of treatment.  These
instruments, either simple or medicated, may be introduced, from time
to time, or may be worn permanently.
  In some cases, in order to produce the desired result, it is  sufficient
to pass a bougie once or twice a day, and leave it in the urethra a few
minutes.  But the cure does not always take place in the same manner.
Generally, the morbid secretion is augmented at first, the instrument
acting as an irritant, as Hunter remarks; whilst in some, perhaps the
rarer cases, it insensibly dries up,  without being previously increased.
As  soon as the morbid secretion  is  sufficiently revived, or stops, the
use of the instrument  must  be  suspended; in the first case, it might
keep up or aggravate the disease;  or, in the second case, bring it back
again,  after having cured it.
  When the discharge continues in statu quo, under the  simple intro-
duction of bougies, gradually increased in  size, or, if too much irrita-
tion results from passing them repeatedly, we should direct them to be
worn  constantly.  In this way, also, we obtain a gradual cessation of
the discharge in the rarer cases, or else we excite a copious and decided
suppuration, which compels  us to suspend the treatment, after which
a permanent cure  generally follows.
  When bougies and sounds exert no decided action, they may succeed
better smeared with a  little  weak or strong mercurial ointment, and
continued  until an increase  in the discharge is produced.  We may
obtain a very good effect by using an ointment made of one grain of
nitrate of silver to a drachm of  cerate.
  Cauterization.—The most active treatment of obstinate  gleets is cau-
terization with nitrate of silver, following the rules which I have else-
where laid down.   In some  cases, the discharge is  confined to a few
follicles, with longer or shorter excretory ducts, which escape the action
of the above mentioned remedies, unless  they are within view, as is
the case in different varieties of hypospadias.  In the latter case, we
may lay them open with a lancet  or cataract-needle, and  cauterize
them.
  Regimen.—It is  well to mention, in this place, that the regimen, con-
trary to Hunter's  advice, should be  tonic and strengthening, instead
of being as strict as before; noticing, however, the effect produced, so
as to modify it more or less, as may  be necessary.
  Derivatives.—Although I agree with Hunter on the effects of deriva-
tives in general, I must say,  after collecting statistics on  a large scale,
that I have never  seen the development of a chancre cause a gleet to
stop, and vice versa.
  Internal, or Constitutional Treatment.—In the latter stages  of a dis- 
158
GLEET.
charge, various forms of iron and astringents may have a good effect;
but much less reliance can be placed on true anti-blennorrhagics.  Di-
rect treatment should be preferred.
   Coitus.—Sexual intercourse  is often the final  requisite for a cure.
In some patients, coitus at intervals is sufficient; in others, a little irri-
tation should be excited by its repetition.
  The requisite for success, in the majority of cases, is  to  make  the
chronic pass into the acute stage for a time.—Ricord.]


                   § 4. 0/* the  Remaining Chordee.

  This symptom, I have  already observed, often  remains after every
mark of the true virus is removed, and may or may not be attendant
on any of the other continuing symptoms.
  Mercurial ointment applied to the part may be of service, and, if
joined with camphor,  its  powers will be  increased.  I  have known
electricity  cure a chordee of long standing.  If it is the spasmodic
chordee that remains, bark should be given.


         §  5. Of the Continuance of the Irritation of  the Bladder.

  The irritation of the bladder sometimes continues after every other
symptom has ceased,  and it may be an attendant upon all or any of
the other continuing symptoms;  it seldom lasts with the same violence,
although it is often very troublesome.  When this irritation is kept up
with the same violence, the bladder itself  may be suspected of being
diseased; or it may arise  from its connection with other parts, such as
the urethra, or prostate gland; for  a  stricture in the urethra coming
on, will prove the cause of its  continuance, and a disease in the pros-
tate gland will do the  same.
  Neither of these diseases will probably follow the gonorrhcea so
closely as  to keep up  this irritation, though perhaps  they may have
been taking place prior to the  gonorrhoea, and  so contribute to its
increase and  continuance, which may probably  be ascertained by a
history of the patient preceding the present complaint; however,
before the bladder itself is attempted to be cured, a bougie should be
passed, and if no stricture is found, then the prostate gland should be
examined, as shall be described.
   When the disease is in the bladder only, I think the pain is princi-
pally at the close of making water,  and for a little while after.  The
cure  of this  symptom consists  in  opiate clysters, cicuta,  bark, sea-
bathing, and I should be inclined to recommend the application of a
blister to  the perineum in men. How far  opiate clysters  can affect
the bladder in women as  they  do in men, I am not certain.1

  1  The irritation of which Hunter is here speaking, continues especially at the neck
of the bladder, and it is rare for the body of this organ to participate in it.  When
ordinary means fail, cauterization with  nitrate of silver may be employed with great
chances of speedy success.—Ricord. 
SEQUELS  OF  SWELLED TESTICLE.
159
          § 6. Of the Remaining Hardness of the Epididymis.

  This  symptom I  have observed  remains long  after every other
symptom  is removed, and may continue even for life;  but seldom or
ever any bad consequences happen from it if the vas deferens is not
rendered impervious;  and not even then if it is  only in one testicle,
the other  being  equal to all the purposes of generation.  As this is
the case, we must at once see  that no certain method of resolution is
yet known.  The application of the steam of hot water  with camphor
may be tried, especially in such cases as are not  disposed' to be per-
manent ;  and the scrotum may be rubbed with  mercurial ointment,
joined with camphor.  But in most cases this  practice will prove too
tedious, or rather too inefficacious to be long persisted in.
   [Ricord.—After gonorrhceal epididymitis, it  often  happens that
the epididymis  remains  engorged and indurated, or at least hyper-
trophied.   The  cauda of the  epididymis especially maintains an in-
creased volume.  As Hunter remarks, it generally does no harm; but,
under some circumstances, this continued abnormal development of
the epididymis is due to  a strumous diathesis,  and is only the prelude
or exciting cause of tubercular sarcocele, which is so common and so
frequent.
   Indeed, tubercular sarcocele succeeds gonorrhceal epididymitis so
frequently, that, in Germany,  this tubercular affection is considered a
specific consequence of a gonorrhceal virus.  This, again, is a mistake.
Tubercular degeneration in this case differs in no respect from what
it is under any other circumstances.
   I cannot speak of  tubercular sarcocele without  remarking on  an
extraordinary idea lately advanced by M. Yidal (de Cassis), who says
that, when only one testicle is affected, the tubercles are malignant;
that is to say, that tubercles are to be feared elsewhere, or, in other
words, a  tubercular diathesis exists; whilst, if the two testicles are
affected, nothing farther  is to be dreaded.
   A person must be ignorant of the laws of tuberculosis in general,
and of tubercular sarcocele in  particular, to advance a  like assertion
before such a body as the Surgical Society.
   I lately exhibited to the Academy of Medicine1 two cases of tuber^
cular affection of the urethra,  which,  during life, gave rise to a symp-
tomatic gonorrhceal discharge in subjects who presented at the  same
time tubercles in the prostate, in the two epididymes, in the bladder, in
the ureters, in the kidneys, and in the lungs.]

   [Editor.—Both vasa deferentia may become  obliterated and  produce
sterility, as a consequence  of gonorrhceal epididymitis, as shown by the re-
searches of M. Gosselin.  See Part III.  Chap. YIIL]

        1 Bulletin of the Academy of Medicine, Paris, 1850, vol. xv. p. 565. 
 
PART   III.
                      CHAPTER  I.

OF DISEASES SUPPOSED TO ARISE  IN CONSEQUENCE OF VENE-
       REAL INFLAMMATION  IN THE URETHRA  OF MEN.

   The gonorrhoea produces, or at least is supposed to produce, besides
those disorders already mentioned, many others which are totally dif-
ferent from the original disease.   How far they do all or any of them
arise in consequence of this disease, is not clear;  but as they are  dis-
eases of the urethra, and are both numerous and important, I mean to
treat fully of them in this place.  If any of these diseases arise from
a  gonorrhoea, they are most probably not  the consequences of  any
specific quality in the venereal poison, but are such as might be pro-
duced by any common inflammation in  those parts, as was observed
of the continued symptoms.
   In this investigation, we shall find some of the complaints arising
out of each other, so that there is frequently a series of them.  Thus,
a  stricture of the urethra produces an  irritable bladder, a  frequent
desire to make water, increased  strength of the bladder, a dilatation
of the urethra between  the bladder and stricture, ulceration, fistulas
in perinaeo, dilatation of the ureters, and enlargement of the pelvis of
the kidneys; besides other complaints that  are sympathetic, such as
swellings of the testicle,  and of the glands in the  groin.  I shall treat
of the diseases of those parts in the order in which they most com-
monly arise.
   It may be  observed that most of  these diseases, especially the dimi-
nution of distensibility in the bladder, attack  men  advanced beyond
the middle age; although many, if  not all of them, are at times found
in younger subjects; and the circumstance of their  appearing at  this
period arises probably in some degree from a long habit of an unnatural
mode of life producing many diseases, such as gout; for certainly such
complaints do not so frequently take place among the more uncivilized
nations.
   The most frequent disease  in  the urethra is an obstruction to the
passage of the urine; it happens both in young and old, although most
frequently in the latter.  Before I begin to treat of this subject, I shall,
for the better understanding of the  whole, make some observations on
the uses of this passage in its natural state.
       11 
162
STRICTURES.
   It may first be observed, that the urethra in man is employed  for
 two purposes.   On  this occasion I may be allowed to make the fol-
 lowing general remark, that nature has not been able to apply any
 one part to two uses with advantage, as might be illustrated in many
 instances in different animals.   The animals whose legs are  contrived
 both for swimming and walking, are not good at either; as seals, otters,
 ducks, and geese.  The animals also whose legs are intended both for
 walking and flying, are but badly formed for either, as the bat.  The
 same observations are applicable  to fish, for  the flying fish  neither
 swims nor flies well; and whenever  parts intended  for  such double
 functions are diseased, both are performed imperfectly.   This is im-
 mediately applicable to the urethra, for it is intended as a canal  or
 passage both for the urine and the semen.   The urine  requires the
 simplest of all canals, and of no greater length than the distance from
 the bladder to the external surface, as we find  the urethra in women,
 birds, the amphibia,  and fish;  but the passage for the semen in the
 quadruped requires to be a complicated canal, and of a length capable
 of conveying the semen to the female, provided with many additional
 and necessary parts, as the corpus spongiosum urethras, musculi accele-
 ratores, Cowper's glands, prostate gland, and vesiculae seminales.  As
 all these parts are to serve the purposes of generation,  and as the dis-
 eases of this  canal are  principally seated in them, we at once see how
 much the urinary organs must suffer from a  connection with parts  so
 numerous and so liable to disease; and what adds to the evif is, that
 the actions of the  urinary organs are constant, and absolutely neces-
 sary for the well-being of the machine, whereas the evacuation of the
 semen takes place only during  a  certain portion of life, is then only
 occasional, and  never essentially  necessary to the  existence  of the
 individual.   The force of this observation is at once  seen by making
 the comparison between the inconveniencies  that attend the expulsion
of the urine in the male and in the female.
   The canal of the urethra is liable to such diseases as are capable of
 preventing in some degree the passage of the  urine  through it; and
 in some of these diseases the passage at last becomes completely ob-
structed.  In all cases  there is  a diminution of the size of the canal,
 but in different ways.  There  are five modes of obstruction, four  of
 which  are diseases of the passage itself; the fifth is a consequence  of
the diseases of other parts.  Three of the former are  a  lessening  of
 the diameter of the passage; the fourth an excrescence in the passage;
 the fifth arises from the sides  being compressed, which may be  done
 either by exterior contiguous swellings, or by a swelling of the prostate
 gland.
   [Ricord.—Strictures of the urethra are sometimes simply spasmodic,
 but are more commonly due to an organic change in  the canal; or, in
 somewhat rarer  cases, they depend on  affections of  the  neighboring
 parts, or on different combinations of these conditions.
   I. Spasm.—It is with reason that Hunter, as well  as  all  good ob-
 servers, admits  the existence  of strictures without any alteration of
 tissue.   Indeed, daily observation  affords instances of such, not only
at the neck of the bladder, and in the membranous or  muscular por- 
STRICTURES.
163
tion of the urethra, but in every other part of the canal, where they
are the result of a kind of tonic action.
  Irregular in the time of their manifestation, in their situation, their
progress, their duration, their final cessation, and their reappearance,
we  cannot, in every case, readily specify the immediate or the predis-
posing cause of spasmodic strictures;  but even if a plausible explana-
tion were not found in the constitutional and local irritability of some
individuals, and in the muscular structure of certain regions, experi-
ence would still furnish proof of their existence, which no ingenious
theoretical reasoning could overthrow.
  II. Organic Changes.—Most strictures are undoubtedly due to a
change either in  the  surface of the canal, or in the substance of its
walls.
  First Variety.  Alteration of the Surface.—Strictures may be caused
by  ulcerations with salient edges, such as I have shown at my clinique;
or  with surfaces more or less fungous, as was observed some time ago
by  Brunner and Mery.
  In certain cases, which are more common than some modern writers
suppose, the urethral canal is obstructed, and its area encroached upon
by  true vegetations  (the caruncles and carnosities  of the ancients),
whose existence is denied by Morgagni, Desault, and others, but rightly
admitted by Hunter, Bell, Andre*, and Baillie.  These vegetations may
exist in any part of the canal, even posterior to the verumontanum, as
stated by Lobstein, Wegelin, and even Scsmmerring.   I have met with
some well-developed examples at the meatus urinarius, where they are
very common in both sexes; in the fossa  navicularis, of which I have
lately shown a specimen at my clinique; in the membranous and pro-
static portions in the same subject, who died at the Hopital des Yene-
riens.  In women, these vegetations are still more common.  M. Amus-
sat cites an example, and  out  of a large number of cases, which I
might report, I have elsewhere mentioned a very remarkable instance.1
  Laennec thought that plastic exudations might form on the mucous
membrane of the urethra, and, after becoming organized, give rise to
false membranes, capable of obstructing the canal.
  Since the works of Brunner and Mery, numerous observations, which
go  to support the opinion of Littre, have placed the frequent existence
of cicatrices in different parts of the urethra beyond a doubt.  Ulcera-
tions, varying in their nature and situation; lacerations, such as occur
in chordee; other solutions  of continuity, produced by various causes,
such as catheters, external violence, etc., and the loss of substance by
gangrene are often followed by cicatrices, which contract the urethra
and shorten it in some cases, or give rise to prominences on its surface,
such as connecting bands, projecting points, valvular  depressions, or
diaphragms varying in size, form, and extent.
  Hypertrophy and engorgement of the folds of the urethra, especially
those at the neck of the bladder, may also form projections, analogous
to  those which depend on  cicatrices; but  the latter are limited and
remain  stationary, while the former may increase in consequence of

          1 Practical Treatise on Venereal Diseases, Paris, 1838, p. 691. 
164                      STRICTURES.
 the  continuance of the morbid  state to which they are due, but are
 susceptible of resolution when this ceases.
   We find also on the mucous membrane of the urethra vascular growths
 of various sizes, which diminish its calibre to a certain extent. Whether
 we adopt the explanation  of these varicose enlargements given by
 Scemmerring, Larbaud, and others, or not, they are more common in
 the posterior part of the canal, and at the opening of the neck of the
 bladder, where  they represent a kind of hemorrhoidal state.   They
 are also not unfrequently observed anterior to  certain strictures, as a
 consequence of  the obstruction which these  exercise to the return of
 the blood.
   Some patients in this state, after having trouble  in  passing their
 urine, find their stream restored after a discharge of blood occurring
 spontaneously, or following the passage of a sound.
   Second  Variety.  Alterations in the Walls of the Canal.—Engorgement
 of the whole thickness of the urethral walls, and  of the muscular
 fibres which encircle certain portions, as  the neck of the bladder, are
 also a frequent  cause  of strictures.   But this  engorgement does not
 always  present  the same form; circumscribed  or diffuse, it occupies
 either one point, or the whole circumference of the urethral  walls;
 and, as  in other tissues, it  is combined with softening or induration.
 True fungous  degeneration sometimes  results  from  it; whilst, in
 numerous cases, callosities assuming a fibrous condition ensue.
   But there is one morbid alteration, which the  theories in vogtie have
 prevented from  receiving its due attention; I mean  those engorge-
 ments, more  common  than  people think, dependent upon the specific
 induration, which often attends a chancre in the urethra, as well as in
 other regions.  These  indurations which constitute a large number of
 strictures, generally resist ordinary local treatment, or become  aggra-
 vated under the influence  of mechanical remedies,  but yield with
 astonishing facility,  in some  cases, to a well-directed antisyphilitic
 treatment.
   Cancer or scrofula may cause swellings of the urethra and produce
 strictures.
   III. Affections external to the Canal.—The  most common
 affections which  proceed from parts external to the urethra, and distort
 or constrict it, are  inflammation of the  neighboring  cellular  tissue,
 terminating in suppuration, causing a loss of substance, and producing
 cicatrices;  or inflammation, followed by indurations  in the form of
 nodosities or rings, which cause  a deviation in the canal, elevate its
 walls, or strangulate it  completely.  Next in order come the swellings
 and diseases of the prostate, which, according to  the common notion,
 account for most of the real or  apparent  changes in the calibre and
 direction of the deeper  portions of the urethra.  And, finally, we have
 contractions of the muscular fibres,  which line what  has been called
 the pyloric valve of the neck of the  bladder.  This peculiar arrange-
ment  of the  mucous membrane  and the muscles of this region, has
beenstudied especially by M. Mercier, in a work published in 1841. It
 must not be confounded with the  valvular projections of the prostate, 
STRICTURES.                      165
which Mr. Guthrie calls the transverse bar, and M. Leroy d'Etiolles the
prostatic collar.
   It is also clear that everything capable  of acting on the exterior of
the canal, and of becoming fixed in its cavity, may, to a certain extent,
be a cause of stricture.
   IY. Compound Causes.—The morbid states, which I have  men-
tioned, may exist alone, or else, uniting in various ways, give rise to
compound strictures.—Ricord.]

                         %1. Of Strictures.

   The first three I shall now consider, of which the first is the true
permanent stricture  arising from an alteration in the structure of a
part of the urethra.   The second is a mixed case, composed of a per-
manent stricture and spasm.   The third is the true spasmodic stricture.
Most obstructions to the passage of the urine,  if not all, are attended
with  nearly  the same symptoms, so  that there are hardly sufficient
marks for distinguishing the different causes.  Few take notice of the
first symptoms of a  stricture till they have either become violent, or
have been the cause of other inconveniences.  For instance, a patient
shall have a  considerable  stricture without observing that he does not
make water freely; he shall even have, in consequence of a stricture,
a tendency to inflammation, and suppuration in the perineum, and not
feel any obstruction to the passage of his urine, nor  suspect  that he
has any other complaint than  the inflammation in the perineum.  In
all of these obstructions the stream of water becomes small, and that
in proportion to the obstruction; but this symptom, though probably
it is the first, is not always observed by the patient.  In some, the
water is voided only in drops, and then it cannot  escape notice; in
others, the stream of urine is forked or scattered: under such circum-
stances, the passage  should be examined with  a bougie; and if one of
a common size passes with tolerable ease, the fifth cause of obstruction
is to  be suspected, which  will  most probably be found to be a  swelled
prostate gland;  for any other  cause that can produce a compression of
the sides of the urethra sufficient to obstruct the urine, will be known
to the patient, such as a tumor  forming anywhere along the canal, or an
inflammation along its sides.  If, therefore, neither of these is known
to exist, the prostate gland should be examined, as will be described
hereafter.
   The spasmodic obstruction will commonly explain  itself when the
symptoms are well investigated, for the obstruction arising from this
cause will not be permanent.  These obstructions, but more particu-
larly  that from  a  permanent  stricture, are generally attended with a
discharge of  matter or a gleet.   This is often considered by the patient
as the whole  disease, and he applies to the surgeon for the cure of a
gleet.  The surgeon often perseveres in attempting the cure of this
disease; but, no success  attending  him, at last  other  symptoms are
observed, and a stricture is suspected, either by the surgeon or patient
In diseases of this passage, and also of the prostate gland and bladder,
there is commonly an uneasiness about the perineum,  anus, and lower 
166
STRICTURES.
part of the abdomen, and the patient can hardly cross his legs without
pain.
  [Ricord.—The above general sketch of the symptoms and differ-
ential diagnosis of the varieties of stricture admitted  by Hunter, is
evidently  very incomplete,  and leaves  more to be supplied than is
suited to the  compass of a note; hence I  will indulge in only a few
reflections.
  Hunter makes the remark, which many persons have  repeated, that
the jet of  urine diminishes in proportion to  the  size of the stricture.
This assertion is substantially true, but is not, however,  absolutely so.
In some patients, the jet is tolerably large, and yet a sound of small
diameter cannot pass the stricture; others, on the contrary, in conse-
quence of inertia of the bladder, projection  of the valve at its neck,
or too great  tonic action of the canal, have a very small stream, or
only pass  their water drop by  drop, though a sound meets with no
obstacle in the urethra.  The distance to which the stream is thrown
is explained in the same way.
  The bifurcation of the stream has not the same value as a diagnostic
sign in every case.  Some mucosity arrested in the canal may form a
plug for a time, or cause the walls to adhere at some  points, so as to
divide the jet of urine in its passage; but, in that case,  the jet, which
was bifurcated at the commencement of emission,  immediately becomes
straight again after it has brought away the mucosity.   On the con-
trary, when the bifurcation of the jet is due to a stricture of the canal,
it continues during the whole time of emission, or at least appears at
first, and perhaps disappearing at the moment when the bladder exerts
its  greatest contractile power, reappears toward the end  of emission.
  In the latter case, bifurcation indicates  either  a projection into the
canal, or a permanent adherence of the  urethral  walls at some point
of  its course.  I showed a patient, at my clinique, the sides of whose
canal were adherent  from right to left, for the  extent of an inch  back
of  the fossa navicularis; thus resembling a double-barrelled gun, or
two superposed cannon.  In this patient, there were  two perfectly
distinct jets.   This adherence was easily destroyed by dividing it.
  Other changes in the stream, such as a scattering  or spiral form,
are not always rightly interpreted.  For these changes  to  have any
value as symptoms, they must take place at the meatus;  for it is well
known that a more or less decided spiral motion takes place in the
jet, at variable distances from the meatus, according to  the force with
which the urine is expelled by  the bladder through a sound urethra.
   Hunter says scarcely anything on  exploration of the  canal, and
yet this is the most certain means of diagnosis.  Exploration may be
made with conical or cylindrical  bougies,  and  with  flexible, soft, or
solid sounds.  We  may employ exploring instruments adapted to
taking an impression of the stricture, and called porte-empreintes.   The
exploration may be made from  before backwards, or from behind for-
wards.
   It often happens, when we suspect stricture in a patient, that a fine
bougie is arrested where a large instrument  enters; sometimes, with  a
straight instrument, we think we meet with  an obstacle, which is soon 
PERMANENT  STRICTURES.
,167
passed by a curved instrument.  Where a stiff instrument is stopped,
a flexible one, even of larger size, passes without  difficulty; so that,
until every mode of exploration has been tried, especially in the pos-
terior  regions of the  urethra,  we  cannot conclude  that  there is a
stricture.  I will say  the same of impressions taken by Ducamp's
method; as M. Amussat justly remarks, the instrument is sometimes
stopped at points where there is no stricture; and, what is still worse,
in the bulbous and posterior portions of the canal, impressions may
be obtained where no alteration  of tissue  exists.  Exploration from
behind forwards, by means of the lenticular explorator of M. Amussat,
or M. Tanchou's probe-pointed  stylet precursor, does not possess  all
the accuracy that is attributed to it.  However, some strictures may
be recognized by M. Amussat's method on their first appearance.  The
flexible .bougies, with  olive-shaped or  spherical  points, invented  by
M. Leroy d'Etiolles, are valuable instruments for  exploration  of the
portions of  the urethra in front of the prostate.  In  the  exploration
of the prostatic portion and the neck of the bladder, great advantage
may be derived  from  M. Mercier's sound with a  short beak  curved
almost at a right angle.
  Laying aside  the phenomena which take  place in respect to the
emission of the urine and the ejaculation of the semen, our certainty
of the existence of a stricture depends entirely either on  an absolute
impossibility of introducing the different explorators above enumerated,
or on their being grasped by the urethra, when introduced within the
narrowed portion.
  A constant gleet, a consequence of chronic inflammation, which  is
the precursor of most strictures, is particularly obstinate after the ap-
pearance  of the latter, and may even increase from  inflammation  of
the tissues  situated immediately behind the constricted parts, which
therefore tend to contract still farther in this direction.
   Yet, if an obstinate discharge from the urethra, however slight, is
sufficient to lead us to suspect the existence of a stricture, we must
beware of believing all adhesions of the lips of the meatus, the least
flake of mucus, or the threads which float in the urine of some patients,
to be incontestable proofs  of a  stricture, as M. Amussat asserts, even
when the most careful  exploration has failed to discover anything.—
Ricord.]
                     CHAPTER  II.

               OF THE  PERMANENT STRICTURE.

  In the permanent stricture (see Plate I. Fig. 1), the patient seldom
complains till he  can hardly procure a passage for  the urine; and fre-
quently has a considerable degree of strangury, and even other symp-
toms that happen in stone and gravel, which are therefore too frequently 
168                 PERMANENT  STRICTURES.
supposed  to  be  the causes  of the complaint.   The disease generally
occupies no great length of the passage; at least, in most of the cases
that I have seen, it extended no farther in breadth than if the part had
been surrounded with a piece of packthread, and in many it had a good
deal of that appearance.   I have, however, seen the urethra irregularly
contracted for  above  an  inch in length, owing to its coats or internal
membrane being irregularly thickened, and forming a winding canal.
  A stricture does  not arise in all cases from an  equal contraction of
the  urethra  all  round, but  in some from a  contraction of one side,
which probably has given the idea of its having arisen from an  ulcer
on that side.   This  contraction of one side only throws the passage to
the opposite  side, which  often renders it difficult to pass the bougie.
The contracted part is whiter  than any other part of the urethra, and
is harder in its consistence.  In  some few cases there are more  stric-
tures  than one.   I have seen half a dozen  in  one  urethra, some of
which were more contracted than  others; and, indeed, many urethras
that have a  stricture, have  small tightnesses in  other parts of them.
This we learn from the successive resistance felt in passing the bougie.
  Every part of the  urethra  is not equally subject to strictures, for
there appears to  be one part which is  much more liable to them than
the whole of the  urethra besides, that  is, about the bulbous part.  We
find them, however, sometimes on this side of the bulb, but very seldom
beyond it. I never saw a stricture in that part of the urethra which
passes through the  prostate  gland ;2 and the  bulb,  besides being the

  1 Ducamp says that we generally find only one or two strictures in the same subject,
and he is right.  Yet Hunter met with six, M. Lallemand, of Montpellier, seven, and
Colot, whose veracity on this point has always been called in question, says that he
has observed eight.  The students following my clinique at the Hdpital des Veneriens,
have seen a patient, who had been an inmate of other hospitals of the capital, and
whose urethra was contracted throughout its whole extent, with here and there a break;
there were also  ten fistulous openings, the most anterior on one side of the frsenum,
and the others scattered along the spongy portion of the canal, and in the vicinity of
the bulb and the perineum.  Since the publication of the first edition of this work, I
have met with  two  cases in which the urethra resembled a string of beads between
the fossa navicularis and the perineum.   The  canal in its whole extent could be tra-
versed only by  a bougie eight  hundredths of an inch in diameter, and the yard was
constantly in a  state of  semi-erection.—Ricord.
  *  Ricord.—It  is true that strictures  in the neighborhood of the bulb are the most com-
mon of all; and  it has even been said that,  when there are several, one of them is always
found in  this region.  Yet this rule has  so many exceptions, in the anterior portions
of the urethra,  that I am surprised that M. Civial^ has met with only two cases.  As
to the prostatic portion  of the  canal, in which Hunter says he never met with stric-
tures, it may be asserted, in spite of  the observations of Bell, and the denial of Scem-
merring, that it is sometimes the seat of contractions, which are not a result of disease
of the prostate,  and many other cases might be added to the one reported and figured
by M. Crosse.
  Moreover, unless the observations are made after death, it is quite diflicult to ascer-
tain the exact depth of  strictures, whatever instruments are employed.  Sometimes,
as M. Civiale justly remarks (Practical Treatise  on the Diseases of the Genito-urinary
Organs, Paris, 1850, vol. i.), we depress the obstruction and push it from the meatus
urinarius; in other cases, resting our instrument on the stricture, we artificially elon-
gate the penis  for the time, or its length may have been inoreased by the habitual
traction which some  patients exercise upon it in their suffering from retention of urine.
Exploration  of the canal in a  relaxed state, according to M. Malgaigne's method, is
seen to be just  as imperfect, when we consider  the power of retraction of the virile
organ under the influence of the mind, pain, and cold.
  Mr. Phillips's method, which consists in measuring the whole length of the urethra 
PERMANENT  STRICTURES.             •   169
 most frequent seat of this disease, has likewise strictures formed there
 of the worst kind.  They are generally slow in forming, it being often
 several years from their being perceived before they become very
 troublesome.
   The same stricture is not at all times equally bad, for we find that
 in warm weather  it is not  nearly so troublesome as in cold.   These
 changes are often very quick.  A  cold  day, even  an hour  of cold
 weather, shall produce a change in  them; and the  same  stricture  is
 almost always worse in winter than in summer.  However, this obser-
 vation is not free from exceptions; I knew one  case that was always
 worse in the summer.   There are other circumstances besides cold that
 make a stricture worse.  A gentleman who had an ague, always found
 the stricture increased during the fit.   It is also increased by drinking,
 violent exercise, and  by the retention of urine  after an inclination
 to void it has been felt. • This last cause is often so great as to produce
 a total stoppage for a time.   It is sometimes rendered much worse by
 a small calculus passing from the  bladder, of the formation of which
 this stricture was probably the cause.  The calculus not passing, will
 produce a total stoppage of urine, the cause of which can hardly be
 known at the time, and if known it could  not be remedied without an
 operation.   (See Plate IY.)
   It  is impossible to  say what is the  cause of that alteration in the
 structure of the urethra which diminishes the canal; it has been as-
 cribed to the effects of the venereal disease, and often to the method of
 cure.   But I doubt very  much if  it commonly, or  even  ever, arises
 from these causes; yet, as most men  have  had venereal  complaints
 some time or  other, it is natural to ascribe the stricture to them, and
 therefore   it may  be  very  difficult to refute this opinion.   Many
 reasons, however,  can  be given why we should suppose that it is not
 commonly a consequence of a venereal inflammation.   Strictures are
 common to most  passages in the  human  body; they are often to be
 found in  the oesophagus; in the intestines, especially the  rectum; in
 the anus;  in the prepuce, producing phimosis;  in the lachrymal duct,
 producing the disease  called fistula lachrymalis, where no  disease had
 previously  existed.  They  sometimes  happen in the  urethra, where
 no venereal complaint has ever been.  I have seen an instance of this
 kind in a young man of  nineteen, who had  the complaint  for eight
 years, and which therefore  began when he was only eleven years of
 age.   It was treated at first as stone or gravel. He was of a scrofulous
 habit, the lips thick, the eyes sore, a thickened cornea of one eye, and
 the general habit weak.  The stricture was in the usual place, about
 the membranous part  of the urethra.  I have seen  an instance of a
 stricture in the urethra of a boy of four years, and a fistula in perinaeo
 in consequence of it.  They are as  common to those who have had
 the gonorrhcea slightly as those who have had it violently.
  I knew a young gentleman who had a very bad stricture.  He had

by means of a catheter, which  allows the urine to flow as soon as it has passed the
neck  of the  bladder and gives the posterior limit of the canal, is just as liable to
error.—Ricord. 
170  .             PERMANENT  STRICTURES.
 had several gonorrhoeas, but they were so slight that they seldom lasted
 a week, nor in any of them did the pain extend  beyond the fraenum;
 but the stricture was about the membranous part.  Cases of this kind
 occur every day.  They are never found to come on during the vene-
 real inflammation, nor for some time after the infection is gone.  There
 have  been thirty, and sometimes forty years between the cure of  a
 gonorrhoea and the beginning of a stricture, the  health being all that
 time perfectly good.   If they arose in consequence  of the venereal
 inflammation, we might  expect  to find them of some extent, because
 the venereal inflammation extends some  way;  and we should also
 expect to find them most frequent in that part of the urethra which is
 most commonly the  seat  of  the venereal disease.  But I remarked
 before, that they are  not so frequent there as they are in other parts
 of the urethra.
   It is supposed by many that strictures arise from the use of injec-
 tions in the cure of the  gonorrhcea; but this opinion appears to be
 founded in prejudice; for  I have seen as many strictures after gonor-
 rhoeas that have been cured  without injections  as after those cured
 with them.
   Such modes of accounting for strictures give no explanation of those
 where there has been no  previous gonorrhoea, or where the gonorrhoea
 has not been cured  by  injections; and, indeed, if we  consider the
 mode  of cure of strictures, we must see that an injection is a mild
 application to the urethra compared to a bougie; yet a  bougie has
 never  been  supposed or  known  to  be the  cause  of  a stricture.
 Farther, some have injected by mistake, very irritating liquors, such
 as the undiluted extract of lead, and caustic alkali, without giving the
 least  tendency towards a  stricture, although they produced violent
 inflammation  and even  sloughing of  the internal  membrane of the
 urethra.
   By many they have been supposed to  have arisen from the healing
 of ulcers in the urethra; but  as I never  saw an ulcer in these parts,
 except in consequence of a stricture, and as I do not believe there ever
 is an ulcer in the case of a common gonorrhcea, I can hardly subscribe
 to that opinion.
   [G. G. B.—Many well authenticated facts disprove the common pre-
judice which attributes stricture invariably to gonorrhcea or to the use
 of injections.  But when  the author goes so far as to question whether
 it ever arises from these causes, his opinion  is contradicted both by
 reason and by experience.   It would appear that any irritation on the
 urethra, if  sufficiently long continued,  may give rise to stricture.  It
 may be consequent on stone in the bladder, on disease of the prostate
 or disease of the bladder, on acid urine, on repeated attacks of stran-
gury occasioned by the application of a series of blisters.   But of all
sources of  irritation which can affect the urethra, the most common
and the most  severe  is gonorrhoea, and  hence a  large proportion of
cases of stricture follow so immediately on this disease as to be  justly
attributable to it.  There are  few cases of gonorrhoea in which the
stream of urine is not diminished in size, from the existence of some
degree of spasmodic contraction  in the membranous  portion of the 
PERMANENT  STRICTURES.
171
canal.  If the gonorrhoea lasts long, this spasm  may become habitual,
and terminate in stricture;  and the likelihood of such a result is much
increased if the inflammation  is not confined to the extremity of the
urethra, but extends to the bulb and neck of the bladder.
  How far injections have a tendency to  produce the  same effect is
more doubtful.   When they are successfully used on the first appear-
ance of the discharge, it is probable that, by cutting short the disorder,
they rather prevent than promote stricture.   But where injections
fail, they  unquestionably in many cases extend  the  sphere of the
inflammation, and involve those parts of the urethra which are in the
vicinity of the bulb, and are especially liable to this affection.  Again,
the discharge,  as the author  has elsewhere  observed, relieves the
spasm  of a stricture.  In cases where there exists already spasmodic
contraction of the urethra, injections, by diminishing or arresting the
discharge, will undoubtedly tend to increase the spasm and to render
it permanent.
  The old opinion was, that a stricture was the cicatrix of an ulcer
which  existed  during a gonorrhoea.  This  notion the author justly
repudiates.   But  he must not be understood to mean that ulceration
may not sometimes arise from other  causes, and leave behind  it a
stricture.   When the urethra has been lacerated by external violence,
as by a blow on the perineum, stricture will usually follow, and will,
in most cases, be of a kind which  is  peculiarly intractable  and
obstinate.—G. G.  B.]
   [Ricord.—It is very certain that gonorrhoea is not the only cause of
stricture.   I lately showed a  young man  at my clinique, twenty-five
years old, who  had been troubled with dysuria from early youth, and
yet he had never had any discharge, and his symptoms could not be
explained by the presence of a foreign body.  This young  man, on
entering the hospital, had a stricture in the posterior part of the ure-
thra, and the most careful examination could not detect  any vice of
conformation or pathological alteration of the prostate.  I have under
my care at the  present moment a young man at Versailles who is simi-
larly affected, Avith this difference only, that he  has a callous stricture
of the membranous portion.
  But, though other causes are capable of producing strictures of the
urethra, it is incontestably true, that the most frequent causes are the
so-called venereal diseases, among which gonorrhoea should be ranked
first.
  Gonorrhcea, which, as we have  elsewhere proved, is not a virulent
disease, identical  with chancre, produces changes  in the ^urethra  and
consequently strictures, either in its  acute stage, contrary to what
Hunter says, or, more commonly, in its chronic stage.
  Indeed, nothing is more common than to meet with various degrees
of dysuria and even more or less complete retention in the acute stage
of urethritis; and this sometimes even during the first few days of the
disease; thus are  caused those strictures which are called inflammatory.
These strictures are the consequence of an engorgement, which is, to
a certain  degree, phlegmonous in its character, or of an oedematous
infiltration of the submucous  cellular tissue.  They disappear on the 
172
PERMANENT  STRICTURES.
cessation of the acute stage; but it is not uncommon to see them  last
and  become permanent, by passing into the chronic stage, together
with the inflammation which produced them.  They generally occupy
a considerable surface, and are met with most commonly in parts ante-
rior to the bulb; and the earlier they occur in the disease, the nearer
they are to the meatus.  If we assigned  any value  to  this situation,
which Hunter regards as specific, these strictures would be the imme-
diate consequence of the virulent affection; but it has been seen from
what  I  have previously said, that  inflammation of  the urethra, com-
mencing in the anterior portion and extending  to the posterior, does
not change its nature  because it changes its seat;  and if those altera-
tions of tissue which give rise to strictures  are more common behind
than before, it  is because the chronic inflammation persists there longer
than anywhere else.
  In the acute stage, such engorgements are more  or less soft,  easily
torn, and vascular;  but if the  inflammation continue a short time, it
produces induration of the mucous membrane, and especially of the
subjacent tissue.  These indurations  are sometimes combined with
permanent hypertrophy; but it must be  confessed  that the diseased
parts  commonly become atrophied, or contract, as  if the canal were
constricted by a cord.  In the  latter case, the affected part presents
only a fibrous  tissue, the result of capillary  phlebitis, which causes the
obliteration and transformation of the vessels in  the substance of the
mucous membrane and subjacent tissues, as M. Mercier has very well
shown.
  If Hunter had been less influenced by his theoretical views, and had
recognized  the frequent existence of urethral chancres, he would have
found, as I  have, strictures due to specific induration, and directly de-
pendent on the virulent affection.
  Nothing is more destitute of proof than the assertion that gonorrhoeal
inflammation is driven backwards  by the use of  injections; for it is
well  known that, independently of  this cause, the disease left to itself
soon involves the posterior  parts of the canal.
  Again, when injections favor resolution of the engorged tissues, and
gradually dry  up a discharge, far from adding to the inflammatory or
spasmodic symptoms,  they cause them to diminish and disappear at the
same time with the  suppuration.  Contrary cases are exceptions.  As
to ulcerations,  it is not necessary for me to repeat what I have already
said; pathological anatomy has placed their existence beyond a doubt,
and the same is true of the cicatrices, which are a consequence of them.
—Ricord.]


                       §  1.  Of the Bougie.

  The bougie, with its application, is perhaps one of the  greatest im-
provements in surgery which these last thirty or forty years have pro-
duced.  When I compare the  practice of the present day with what
it was in the year 1750, I can scarcely be persuaded that I am treat-
ing the  same disease.^ I remember when, about  that time, I was at-
tending the first hospitals in this city, the common bougies were either 
TREATMENT.
173
a piece  of lead,1  or  a small wax-candle;  and, although the  present
bougie was known then, yet a due preference was not given  to  it, or
its particular merit understood, as we  may see from the publications
of that time.
  Daran was the first who improved the bougie and brought it into
general use.   He wrote professedly on the diseases for  which it is a
cure, and also of the manner of preparing  it; but  he has introduced
so much absurdity in his descriptions of  the diseases,  the modes of
treatment, and of the  powers and composition of his bougies,  as to
create disgust.  However, this absurdity has  been much  more effectual
in introducing the bougie into universal use than all the real know-
ledge of that time, directed by good  sense, could  have been.  Such
extravagant  recommendations  of particular remedies are not at all
times without their use.  Inoculation would have still been practised
with caution had it not been for the enthusiasm of  the Suttons.   Pre-
parations of lead would not have been so  universally applied if they
had  not been recommended by Goulard in the most  extravagant terms;
nor would the hemlock have  come into such general use if its true
merits only had been held forth.   Improvements are often overrated,
but they come to their true value at last.  Sutton has told us that the
cold regimen, in extreme, is infinitely better  than the old method; but
from general practice  we  have learned that moderation is best, which
is all we yet know.
  When Daran  published his observations on the bougie, every sur-
geon set to work to discover the composition, and each conceived that
he had found  it out, from the  bougies he  had made producing the
effects described by Daran.  It never occurred to them that any extra-
neous body, of the same shape and  consistence, would do the  same
thing.

           § 2. Of the Treatment of the Permanent Stricture.

  The cure of the permanent stricture  is, I  believe,  to be accomplished
only by local applications.  Mercury  has  been given, upon  the erro-
neous supposition of its being venereal, but without success.  The cure
is either a dilatation of the contracted part, or a destruction of it by
ulceration or escharotics.   The dilatation is  performed by the bougie,
and  this is seldom or never more than  a  temporary cure; for, although
the passage may be dilated sufficiently for the urine to pass, yet there
is always the original tendency to contraction, which generally recurs
sooner or later.2   The ulcerative process is also effected by a bougie,

  ' When lead was used in place of bougies it has happened  that a piece  of the end
has broken off in the bladder,  which has been  dissolved by injecting quicksilver.  I
at first suspected that quicksilver could not come in contact with lead while in water,
so as to dissolve it; but, upon making the experiment, I found it succeeded.
  2 In cases of stricture, when a patient applies for relief, it  may often be proper to
inquire into the history of the case previous to the passing of a bougie, especially to
inquire if he ever used bougies before ; if he has, then to inquire into the result; if
they passed readily, or if  they did not pass the stricture at all;  if the first, then
nothing farther need be asked ; but if the last, then  to inquire if he or his surgeon
observed that they were gaining ground with the bougie, viz :  if the bougie went far-
ther in before it was left off than at first; if so, then ask him  how far.  If they have
• 
174                PERMANENT  STRICTURES.
and the destruction by escharotics is by means of caustics.  It often
happens, in strictures, that the  passage is so diminished as hardly to
allow any water to pass, producing often a total stoppage;  nor will a
bougie immediately  pass;  and if it can be made to pass, yet no water
follows it when withdrawn.  In such cases, therefore, we must have
recourse to the means that afford a temporary relief, such as the warm
bath, which counteracts the effects of cold, and quiets any spasms that
may have  taken place  in the  parts, and clysters with opium, which
have still more effect.  Producing an evacuation by stool often lessens
the spasm, for a spasmodic suppression of urine frequently arises from
a constipation, even  where there is no stricture.
  The cure by dilatation is, I imagine, principally mechanical when
performed  by bougies, the powers of which are, in general, those of a
wedge.   However, the ultimate  effect of them is not always so  simple
as that of a wedge upon inanimate matter, for pressure produces action
of the animal powers, either to adapt the parts to their new position,
or to recede by ulceration, which gives us two very different effects of
a bougie, and of course two different intentions in applying them: one
to produce dilatation, the other  ulceration, which last is not always so
readily effected.
  It generally happens, as has been already observed, that the disease
has gone considerable lengths before application has been made for a
cure, and, therefore,  the  stricture has  become considerable, insomuch
that it is often with great difficulty that  a small bougie can be made
to pass.  If the case is such as  will readily admit the  end of a small
bougie to  pass, let it be ever so small, the cure is then in our power.
It often happens, however, that  the  stricture is such as will resist the
passing of  a  small bougie at first, and even after repeated trials.  Yet
it is necessary to persevere with the small  bougie, for sometimes it
happens that the passage through the stricture is not  in a line with the
urethra itself, which of  course obstructs the bougie;  such strictures, I
suspect, are not equally placed all round, so as to throw  the small pas-
sage remaining into  the centre of the canal.
  In many cases, where  the stricture is very considerable, much trou-
ble is  given  by occasional spasms,  which will either resist  the bougie
altogether, or only let a very small  one pass, though at another time
they will admit one  larger.  In such cases, I have been  able to get the
point of the bougie sometimes to enter, by rubbing the perineum exter-
nally with  the finger of one hand, while I pushed the bougie on with
the other.  This, though it xloes not  always succeed, yet is  worth
the trial.   Whether  it alters the position of the stricture, so as to  give
entrance to the point of the bougie, or by sympathy removes the spasm,
I will not  absolutely determine, but I believe  it rather acts by sym-
pathy.  In such cases of spasm in the stricture, I have often succeeded
by letting  the bougie remain a little while close to the stricture, and
then pushing it on;  this mode so often succeeds, that it should always

visibly gained ground without getting  through the stricture, I am afraid that the use
of the bougie must not be pursued, because it is most probable that a new passage has
been formed,  which makes the passing  of the bougie into the stricture impossible. 
TREATMENT.
175
be attempted when the bougie does not pass, or only passes occasion-
ally.  This will be mentioned more fully when we shall consider the
spasmodic stricture.
  The spasm  may probably be taken off by dipping the glans penis
into cold water, which succeeds sometimes  in the common strangury;
but this cannot be so easily done while a bougie is in the passage.
  In cases of a permanent stricture, though the bougie does not at
first pass, yet, after repeated trials, it will every now and then find its
way, which helps  to render a future trial more certain and easy.   It,
however, too often happens that  the future success does not immedi-
ately depend upon passing the bougie once or twice, for it shall pass
to-day and not to-morrow; and this uncertainty shall last for weeks,
notwithstanding every trial we can make;  yet I may observe that, in
general, its introduction becomes gradually less difficult, and, therefore,
in no case should we despair of success.  It is imagined by some that
the best time for trial in these cases is just after making water, as the
passage is supposed to be clear, and more in a straight line;  but this
is not confirmed by practice.
  It is not an easy matter, in cases where the passage is very small,
to know whether the bougie has entered the stricture or not,  for such
slender bougies as must generally be used at first bend so very easily
that the introducer is apt to think it is passing, while it is only bend-
ing.  A  surgeon,  however,  should, in general, first make himself
acquainted with the situation of the stricture by a common-sized bou-
gie, and afterwards make use of a smaller one, and when he comes to
the stricture, push gently, and for a  little time only.  If the bougie
has passed farther into the penis, he will know how far it has entered
the stricture by taking off the pressure from the bougie, for if  it recoil,
he may be sure that it has not passed, at least has not passed far, but
only bent; for the natural elasticity of  the  bougie, and the direction
of the passage having been altered by it, will force it back again.  But
if it remain fixed, and do not recoil, he may be sure that it has entered
the stricture.
  In using a very small bougie, however, these observations are not
so applicable, for it may be bending, or  bent, without being percepti-
ble.   It often happens  that  a bougie will enter only a little way,
perhaps not more than one-tenth of an inch, and then bend if the
pressure be continued.   To determine whether this  be the case, it is
necessary to withdraw the bougie and examine its end; if the end  be
blunted, we may be sure the bougie has not entered  in the least;  but
if it be flattened for an eighth or tenth of an inch, or grooved, or have
its outer waxy coat pushed up for that length; or if there be a circular
impression made  upon the bougie where the stricture is, or only a
dent on one side, both of which last I suspect arise from spasm at the
time, we may then be sure that it has passed as far as these appearances
extend.  It becomes, then, necessary to introduce another exactly of
the same size,  and in the same manner, and to let it remain as long as
the patient can bear it, or convenience will  allow; and by repeating
this we may overcome the stricture.   Sometimes we can judge of  its
having entered the stricture, by pulling  it gently out; for if it stick a
• 
176
PERMANENT STRICTURES.
little  at  the first pull,  we may be certain it has entered;  but the
appearance of the  bougie itself  will give the best information.1  In
such cases I have always directed my patient to preserve the bougie
for my inspection, exactly in the same form it was when it was with-
drawn.  But when it passes with ease, this nicety is not necessary.
  The time that each  bougie ought to remain in the passage must he
determined by the feelings of  the patient;  for it should  never give
pain,  if possible.  To go beyond this point is to  destroy the intention,
to increase  the very symptoms that are meant to be relieved, and to
produce  irritation,  which for a time renders the farther application of
the bougie, improper.  While the bougie is passing, if the patient feel
very acutely, it should not be left in the urethra above five or at most
ten minutes, or not so long if it give great pain; and each time of
application should be lengthened so gradually as to  be insensible to
the feelings of  the patient and the irritability of the  parts.   I have
known it days, nay, in many patients, weeks, before they could allow
the bougie to remain in  the passage ten or even five minutes,  and yet
in time they have been  able to bear it for hours, and  at last  without
any difficulty.   The best time to let it remain in the passage is when
the patient  has least to do; or in the  morning, while he is  in bed,
provided he can introduce it himself.
  The bougie  should be increased in size according to the facility
with which the stricture dilates, and  the ease with which  the patient
bears the dilatation.  If the parts are very firm  or very irritable, the
increase  of  the size of the bougie should be slow, gradually stealing
upon the parts, and  allowing  them  to  adapt their structure to the
increased size.   But if the sensibility of  the parts will allow of it, the
increase  of  the size of the bougie may be somewhat quicker, though
never more quick than the patient can bear with ease.  The  increase
should be continued till a bougie of the largest size passes freely;  nor
should this be laid aside till after three weeks or a month, in order to
habituate the dilated part to its new position or to take oft' the  habit of
contracting from the part as much as possible.   But, as was observed
before, the permanency  of this cure can seldom be depended upon.
  Instead of proceeding with the caution recommended, it has been
practised with  success  for a time  to force a common  sized bougie
through  a stricture that only  allowed a small  one to pass.  This, I
suppose,  either  tore  the stricture or weakened it  by stretching it
suddenly so as to render it unable to recover its contractile power for
a considerable time after.  I have seen where this has  produced good

  1  It may be remarked that there are  some lacuna? (vide Plate I. Fig. 2) near and
also a little way from the glans penis, which often stop the bougie, and give at first
the idea of a stricture.  I have known them taken for such ; and when the bougie
stops so near to  the glans  this is to  be suspected, therefore we should vary the
direction of the point of the bougie, bearing it against the under side of the urethra.
When  the bougie stops in  one of those lacunae, I think that the  patient appears to
have more pain than from a real stricture.  The valvular part of the prostate gland
formed by disease (vide Plate V.), very often obstructs the  bougie, and is taken for a
stricture by those who are not well acquainted with the different obstructions in this
canal; and by those who are, it is a means of discovering disease in this part; and,
indeed, in  a natural state of  parts, I think I can  ascertain when I come to this part
with a bougie. 
TREATMENT.                       177
effects, and for a time removed the permanent stricture and prevented
spasm.   This is a practice, however, which I have never tried, having
always preferred the mild treatment where I could pass a bougie.
  I have known the passing of the bougie remove, almost immediately,
a swelling of the testicle, which had arisen from  the stricture; there-
fore such a symptom should not prevent the use of the bougie.
  In cases of strictures where the  bougie is used, the patient is com-
monly in other respects well, and is with difficulty persuaded to res-
train from his common habits, often making too free in eating, drink-
ing, and exercise;  which  are  all in many cases pernicious,  more
especially where inflammation and suppuration have taken place.   It
is, therefore, the duty of the surgeon  to restrict the patient for  some
time within  certain bounds,  till he finds  by trials what the parts are
capable of bearing without producing inflammation.
   [Ricord.—We cannot consider every case of stricture of the urethra
as a morbid  state, which  necessarily requires treatment.   Some stric-
tures are the final  termination of  diseases of the urethra, and are to
this canal what cicatrices, or union of the parts, are to other tissues
in general.   In such cases the direction of the urethra may be altered
or its caliber diminished ; but if no morbid discharge, and no excessive
disarrangement of its functions result, and the neighboring parts, such
as the prostate, the spermatic passages, the bladder, etc., do not suffer,
there is  no necessity, because the  canal  has  lost a quarter or half a
line of its diameter, to apply treatment which is often more injurious
than useful.  I know  that the  earlier strictures  are attacked, the
sooner they  are cured; but to make this  a general rule, we must take
exception in favor of those kinds of stricture which may be called
final.1
   Strictures  should be subjected  to  treatment, therefore, only  when
they tend to increase or when they interfere  with the direct functions
of  the urethra, and those of the neighboring organs connected with it.
   Hunter, as may be seen, and many  other authors who have imitated
or servilely  copied him, direct only local  applications in the treatment
of  permanent strictures.  And yet various circumstances connected
with the  individual, such as his general strength or weakness, an in-
flammatory or nervous temperament,  etc., may  furnish indications for
local or general treatment other than that required for the simple de-
struction of the obstacle in the canal.  Complications or diseases  of
the organs, whose functions are more or less connected with the urethra,
also require  important modifications.   But above all, that kind of stric-
ture which forms the most absolute exception to Hunter's rule, is that
stricture  which depends on  the  specific  induration of a chancre, and
which is  generally refractory under local treatment, but yields to the
constitutional remedies employed for  indurated chancres.
   We must divide the treatment  of strictures, then, into general and
local.   The  first may be simple, and directed against the inflammation,

  '  For an instance of literary piracy, see the chapter on Strictures, in Acton on
Diseases of the Urinary and  Generative Organs, page 84 of the American edition,
where page after page is copied from these notes of M. Ricord, without the slightest
credit being given.—Ed.
       12 
178
PERMANENT STRICTURES.
 spasm, different complications, etc.; or special, and intended to oppose
 the specific cause of the disease, as in indurated chancres.   The second
 comprehends simple resolvents, dilatation, caustics, the use of instru-
 ments for superficial and deep scarifications, incisions, etc.
   Resolvents.—Most inflammatory strictures, or those occurring in the
 acute stage of gonorrhcea, yield to general or local antiphlogistics; but
 they are often cured by the simple use of resolvents, both at this period
 and especially when they have passed into the chronic stage, unless too
 deep changes  in the tissues have already taken place.   Thus, resolvent
 ointments,  especially mercurial ointments, succeed  very frequently
 when they are applied externally or within the canal to those engorge-
 ments, which  may even sometimes be felt externally without the need
 of any other  exploration.
   If, in every case of morbid discharge from the urethra, the state of
 the tissues had been ascertained beforehand, as I have many times done
 at my hospital  and  in  my private practice, physicians would be con-
 vinced that a  large number of strictures due to soft hypertrophy, yield
 to  resolvent  injections,  which are wrongfully accused of producing
 them when they happen to fail.
   Dilatation.—We may, however, say with truth that the majority of
 strictures resist these means, and require others which  are more active;
 among which we must first mention dilatation, as Hunter does.  Dila-
 tation is the treatment which is the most generally applicable; which
 succeeds the  best of all; and which, in the majority of cases, is the
 necessary adjuvant of other means.
   Not forgetting  Hunter's excellent practical observations, so often
 copied and given as original, we may thus sum up the subject of dila-
 tation in the present state of science:—
   1. Dilatation may be sudden, as in  the method attributed to the
 ingenious surgeon of Lausanne, Mayor, although it  was  previously
 mentioned, without approbation, by Hunter.  Its principle consists in
 attacking the stricture with  an instrument, which is the more voluminous
 the more difficult the stricture is to overcome.
   2. Dilatation may be rapid;  that is to say, an instrument is first
 used which passes the stricture without violence;  it is then replaced
 by others, of  increasing diameter, as fast as the previous instrument
 ceases to be grasped by the stricture.  This method, which has been
 extolled especially at Montpellier, by MM. Lallemand, Chrestien, &c,
 has  received  some  commendation at  Paris from Professor Yelpeau,
 although  most  practitioners, and  particularly Hunter, censure it, and
 often with justice, on account of the frequent relapses which follow it.
   3. It is better that dilatation should be gradual; experience having
 proved, in accordance with Hunter's  views,  that  the result is  more
 permanent when it has  been obtained slowly and with little violence.
 Be'nique^s method' has certainly sprung from Hunter's precepts.
  4. Finally,  dilatation  is  temporary  or  permanent.   As a  curative
treatment, dilatation has a favorable and permanent effect only in stric-

  1 Benique's method "consists in introducing a small bundle of fine bougies into the
urethra, and pushing each one successively until the one opposite the opening in the
stricture is introduced."—Ed. 
TREATMENT.
179
tures due to simple hypertrophy, combined especially with softening
of the tissues.    When  the induration  is well  marked and callous,
when there are inodular or fibrous degenerations, true cicatrices, or
vegetations, success  is less durable; we  then only stretch the parts,
which soon recover their former state when we cease to separate them.
  In making use of gradual dilatation within the bounds which Hunter
so well marks out, we must regard the following rules, in order to decide
between its temporary or permanent application.
  Temporary dilatation should be preferred whenever the reintroduc-
tion of  a bougie is not too difficult or too painful;  whenever the in-
strument ceases to be grasped in  a short time by the stricture;  and
whenever, in successive visits, it may not only be replaced with facility,
but a larger one substituted for it.
  When the contrary is true, permanent dilatation must be employed.
  In every case, as soon as an instrument which is left in temporarily
or permanently, irritates too much, produces spasm, pain, or direct or
sympathetic  reaction, it  must be removed, and  not introduced again
until repose and appropriate accessory treatment have caused the super-
vening  symptoms to disappear.
  In all cases where dilatation is used, it acts like  compression, and
produces simple resolution of the tissues, or excites a kind of purulent
dissolution.  It sometimes  tears the diseased parts, as in M. Mayor's
method, or else it causes ulceration, which  is not always favorable,
owing to the immediate effects mentioned  by Hunter, or to the cica-
trices, which  are the necessary and sometimes injurious consequence
of  it.
  To perform  dilatation, the dilating  instrument must, of necessity,
penetrate within the stricture.  But this  is not always  easy or even
possible to effect.  Without dwelling in this place  on the rules  for
catheterization, which should be followed, in order to pass the stricture,
I will recall the judicious remark of Hunter on the undoubted advan-
tage of compression of the anterior portion of strictures which cannot
be  passed; a rule to which Dupuytren attached so much importance,
and which no modern writer can censure, except for want of knowledge
how to  suitably apply  it.  Indeed, whatever theory we adopt, whether
of  a disgorgement by pressure, a purulent dissolution, or a progressive
destruction by  ulceration of  the tissues at the constricted point, it is
incontestably true that, without the stricture being passed,  the scanty
emission of urine returns to its normal state under the influence of this
treatment, and  the symptoms of retention disappear long  before the
instrument reaches the bladder.
   Cauterization.—(See page 188.)—Ricord.]

             § 3. Of the Cure of Stricture by Ulceration.

  The cure of  a stricture by means of ulceration  is likewise effected
by  a bougie.  This method  may be employed both  in cases where a
bougie  will and where it will not pass.  In the first case there is not
the same necessity for ulceration as in  the  second, because where a
bougie  will pass there  is no immediate danger arising  from the stric- 
180
PERMANENT STRICTURES.
ture which  may therefore be dilated, as  has been  already described.
But if this method should  be preferred to a slow dilatation, which
allows the parts time to adapt  themselves  to their  new position, the
stricture may be destroyed by producing ulceration in the parts, espe-
cially if they are not irritable, but admit of considerable violence.
  When this is intended, the bougie should be introduced as far into
the stricture as possible, and the size of it increased as fast as the sen-
sations of the patient can well bear.  This will produce ulceration in
the part pressed, which  is a more  lasting cure, because more of the
stricture is destroyed than when the parts are simply dilated.  I believe,
however, there are few patients that will  submit to this practice, and
indeed few will be able to bear it; for I have seen it bring on violent
spasms in the  part, which have produced  suppression of urine, and
proved very troublesome.  Therefore, as there is no absolute necessity
in such cases for pursuing this  method, I do not recommend it  as a
general practice, although there have been cases in  which it has suc-
ceeded.  Where this method is to be  practised, it might probably be
right to accustom the passage to a bougie for some time before such
violence is used.
  If the smallest bougie which can possibly be made cannot be made
to pass by some degree of force, dilatation becomes  impracticable, and
it is necessary that something else should be  done  for the relief of
the patient;  for the destruction of the stricture must be effected.  In
many cases it may be proper to attempt this by ulceration of the part;
for we find from experience  that a  stricture may be removed by the
simple pressure of a bougie.   This effect must arise from the irritation
of absorption being given to the diseased part, which, from the stric-
ture not being an originally-formed  part, nor having any power of
resistance equal to the original one, is more susceptible of ulceration,
and thereby is absorbed.  The bougies, which  are only to produce
ulceration in consequence of their being applied to the stricture, need
not be so small as in the former cases, as they are not intended to pass;
and by being of a common size they will also be more certain in their
application to the stricture.  The force applied to a bougie in this case
should not be great; for a stricture is the hardest part of the urethra;
and if a bougie is applied with a considerable degree of pressure, and
left in the passage, it sometimes happens that the end of  it slips off
the stricture  before there is time  for ulceration, and  makes its way
into the substance of the corpus spongiosum by the side of the stric-
ture;  and if the pressure be continued still longer, it will make a new
passage beyond the stricture in the corpus spongiosum urethras.1   This
more  readily happens if the stricture  be  in the  bend of the canal, as
in such cases the bougie can hardly be applied exactly to it, not having
the same curve.   Such mischief I have seen more than once;  and
sometimes the bougie has been pushed so far as  to  make its way into
the rectum.
  It often requires a considerable time before the whole is so far ulcer-
ated as to admit the bougie, and this tires the patient, and almost makes
1  Vide Plate II. 
TREATMENT.
181
him despair of a cure.  In this process, great attention should be paid
to the seeming progress of the cure; for if it appears to the surgeon
that he is gaining ground by the bougie passing farther in, and yet the
patient does not make water better in the least, then  he may be  sure
that he is forcing a new passage.1
   When the stricture has so far yielded to these means as to admit a
small bougie, the dilatation is to be made as  in the former case where
a bougie passed at first.  Whenever a bougie of a tolerable size passes
with ease, and the parts and patient have become accustomed to  it, it
is no longer necessary that the surgeon should  continue to pass it; the
patient may be allowed to  introduce bougies himself; and when he
can do it readily the business may be trusted to him, as he can make
use of them at the most convenient times, so that they may be applied
longer at a time and oftener, the surgeon only  attending occasionally.
This practice of the patient under a surgeon's eye, by which he is taught
how to pass them, becomes more  necessary  as strictures are diseases
that commonly recur; and therefore,  no man who  has ever  had  a
stricture, and is cured of it. should rely on  the  cure as lasting, but
should be always prepared for a return;  and should always have some
bougies by him.  He should not go a journey, even of a week, without
them; and the number should be according  to the time he is to be
absent, or to the place whither he is going, for in  many parts of the
world he cannot be supplied with them.   The bougies for such purpose
should be of different sizes, as it is uncertain in what degree the dis-
ease may return.
   Bougies, in all cases, from  their shape and from the  action of the
parts, readily slip out, whereby the cure is retarded; but  it is much
worse when they pass into the bladder, which  can only take place  in
cases where the stricture is in some measure overcome.  The  conse-
quence of a bougie passing into the bladder must at once  appear  in
its fullest force to every one;  it subjects the  patient in  most cases  to
be cut as for the stone; and, indeed, if it is either not  soon thrown out
or cut out it becomes the basis of a stone. A young man was cut for
a bougie only a fortnight after it had passed into the bladder, and it
was almost wholly crusted over •with calculous  matter.  Bougies have
been known to be forced out of the bladder  along with the water by
the action of that viscus, and  in several folds.  It is probable that the
bladder in a natural state has not power sufficient to  perform such an
action;  but we shall show that in cases  of strictures where  the resist-
ance to the passing of the water is  very much increased, the strength
of the bladder becomes proportionably greater.  This happens princi-
pally in strictures of  long standing.
   Such accidents are often observed before the outer end of the bougie
has got beyond the projecting part of the penis, but even then  it  is
difficult of extraction.  I have succeeded in some of these  cases by
fixing the bougie in the urethra some way below its end; for instance,
in the perineum, by pressing against it with one hand, and pushing

  1 This makes it necessary, in all cases of strictures where bougies will not pass, to
be very particular in our inquiries whether the patient has used bougies formerly, and
whether there may not be reason to believe that they had taken a wrong direction. 
182
PERMANENT  STRICTURES.
back the penis upon the bougie with the other hand;  then laying hold
of the penis upon the bougie, removing the pressure below, and draw-
ing the whole up; and, by performing these two motions alternately, I
have been able to lay hold of the end of it.  However, this does not
always succeed;  for when the bougie is either small, or becomes soft,
it will not admit of the penis being pushed down upon it without bend-
ing; or if the thick end of the bougie has got beyond the movable or
projecting part of the penis, then this mode of treatment  becomes im-
practicable.   I have succeeded in these last cases with  the forceps for
extracting the stone out of the urethra; but if it has got into the bend
of the urethra, this practice will also fail; and in such a state it would
be most advisable to pass a catheter down to it, and cut  upon that; and
probably the above-mentioned forceps, introduced through the wound,
might then lay  hold of its end; or by  cutting a little farther, so as to
expose some part of  the bougie, it might be easily extracted, without
the necessity of cutting into the bladder.  This part of the operation,
however, would be very difficult in a fat or lusty man.
   To prevent the inconvenience of the  bougie coming out, or the mis-
chief of its passing in, it is necessary to tie a soft cotton thread round
that end of the  bougie which is out of the urethra, and then round
the root of the  glans.  This last part should be very loose, for an ob-
vious reason; and the projecting part of the bougie should also be bent
down upon the penis, which makes it both less troublesome and more
secure.
   [Ricord.—The fall of a bougie or a sound into the bladder, although
it has sometimes occurred, is however a rare occurrence.  To prevent
such an unpleasant accident, it is sufficient, in most cases, to have the
external end of the bougie armed with the rim of sealing-wax, which is
usually applied, and  which prevents it  passing the meatus  urinarius;
or else, when the bougies are made of soft wax, their  extremity may
be bent like a hook over the glans, or a rim may be formed by wind-
ing thread around it.   However, when a better arrangement is desired,
it is always preferable to attach the strings of the sound  to a suspensory
bandage, or to use a ring, as Dupuytren did: I prefer the former.  In
this way, the changes of volume in the  penis are left perfectly free, and
no constriction exercised or pain excited.
   Yet, in case an instrument should fall into the bladder, there would
be less occasion to resort to lithotomy, at the  present  day, than in
Hunter's time.   The recent  improvements in the extraction of foreign
bodies from the bladder introduced by MM. Civiale, Leroy d'Etiolles,
Amussat, Heurteloup, Segalas, etc., would be sufficient,  in the majority
of cases, to remove it.]


          § 4.  Of the Application of a Catustic to Strictures.

   When a bougie can readily pass, there is no necessity for using any
other method to remove  the stricture; but there are  too many cases
where a bougie cannot be made to pass, or so seldom that it cannot be
depended upon for a cure.  This may arise from several causes. First,
the stricture may be so tight as not to allow the smallest bougie to pass. 
TREATMENT.
183
Secondly, the orifice in the stricture may not be in a line with the ure-
thra, which will make it uncertain, if not impossible, to pass a bougie.
Thirdly, there may be no passage at all, it having been obliterated by
disease, and the urine discharged by fistulas in perinaso.
   The first very rarely occurs; for if the passage in the stricture be in
a line with the general canal, a small bougie will commonly pass; and,
although it may not readily do so upon every trial, it will be sufficient
to make way for another bougie, which is all that is wanted.
   The second case, where the canal is not in a line with the common
passage, may arise from three  causes.  First, when the stricture is in
the bend of the urethra, although the passage through it may be in the
centre of the canal, yet as the bougie cannot  have the exact curve, it
will be very uncertain in its application.   Secondly, from an irregu-
larity in the formation of the stricture,  which may throw the passage
to one side, even in the straight part of the urethra; and thirdly, from
ulceration having taken place, producing fistulas in perinaso, which often
make the canal irregular in its course.
   The third case where the application of the caustic may be necessary
is where there is no passage at all, which happens from ulceration and
abscesses in the perineum opening externally;  and in the healing of
them the passage is often closed up entirely.  In all the  above-men-
tioned cases I have succeeded with the caustic beyond expectation.
   If the obstructions are anywhere between the membranous part of
the urethra and the glans, where the canal is nearly straight, or can
easily be made so  by the introduction of a straight instrument, it  be-
comes an easy matter to destroy them by caustic; but if beyond that,
it becomes then more difficult.  However, at the beginning of the bend
of the urethra the obstruction  may be  so far removed as to admit of
the passing of a bougie, or at least to procure a tolerably free passage
for the urine. I have seen several cases where it was thought necessary
to follow this practice; and it succeeded so well that after a few touches
with the caustic the bougie could be passed, which is all that is wanted.
The success in these cases was such as would incline me  to  have re-
course to this practice very early; indeed, whenever I could not pass
a small bougie through the stricture.  I look upon  the  caustic as a
much safer method than using  pressure with a bougie, for the reason
before mentioned,  that is, on account of the danger of making a new
passage, without destroying in the least any part of the obstruction.
   Most of the strictures which I have examined after death appeared
to have been in the power of such treatment.   However, I have seen
one or two cases where the contraction was of some length and irregu-
lar, which would have puzzled  me if I had attempted the cure with
the caustic; because I should have been  apt to suspect that I was mak-
ing a new passage by my gaining  ground, and yet not relieving the
patient by the removal of the symptoms.
  I have often tried this practice in  strictures where there were also
fistulas  in  the  urethra, and where the water came through different
passages.  Such cases were not the most  favorable, yet  I have suc-
ceeded in the greater part of them: that is, I overcame the stricture,
and  could  pass  a  bougie freely.   I have seen several cases of fistulas 
184                PERMANENT  STRICTURES.
of these parts where the natural passage was obliterated by the stric-
ture, in which I have succeeded with  the caustic, and the fistulous
orifices have readily healed.
  It does not happen always, in cases of obstruction to the passage of
the urine, that when the obstruction is removed by the caustic, and the
water of course passes freely, a bougie will also pass.   This, I appre-
hend, arises from the caustic not having destroyed  the stricture in a
direct line with the urethra, so as to allow a bougie to catch the sound
urethra beyond.   But this appears to me of little consequence, as  it is
as much in the power of the bougie to prevent a return at this part as
if it had passed on to the bladder;  for if the  water flows readily,  it is
certain  that the caustic has gone beyond the stricture, although it may
not be in the direct line, and that the only risk of a return of obstruc-
tion will be at the. old stricture; but as a bougie can now pass beyond
that part, it does as much good as  if it passed into the bladder; for I
have known several cases where the bougie appeared to have the same
effect as if it had passed on to the bladder.
   The application of the caustic need not be longer than a minute, and
it may be repeated every day, or every other day, allowing time for
the slough to come off.  But there are  other  causes  that may prevent
the repetition of the caustic,  besides waiting for the  separation of the
slough ; for sometimes the use of it brings on irritation, inflammation,
or spasm in the part, which frequently occasions a suppression of urine
for a time, against which all  the means used  commonly on such occa-
sions to procure relief  must be employed, and we must wait till these
symptoms are gone off.   If the patient can  make water immediately
after the application, it will  be proper,  as it will wash  away any caus-
tic that may have been dissolved in the passage, which, if left, would
irritate the parts.   A little water injected into the urethra will answer
the same purpose.
   About the year 1752,1 attended a chimney-sweeper laboring under
a  stricture.   He was the first  patient  I  ever had under this disease.
Not finding  that I gained any advantage  after six months' trial with
the bougie, I conceived that I might be  able to destroy the stricture
by escharotics;1 and my first attempt was  with red  precipitate.  I
applied to the end of a bougie some salve, and then  dipped it into red
precipitate.   This bougie I passed down to the stricture; but I found
that it  brought on considerable inflammation all along the inside of

  1 Having lately looked over some authors on this disease, I find that this is not a
new idea.
  [Alphonso Ferri was one of the first persons to employ escharotics.  Ambrose Pare-
says that he had previously effected cures  by cauterization, which he used to employ
after trying rupture, filing, and comminution, when there were hard carnosities ; methods,
by the way, which might account for certain modern inventions.  Loyseau, as is well
known, cured Henry IV. by cauterization, but not without serious results, for which
he was indicted.
  Those  who first practised cauterization, used red precipitate, orpiment, verdigris,
etc., like Hunter. Latterly, M. Jobert, surgeon at Hotel Dieu, to whom science is much
indebted, has proposed dried alum, applied in the same way that Hunter used red pre-
cipitate with the chimney-sweeper of whom he speaks.  In some cases, in which I
have had recourse to this practice, I have found the same inconvenience with alum
that Hunter did with red precipitate.—Ricord. ] 
TREATMENT.
185
the passage, which I attributed to the precipitate being rubbed off' in
passing the bougie.  I then introduced a silver canula down to the
stricture, and  through this canula passed the bougie with precipitate
as before.  Not finding, however, that the patient made water any
better, and not as yet being  able to pass the smallest bougie through
the stricture, I suspected that the precipitate had not sufficient powers
to destroy it.  I therefore took a small piece of lunar caustic, and fas-
tened it on the end of a wire with sealing-wax, and introduced it through
the canula to the stricture.  After having done this three times, at two
days' interval, I found  that  the man voided his  urine more freely.
Upon  the application  of the caustic a fourth time, my canula went
through the stricture.1   A bougie was afterwards passed for some little
time, till he was perfectly well.
   Having succeeded so well in this case, I was encouraged to apply
my mind to the invention of some instrument better suited to the pur-
pose than the before mentioned, which I have in some degree effected,
although it  is not yet  perfectly adapted to all the  situations of stric-
ture in the urethra.  The caustic should be prevented from  hurting
any other part  of  the  canal;  which is best done by introducing it
through a canula to the stricture, making it protrude a little beyond
the end of the canula, by which it acts only upon the stricture.  The
caustic should be fixed in a small port-crayon.  It is necessary to have
a piece  of silver of the length of the canula, with a ring at one end,
and a button at the other of  the same diameter with the canula, form-
ing  a kind of plug, which  should  project  beyond the  end  of the
canula  that enters  the  urethra, by which means it makes a rounded
end ; or the port-crayon may be formed with this button, at the other
end.  The button being introduced into the canula, it should be passed
into the urethra, and  when it  reaches the stricture,  the silver plug
should be withdrawn, and the port-crayon with the  caustic introduced
in its  place;  or, if the plug and port-crayon are on the same instru-
ment, then it is only withdrawing the plug, and introducing the port-
crayon with the caustic.  This plug, besides giving a smooth rounded
edge to the canula, answers another good purpose,  by preventing the
canula  from being filled with the mucus of the urethra as it passes
along, which  mucus would be  collected in the end of it, dissolve the
caustic too soon, and hinder its application to the stricture.2
   If the stricture be in  the bend of the urethra, the canula  may be bent
at the end also; but it  becomes more difficult to introduce a  piece of
caustic through such a canula,  for the  plug and  port-crayon must also
be bent at the end, wbich cannot be made to pass through the  straight
part of  the  canula; but this I have  in some measure obviated by
having the canula made flexible, except at the end  where it is to take
the curve.3
   After the bougie can be made to pass, the case is to be treated as a
common stricture, either by dilating it slowly, or by quickly increasing
the size of the bougie, and thus continuing the ulceration.

  1 Wiseman had the same idea, but probably the clumsy way  in which he attempted
to put it in execution might be the reason why he seems to have pursued it.
  2 Vide Plate III. Fig. 1.                     3  Vide Plate III. Figs. 2 and 3. 
186                PERMANENT STRICTURES.
   There are sometimes more strictures than one ; but it seldom hap-
 pens that they are equally strong.  One only becomes the object of
 our attention.  The smaller ones may, however, be sufficient to hinder
 the passing the canula to that which is to be destroyed by the caustic.
 When that  is  the case, those  small strictures are to be dilated with
 bougies, as  in common,  till they are sufficiently large  to  allow the
 canula to pass.1
   [G. G. B.—Since the time when Mr. Hunter wrote, the use of caustic
 in the cure of strictures has been greatly extended, chiefly through the
 labors  of Sir E. Home,  whose valuable work  on  strictures  in  the
 urethra  and oesophagus  should be consulted by all who wish to be
 acquainted with its various effects in detail.
   The mode of applying the caustic has been greatly improved.  The
 use of  the canula has  been discarded, and an armed bougie has been
 substituted in its place ;  that is, a small piece of nitrate of silver  has
 been let into a common bougie, in such a manner as to present only
 on the surface of the extremity, and to be encircled on all sides by the
 plaster of which the bougie is composed.  This instrument  can be
 applied with  far greater  accuracy than the canula;  the bougie can
 with ease be adapted to the curvature of the urethra, and the sides of
 the  canal are protected from the action of the caustic.  It appears that
 this contrivance was invented  by Mr. Hunter himself, who employed
 it many years before his death in preference to that which he has
 detailed in this work.
   When it is  intended to apply the caustic, it is  necessary in the first
 instance to pass down  to the stricture a common bougie, of such a size
 as moderately  to fill the passage, and composed of such soft materials
 as readily to receive the impression  of the part  against which it is
 pressed.  By first introducing this bougie, and keeping it for the space
 of a minute  pressed against the stricture, the surgeon obtains  several
 advantages.  The urethra  is opened, and the subsequent passage of the
 armed bougie  rendered more easy and rapid; the exact distance of the
 stricture from  the orifice is ascertained; and  such a cast is taken of
 the stricture as to show accurately its size and shape, and to ascertain
 what effect has been produced  by previous applications of the caustic.
 Ihis information is so necessary that without it the treatment  by

 twL1Jded: " A' M soldi.er ln £e 16th regiment of light dragoons, had a stricture
 ZZnJJ^  aI°' ? • Tf m St* Jnomas's HosPital; bougies were passed, and he got
 pretty well. About eight years afterwards the stricture began to recur, and has been
 growing worse ever since, and for these two years past he has not been able to do his
 ffi«  «,   ' 1?nlfucominS from kim ^ drops.  In this  state he applied to me.
 ™« the ™*llest Wie could not be made to pass, I desired that a full-sized one
 might be passed down to the stricture, and its end pressed against it, for as  long a
 rSome wee°ksen  Th* Z^^ ^^ ™*> and  ^continue Ss pr3e
 sLoTe oTnriL JSn  *\?  Wlth°Ut any ad™ntage-  Being  now afraid of a total
 theTrin^tZZ   -Ut theflcommon m*ans of relief, and there being a sensation in
 hreftTmes^n  tb. w^g inflammation> 1  resolved to us« the caustic.  I applied it
fnlH Jl iff w   a °l£\at tW0 days'interval; and, after the last application, he
told me he had made water much more freely and less frequently than before  I
sStritbb°Ugle °f thC SeC°nd °r tMrd size ab<™ "i sSS, anJ H pas ed th
S™ \S  a 6if6 J^l the bladder* 1 then ordered nim to pass the bougie, 
TREATMENT.                      187
caustic could not be pursued.  The  destruction of  the disease is fre-
quently partial  and irregular.  The armed bougie, notwithstanding
every precaution, is sometimes not applied accurately on the orifice,
or the caustic is dissolved in the moisture of the  passage, and  runs
down to the lower part of the urethra, leaving the  upper part almost
untouched.   These deviations must be accurately ascertained, in order
that they may be corrected in subsequent applications.
  After this  previous step, the armed bougie is  to be introduced, the
distance of the stricture having been first marked upon it.  It should
be of such a  size as to fill the urethra, and should be pressed against
the part  for  the space of a quarter  of a minute or more.  The time
should be partly regulated by the sensations of the patient.  As soon
as a burning pain begins to be felt, it should be withdrawn.  The use
of the caustic should not be repeated oftener than every third or fourth
day,  since that  interval must be allowed for  the separation of the
slough.
  The effects of caustic on strictures have been found in practice to
be somewhat different from those which were anticipated by its first
proposers.   Its first and great effect  is the relief of  spasm.  The mor-
bid irritability of the part is exhausted by the violence of the stimulus.
When the contraction is merely spasmodic, it is  in most instances
entirely removed by one or two applications.  All difficulty of voiding
the urine then disappears, and a full-sized bougie can be passed readily
into the bladder.  When there is a permanent stricture which is more
or less affected with spasm, the spasm will be relieved as speedily, but
the permanent contraction will remain.  The stricture will not be re-
moved, but  its  irritability will  be lessened.  The opening will be
enlarged so  as  to admit a larger instrument than  before, but it will
not be dilated to the natural size  of the urethra.
   These effects are obtained by one  or two applications of  the caustic
as perfectly as by a longer continuance of its use. The actual destruc-
tion of the stricture is a very slow process, and in old indurated stric-
tures is scarcely attainable.  The slough which is produced by the
nitrate of silver  is very superficial, and no material  destruction can be
effected without numerous  repetitions of the remedy.  In the mean
time there is much danger of deviating from the true direction of the
urethra, and  the patient is subject to very serious accidents during the
course.
  Of these accidents, the first is  retention of urine, which is a very
common consequence of caustic.  It arises sometimes from the violence
of the irritation, but at other times it appears to be derived from the
obstruction which is  given by the slough, which, during the process
of suppuration, hangs like a fringe from the edge of the stricture, and,
where the opening is small, seems to oppose a mechanical  obstacle to
the flow of the urine.  Hemorrhage is another effect which is of fre-
quent occurrence, and often proceeds to a  most formidable extent.
This symptom, however, though very alarming to the patient, is never
fatal,  and  as it  invariably facilitates the cure, it can scarcely be con-
sidered as undesirable. Again, caustic very frequently occasions rigors,
especially in those who have previously suffered from them;  and it is 
188               PERMANENT STRICTURES.
by no means rare that its use should be followed by the occurrence of
an abscess in the perineum.
   Moreover, caustic has no advantage over bougies  in respect to the
permanent cure of the malady.  Experience has fully proved that after
a  stricture has been removed by caustic, bougies are still necessary,
and that  unless  they are occasionally passed, it  is  almost certain to
recur.
   For these reasons, the treatment by caustic has of late lost much of
its former celebrity.  Even those advantages which in  some  cases it
unquestionably possesses, have been  insufficient to prevent  it from
falling more and more into disuse.   Surgeons  now generally prefer
.the treatment by bougies, which effects the  same objects, sometimes,
indeed, more slowly,  but on  the whole more certainly, and with less
inconvenience and hazard.—G. G. B.]
   [Ricord.—Methods  of treatment  which take  their rise  in one
country have often fallen into disuse at the time they begin to make a
noise  in  another;  such is  the  history  of cauterization.  Extolled
beyond measure  in England after the appearance of Hunter's works,
this method at  the  present  day is almost entirely abandoned by
English practitioners, as may be seen from what Babington says of it;
and this,  too, in  spite of the efforts of Home, Charles Bell, Wathely,
Macilwain, etc.   Adopted in  France with enthusiasm, on  the recom-
mendation and according to the seductive theory of Ducamp, who was
followed  by  MM. Lallemand, of Montpellier, Amussat, Segalas,  Pas-
quier, etc., it is here on the  point of losing the new favor which it
acquired,  if we are to believe M. Civiale, who, nevertheless, makes use
of it, as some others of its antagonists do.
   If it be desired  to make cauterization an exclusive mode of treat-
ment,  applicable  to every case without distinction, no doubt but that
it is oftener injurious than useful, and that we are apparently able to
do without it in very many cases;  but if we employ it with discern-
ment and prudence only where it  is indicated,  it becomes, if not a
requisite  for cure  in a large number of cases, at least a powerful
adjuvant  to dilatation.
   Thus, many spasmodic strictures yield, only to superficial cauteriza-
tion, employed not for the purpose of destroying the tissues, but simply
to  modify their vitality;  thus, strictures accompanied by ulcerations,
or dependent upon  granulations of  ulcerated surfaces, upon fungous
vegetations, soft hypertrophies, or simple engorgements, get well sooner
and more completely when treated by caustic alone, or combined with
dilatation, than by dilatation alone.   But if cauterization be employed
in  all cases to destroy  cicatrices, which  must be replaced by other
cicatrices  of  greater extent, or if it  be applied  to  hard, fibrous, and
callous strictures, in which resolution is  impossible, far from  amelio-
rating the disease, it  aggravates it and prevents a cure, which other
more appropriate means might have obtained.
   Hunter, as has been seen, recommends cauterization only in those
cases where the stricture cannot be passed,  and then to apply the caustic
to the front of the stricture; whilst, since his time, and especially since
Ducamp took up the subject, cauterization  has  been prescribed only 
TREATMENT.
189
in case the stricture is pervious, and the caustic can be applied to its
walls.
   If Hunter did not  think  it right to recommend cauterization of
strictures which can be passed by bougies, authors, on the other hand,
have been  wrong in rejecting it in those strictures which vain efforts
by other means have proved impervious; and if the testimony of trust-
worthy observers did  not coincide with Hunter's observations in its
favor, my own experience would induce me to recommend  it, doubt-
less in rare cases, but in preference to forced catheterization.  It should
be resorted to  unless we have complete retention of urine, which has
already lasted some time, and which requires prompt evacuation; in
such a case, catheterization  having become  imperative, it  might be
rendered more difficult and less sure by the previous use of  caustic.
   In  the  more numerous cases  in which  cauterization should be
applied to the interior of the stricture, it is  better to  wait  for some
degree of dilatation before using it.   For, though it commonly quiets
spasm; though, to a certain degree, it has  a resolvent effect; though,
as I have elsewhere  said, nitrate of silver possesses a kind of anti-
phlogistic power over mucous membranes, it is none the less  true that,
in some cases, cauterization is followed by inflammation and  swelling;
that hemorrhages are  produced by it; that secretions of greater or less
consistency may follow it, and  cause, like  the eschars which it pro-
duces, obliteration of the passage;  and that  these symptoms are the
more serious the greater obstacle to the passage  of instruments the
stricture presents.
   We may, it seems to me, direct the use of cauterization  as follows:—
   1. Cauterize from  before  backwards, whenever  the stricture  still
permits the passage of the urine, but resists the introduction of every
instrument properly employed for a sufficient time.
   2. Cauterize the interior of the stricture when dilatation is without
effect, or is too slow, or when the stricture  remains stationary after
having yielded  to a  certain  degree, and inflammatory action and the
loss of a part of the benefit obtained result from our farther efforts.
   Cauterization from before backwards may be performed according to
Hunter's, Home's,  or Wathely's method; but  in those cases in which I
have had occasion to use  it, I  have employed a canula, inclosing a
stylet with a curette at its extremity, instead  of on the side, as in the
methods copied from  Ducamp. >
   In one patient  at the hospital, with a circular stricture situated in
front of the bulb, into which, for more than a month, the smallest sized
bougie could but just enter, without passing  it,  a single  cauterization
was sufficient to allow the introduction  of larger sized  bougies, which
afterwards completed the cure.   In this case, the instrument which I
had prepared by M. Charriere, consisted of a fine bougie, designed to
become engaged in the stricture; a hollow  tube  inclosing this bougie,
and bearing  at  its extremity a circular groove  armed with  nitrate of
silver; and finally a canula conductor.
   In this method, as  in Hunter's, the canula conductor  is first intro-
duced as far as the stricture, armed with a bougie which fills it exactly,
so as to prevent any mucus entering from the urethra; the  canula is 
190
PERMANENT STRICTURES.
then withdrawn,  so  as  to uncover the porte-caustique, and the fine
bougie, of which  I have spoken.
  However, we oftener have recourse to cauterization from within out-
wards, that is, on the inside of the stricture.  This method of cauteriza-
tion, perfected by M. Arnott's researches,  is performed in different
ways and with different instruments.
  In Ducamp's method, we first ascertain the depth of the stricture
and its form, by means of the porte-empreinte, and measure its length;
we then introduce the instrument, to which this surgeon gave the name
of porte-caustique, and which consists of a gaduated flexible canula,
about eight inches long, and armed at one extremity with a platinum
socket, which is traversed by a small  cylinder of the same metal.   The
cylinder, one line in diameter, and ten lines long, is attached to a rod,
which  is longer than the canula which incloses it, and is hollowed out
on one of its sides into  a  groove or curette, three lines in length and
three-fourths of a line in width.   Powdered nitrate of silver is placed
in this groove, and melted by means of a blowpipe, or the flame of a
candle, taking care not to heat it so  much as to decompose the salt.
As soon as it is armed with  nitrate of silver, the grooved cylinder is
drawn within the canula by means of the rod to which it is attached.
Then the canula, smeared  with any fatty substance, is  introduced as
far as the stricture, and  being held in place, the rod which bears the
cylinder is pushed forwards, so that the latter, escaping from its socket,
may enter within the stricture.  If the stricture is circular, the instru-
ment is completely rotated; otherwise the grove is directed to the side
of the  urethra to which the  stricture is confined.   The caustic is held
in place a moment; the quantity employed is a tenth of a grain, and
its application is repeated about every three days, until a No. 6 bougie
can be introduced, when dilatation finishes the cure.
  By this method it often happens that the  nitrate of silver is melted
before  entering the  stricture, whatever care be  taken to make the
nitrate-bearing cylinder fit its sheath, by means of a straight or curved
canula, with a central or eccentric  opening, according to the  case;
whence it follows, that Ducamp, who censured cauterization from be-
fore backwards by Hunter's method, really did the very same  thing
himself.
  To avoid the defect in this method, the ingenious Professor at Mont-
pellier, M. Lallemand, proposed to replace the flexible canula of Du-
camp's instrument, by a straight metallic canula in the straight portion
of the urethra, and a curved canula in the curved portion of the canal.
This canula incloses the nitrate-bearing curette, attached to a simple
metallic rod in the straight instrument, but spirally twisted in the curved
instrument, so as  to allow of rotatory motion.   In this method, the
instrument is not  designed to stop before the stricture, but to be  intro-
duced within it, before uncovering the nitrate of silver; for it is only
when we are within the constricted part, that we withdraw the canula
and expose the  curette, directing it toward the affected part, or the
whole  circumference, according  to  the case.   M. Lallemand's  porte-
caustiques  are graduated, or furnished  with a slide,  which can be
screwed to any point, to indicate the depth to which they should be 
TREATMENT.
191
introduced; and they are of different sizes, from No. 1 to No. 6, so as
to fit different sized strictures.   But it has been justly said, that by this
method the curette sometimes projects  before or behind  the stricture
when the canula is withdrawn, and thus the caustic is no longer exactly
and exclusively applied to the affected  part.
  M. Amussat, fearing the  inconvenience which I have  mentioned,
altered M. Lallemand's instrument, and made the orifice of the canula
eccentric, at the same time placing at the extremity of the grooved
cylinder a little  knob, also  eccentric, and designed to complete  the
end of the instrument when suitably adjusted in the canula, but which
was  made  to  project by giving it a semicircular motion.  With this
instrument we  pass the stricture, then push forward the knob, and,
slightly withdrawing it again, endeavor to hook it on to the posterior
edge of the stricture.  As soon as it has caught, the canula is with-
drawn, and the curette exposed, which we apply to any part of  the
circumference we wish to cauterize.
   Yet, however exact and seductive M. Amussat's theory is, to whom
science owes so many clever things, it is clear to all persons of experi-
ence that cauterization with his instrument is no more accurate than
by other methods.  In Ducamp's method you  have the advantage of
determining the anterior edge of the stricture;  in M. Lallemand's, you
traverse it  with the caustic under cover;  two  requisites for  precision
and  safety, which appeared so important to M. Segalas that he endea-
vored to unite  the two in his instrument, one of which is wanting in
the  porte-caustique of M. Amussat.  It  has also  seemed to me that,
since each  method has an undoubted advantage, we may, by perfecting
M. Se"galas's instrument, unite them all in one.   Thus, the instrument
which I have had prepared, and which is figured in Plate 3, has  the
advantage  of stopping in front of  the stricture, and of allowing us to
pass to the other side of it without uncovering the curette; and as soon
as the eccentric knob has grasped the posterior border, and the curette
is uncovered, we  are sure of touching only the  affected part.  In order
to avoid a  final inconvenience, viz.: the danger of the curette becom-
ing detached and remaining in the urethra, or  falling into the bladder,
we may adopt M. Dubouchet's  system, by which  the armed curette,
instead of projecting from the canula, turns within it, and is uncovered
by means of a  window on its surface.  Or, by making the curette, the
spiral, and the  rod, out of a single  piece of platinum, we have nothing
more to fear.
   However, in the majority of cases, when I have recourse  to  super-
ficial cauterization, employed less as  a * means of destruction of the
tissues than as  a resolvent adapted to modify their state—results  which
Ducamp obtained, considering the very small quantity of nitrate of
silver which he used—I employ M. Lallemand's instruments, which are
more simple and more easily managed; and I  do not fear  to encroach
a little on the sound parts.  It is well known that M. Civiale, who, by
the way, is little in favor of cauterization, in order to attain still greater
simplicity, prefers  to use wax bougies, which, being first introduced
within the stricture, take  an impression of it,  and then being  armed 
192
PERMANENT STRICTURES.
with nitrate of silver in the depressed portion, are placed again in con-
tact with the diseased parts.
  To finish the subject of cauterization, which has been modified in so
many ways since Hunter's time, I would remark  that its antagonists
would probably have the field to themselves if we practised the method
recently proposed by Dr. Berton, which consists in attacking strictures
with the actual cautery, by means of a platinum sponge, inclosed in an
instrument' similar to Hunter's or Ducamp's, according as it is desired
to cauterize from before backwards, or from within outwards.  The
sponge is heated by a current of hydrogen gas, according to Dceberei-
ner's method.
  But, it must be confessed, that some strictures will not yield to dila-
tation, and are aggravated by caustic.  Such are, in a large number of
cases, those which depend on cicatrices,  bands, callosities, inodular
indurations, and fibrous degenerations.  Here, however, art still offers
to true practitioners resources which all  speculative theories  cannot
gainsay.   For these  refractory strictures, we may, though difficulties
still confessedly remain, oppose the action of cutting instruments, of
which Hunter does not speak, though they were employed before  his
time.
  Puncture, Superficial and Deep Scarifications and  Incisions.—As in
cauterization, it has been proposed  to apply these means to the ante-
rior portion of strictures which cannot be passed, and are therefore to
be incised; or else, in cases of stricture, whose interior can be reached,
to make mere scarifications  of greater or less depth, so as to produce
disgorgement  and resolution;  or, again, to divide certain  strictures
through their whole  thickness by free incisions.   Puncture of a stric-
ture from before backwards is, doubtless, a  difficult  thing to do, and
often  dangerous, and we are yet far from being able to execute it with
precision in the incomplete state of our knowledge, and with the  im-
perfect instruments which we possess, in spite of the ingenious labors
of M. Reybard.  But more  difficult problems have found a  solution,
and we must not despair of  finding one for this. If, as pathological
anatomy seems to authorize us to conclude from some cases,  we have
less to fear from false routes under extreme circumstances than was  for-
merly supposed; and if, when the alternative presents itself  of punc-
turing the bladder, or of running the risk of a false route, it is, perhaps,
preferable to endeavor to reach the reservoir of urine by the nearest
way to the natural one, it is  still better to attempt an accurate division
of the constricted part, as I  have often done with success, by means of
my urethrotome.  This instrument  consists of a conical canula, either
straight or curved, according to the region  affected, which incloses  a
blade that is made to project at its extremity, in proportion  as  the
canula advances within the stricture, so as gradually to cut a passage
for the rest of the instrument.
  However, as in cauterization, a cutting instrument should generally
be employed only when the stricture can be passed and attacked from
within outwards.  Let it not be said that,  as soon as a  stricture  will
admit bougies, there  is no need of other treatment; for though this is 
TREATMENT.                      193
the general rule, there are numerous exceptions, as honest and unpre-
judiced practitioners will admit.
  When we  have recourse to cutting instruments, the scarifications
should be made the more superficial  the larger the opening in the
stricture is; and free incisions should be made only when there exist
very extensive bands,  or strictures of great thickness.
  In  place of the instruments proposed by MM. Amussat, Se'galas,
Leroy d'Etiolles, Tanchou, Guillon, Reybard, Mercier, etc., I have sub-
stituted one,  by means of which  simple scarifications  or incisions of
various depths can be  made.  This instrument, which is simpler  than
all others, more  easily  managed, and  more conveniently cleaned, is
figured in Plate 3.
   Yet, whether we practise superficial or deep scarifications, or make
free incisions, for which M.  Civiale's urethrotome may be used at the
meatus urinarius,  or in the  substance of the glans, the cure must be
completed by bougies  or sounds.
   Excision.—With regard to vegetations, fungosities and excrescences,
for which excision was proposed  some  time  ago, the  plan lately sug-
gested by M. Leroy d'Etiolles deserves a different appreciation  from
that given it by a recent writer.  This surgeon's system met Avith con-
siderable favor from the Academy of Sciences, and it appears to me
sounder than the system of those persons who have lately proposed
files to file away strictures.
   Ruptures.—It has also been proposed to  burst strictures by me-
chanical dilatation pushed to the rupture of the constricted part, in a
similar way  to that recommended by Prof. Recamier in the treatment
of  anal fissures.   M. Perreve has made some investigations on  this
subject, which deserve serious attention.1  Yet Prof. Rigaud's (of Stras-
bourg) metallic dilatator, with parallel rods, would seem calculated to
give more satisfactory results.
   Forced Injections.—With regard to forced injections, which they have
endeavored to revive,  even  if the theory on which their recommenda-
tion is founded were true, and the presence of a mere plug of concrete
mucus or coagulated blood often  increased the obstruction, they would
still be of but feeble assistance.
   Incisions from without.—Mr. James Syme,  of Edinburgh, in a  tract
published in 1849, proposed to incise  strictures from  without.  The
following is his method :—
   If the patient fear the pain, chloroform is given.  He is  afterwards
placed on the edge of  a bed, and  his lower  extremities held apart by
assistants,  as in  lithotomy.  A  straight or  curved  grooved sound,
according to the region affected, is introduced within the stricture, and
should pass through it.  The surgeon, seated, or resting on one knee,
makes an incision in the median  line of the perineum, or penis, wher-
ever the stricture is situated.  This incision should be an inch or an
inch and a half in  length, and should divide the skin and the subjacent
tissues  external  to  the  urethra.  Then the  operator, holding the
grooved sound in  his left hand, and a straight, narrow-bladed bistoury

          ' Treatise on Organic  Strictures of the Urethra.  Paris, 1847.
       13 
194
STRICTURES IN  WOMEN.
in his right, feels, with his  index finger guarding the point of the
bistoury, for the groove of the conductor;  and as soon as he finds it,
he plunges the point of the bistoury back of the stricture, that is, on
the vesical side.  Having done this, he draws the bistoury from behind
forwards, so as to divide the whole length and thickness of the con-
stricted portion of the canal; after which he withdraws the director.
Finally, a silver catheter, No. 7 or 8, is  passed into the bladder, and
left in forty-eight  hours.   The  catheter  is then removed, and no
farther care taken of the incision, through which the urine flows for
a few hours, or a few days at most.  At the end of eight or ten days,
a middle-sized bougie  is  introduced, and  repeated every week or
fortnight for two months.  But if subsequently there should  be any
great tendency to contraction of the tissues, it would be  prudent to
pass the bougie four or five times in the course of a year.
  In support  of this method, which he considers  preferable to all
others, Mr. Syme quotes eleven successful cases, which, indeed, appear
very encouraging.
  Puncture of the Bladder.—In  impervious  strictures, or when we
have  no time to try to pass a catheter on account of the  danger
threatened  by prolonged retention of urine, we must not  hesitate, so
long as they used to do,  before  puncturing the  bladder above the
pubes.  The bladder, being evacuated, renders cauterization easier, or
at least allows us to employ those means which require time.—Ricord.]
                     CHAPTER  III.

                  OF STRICTURES IN WOMEN.

  Obstructions  to  the  urine  in  women, I  believe, generally arise
from stricture, although not always; for I have known them produced
by compression from some adjacent swelling, and they are common in
utero-gestation,  as also in dropsical or  scirrhous ovaria.   But such
causes are commonly known long  before  this effect is produced by
which the suppression is easily accounted for.  It may also  arise from
excrescences, as in men.
  How far a stricture in the urethra of this sex is really a consequence
of a venereal inflammation I am not certain ;  but I should suppose it
is not, and for stronger reasons still than those which I gave in speak-
ing of the cause of strictures in men; for I can say that none of  the
strictures  that I have seen in women have arisen in consequence of
this disease, at least I had no reason to believe that they did; and I
have  observed  before that in most women who have the venereal
disease in the form  of a gonorrhcea, it  seldom attacks the urethra.
Therefore, if  we find a stricture in a woman who has had the disease,
we are not to impute  it to that, at least till we can ascertain the urethra
was affected; and even then it will remain doubtful. 
STRICTURES IN WOMEN.
195
  Strictures are not near so common in women as in men.  This may
be owing to the great difference in the length of the two canals ;  but
more especially to the canal in women being more simple, and intended
only for one purpose.  The stricture in women does not produce such
a variety of symptoms, or so much mischief, as in men, there not being
so many parts to be affected.
  [Ricord.—Strictures of the urethra are perhaps less rare in women
than is supposed.  The reason that they have been thought to be less
frequent is, that they do not so  soon, nor so often, excite  appreciable
symptoms  in women as in men, and that they are rarely noticed, until
they have caused considerable dysuria, or complete retention.
  As to gonorrhcea,  which is the most common cause of stricture in
women as in men, it is well known that it affects the urethra in women
more frequently than Hunter seems to think.]

               § 1. Of the Cure  of Strictures in Women.

  The cure of strictures in the  urethra of women is similar to that in
men; but it is rather  more simple, from  the simplicity of the parts.
There is, however, an inconvenience attending the passing the bougie
in women  that does not occur in men, which is,  that  in most  cases it
must be passed for  them, it being hardly possible  for a woman to
introduce a bougie herself.  The confinement of the bougie is  also
more difficult;  for although it can easily be prevented  from going
into the bladder by  bending the outer end down upon the mouth of
the vagina, yet it is very difficult  to prevent it from slipping out.  It
will be necessary to have a bandage of the T kind  passing down
between the labia over the bend of the bougie.
  It appears to me that  the caustic would  answer, extremely  well in
such cases; and therefore I should prefer it to  the bougie, both for
convenience and efficacy.
  [Ricord.—Superficial  and deep scarifications,  and incision of stric-
tures, are  of easy  application in women, and free from most of the
dangers which are to be feared in men.]

             % 2. Of the  Gleet in consequence of Stricture.

  I have already observed that it generally happens, if not  always, that
there is a gleet when there is a  stricture in the  urethra.  This I sup-
pose to arise from the irritation  produced  in the urethra  beyond the
stricture, by the urine  in its passage distending  this  part too much,
which distension is increased by the increased strength of the bladder.
This symptom often leads us to  the knowledge of a stricture, or at least
gives a suspicion of such  disease; and when a stricture is known to be
the cause, no attempts should be made to cure the gleet, for it is gene-
rally cured when the stricture is removed; but  if it  still  remains, it
may be cured in the manner recommended in common gleet, as proba-
bly arising from a cause different from stricture. 
196                spasmodic strictures.
                     CHAPTER  IV.

   OF STRICTURE ATTENDED WITH SPASMODIC AFFECTION.

   There are very few strictures that are not more or less attended with
spasms;  but some much more than others, the spasm being in some
cases more the disease than the stricture itself.   But real strictures are
attended with occasional contractions, which make the passing of the
urine much more difficult at one time than another.   In all the cases
that I have seen of this kind, when not attended with spasms, the dis-
ease is not formidable; but, when the parts are in a spasmodic state,
the symptoms are as violent as in the simple stricture.
   As this is a mixed case, it has all the characters both of the perma-
nent and spasmodic stricture; for the urethra in such circumstances is
in a state similar to what it is in the true spasmodic  kind, being very
irritable, giving great pain in the passing of the bougie, and  often re-
jecting it altogether, as will be taken notice of when we shall treat of
that disease.
   Upon considering this subject, we should at first hardly be  disposed
to believe that the spasm in the urethra is in the strictured part, which
can scarcely be supposed capable of contraction; and it might therefore
naturally be referred to the sound part of the urethra, as being brought
on by the waters not flowing freely.  If this is a just mode of account-
ing for it, we must suppose that the contraction is behind the stricture,
that being the only part dilated by the water; and such urethras being
very irritable, that part may contract so as to stop the flowing of the
water altogether.  But some circumstances that occur in practice give
reason to believe that such strictures have the  power of contraction;
for we find the bougie grasped by the stricture when allowed to remain
some time, and the circumstance of the strictured parts refusing the
bougie at times is also a proof of the same.
   There is sometimes this singular circumstance attending these cases,
that when there arises a gonorrhoea, or any other discharge of matter
from the urethra, or an increase of an old gleet, the  passage  becomes
free, and allows the urine to pass as usual; but such relief is uncertain
and only temporary; for whenever the discharge ceases the spasmodic
affection returns.  I think it is probable that it is only the spasm that
is affected  by the discharge, and not the real stricture.  Two remark-
able cases  of this kind fell under  my observation, which I shall now
relate.
   A gentleman had for a long time a complaint in the urethra, attended
with a stricture, which was supposed to be originally from a venereal
complaint.  It was often attended with a discharge, which always pro-
duced a  slight fever on its coming on; but while the discharge lasted 
USE OF  BOUGIES.
197
the difficulty of making water was relieved, and that in proportion to
the greatness of the discharge; and whenever he got a fresh gonorrhoea
the same thing happened.
  Another gentleman had a  difficulty in  making water, supposed to
arise from a stricture.   It was generally attended with such a running
as is common to strictures; but when that discharge was much increased
then the stricture was less in  proportion.   During this complaint  he
contracted two different  infections, both of which relieved him of the
stricture for the time.
  As this is a mixed disease, it may be thought proper to treat it with
a bougie for the real stricture, and for the other to use the method to
be recommended hereafter for the cure of spasm.
  It sometimes happens in these mixed kinds that a  bougie does  not
immediately pass, but is rejected by the spasm; but by letting it lie in
the urethra, almost close to the stricture, for ten, fifteen, or twenty
minutes, you will often make it pass.  This is, as it were, stealing upon
it, and the water will often flow, although the bougie is not attempted
to be passed on.  It is often relieved by gently irritating injections.1
                      CHAPTER  V.

OF SOME  CIRCUMSTANCES ATTENDING THE USE OF BOUGIES;
               THEIR FIGURE AND  COMPOSITION.

   In cases of strictures, where a bougie is used as a wedge, not as a
stimulant, and where a stricture is so far overcome as to let a bougie
pass on, the question is whether it may be better to  pass the bougie
through the whole length of the urethra, so that the end of it shall be
in the bladder, or only to pass it through the stricture a little way, so
that its end shall remain in the urethra.   Nothing but experience can
determine this question; and, perhaps, in such cases we seldom  make
a fair trial, generally pushing the bougie on to the bladder; though if
we observe the consequences of bougies not passing in those  cases
where they either cannot pass far beyond the stricture or not at all, we
find no inconvenience arising from this circumstance, except when they
are applied with too much force, so as  to make  a new passage.   The
common idea  is that it will be more hurtful to allow the end of the
bougie to lie in the urethra than in the bladder; but this seems to be
more founded in  theory than practice.
   Some people have such a quantity of calculous matter in their urine,
or so great a disposition in their urine to deposit its calculous  matter,
that it only requires the presence of an extraneous body in the bladder

  1 Added: " A gonorrhoea or occasional gleet relieves the spasmodic state of a stric-
ture upon the same principle as the passing a bougie a few inches down the urethra ;
the irritation near the glans penis takes off the spasm upon another part of the canal."
—Home. 
198
STRICTURES.
to become an immediate cause of stone; for I have observed in some
that the end of a bougie cannot remain  in the  bladder  a few hours
without being covered with a crust of calculous matter.   Such people
I have generally advised to use as much exercise as all other circum-
stances will allow.
  Bougies, when first introduced, often produce sickness, and some-
times even fainting.   I have seen a patient become sick, the color leave
his face, a cold sweat come on, and  at last  a  deliquium;  but all these
effects soon go off, and seldom return  upon a  second or third trial.
They at first produce an irritation on the urethra, which gives pain in
the time of making water, but goes off on  repetition.   They produce
a secretion of  pus in those cases where there was none, and  generally
increase the discharge where there is one previous to the application
of them; but  this effect gradually ceases.
  It frequently happens that swellings in the lymphatic glands of the
groin arise from the use of  bougies, but I never saw them advance to
suppuration.  As in most of such cases there is a discharge of matter
previous to the bougie being passed, they can hardly  be owing to  the
absorption of  matter, but must arise from sympathy.
   When treating of the stricture, I observed that it was often the cause
of a swelling in one  or both testicles; and farther, that the passing of
a bougie often removed  that complaint.   I may now observe  that a
very common  consequence of the passing a bougie is  a swelling of the
testicle.  This also arises from sympathy, and, like the swelling of the
glands, is a common effect of all irritations of the urethra.1

  1 Added: " In a gentleman who had had a stricture for many years, which at times
is attended with a great deal of spasm, but has never  any irritation in the testicles,
upon my passing a bougie smeared with a stimulating oil, for a few minutes, to remove
the spasm, an irritation and swelling of the left testicle came on.  He afterwards caught
a gonorrhcea, which entirely removed the spasm while it lasted, but also brought on a
swelling of "the testicle."—Home.
  [Ricord.—These are far from being all the inconveniences which result from the pres-
ence of sounds or bougies in the bladder.   As direct effects of their presence, we often
observe inflammation of the neck of the bladder, which excites frequent and urgent de-
sire to urinate ; vesical tenesmus, and incontinence of urine, varying in degree and dura-
tion.  These effects commonly depend on excessive irritability of the organ, or may be
the consequence  of a kind of fatigue and relaxation of the muscular fibres of the neck
of the bladder.  Various degrees of inflammation of the bladder itself are not very un-
common after the use of instruments, which have remained for some time in the cavity
of this viscus.  Ulcerations and perforations are observed in those cases in which
the sound or bougie always rests on the same point.  The repeated  introduction of
bougies or sounds, and especially their prolonged retention in the urethra, often gives
rise to inflammation and abscesses of the prostate.   These instruments frequently in-
flame even the ejaculatory ducts, and may become a temporary or permanent cause
of spermatorrhoea ; they may also determine inflammation of the vesiculae seminales
and of the  epididymis.   Finally, the pressure exercised by bougies and sounds on
certain points of the urethra, may cause still farther complications, as M. Mercier has
shown.  These are the more formidable, the more voluminous, stiffer, and less adapted
to the natural curves of the urethra, the instruments are.  Permanent catheters pro-
duce their most injurious effects at a point corresponding to the suspensory ligament
of the penis, in consequence of the pressure exercised on the  inferior wall of the
cinal.   These effects consist of inflammation, suppuration, abscesses, ulcerations,
gangrene, loss of substance, and perforation of the urethra; whence result infiltration
of urine and urinary fistulse.  The loss of substance which the  canal undergoes in
tl ese cases, is of an elongated form, stretching backwards, when  it has been caused 
USE OF BOUGIES.
199
  It may not be improper here to add some observations on the figure
and composition of bougies.  They ought to be  about two  inches
longer than the distance between the glans and the stricture, or more
if they can pass freely, so as always to allow an inch to bend upon
the glans, and another  to pass beyond the stricture.  The thickness
should be according to the size of the  stricture;  at first, such  as will
pass with a small  degree of tightness,  and this should  be  gradually
i ncreased as the contracted part enlarges.   But when the urethra has
become of the natural size,  the bougie need not be farther increased,
but its use still continued, as has been  observed.
  With regard to the shape, they should not taper from end to end
when very small, but should be nearly of an equal thickness till within
an  inch of their smallest end, after which they should taper to a point,
forming a round wedge fitted to pass into the stricture;  and this form
gives them greater strength than when made to taper from one end to
the other.
  The consistence ought to vary according to the nature of the case
and size of the bougie.  If the stricture  be near the  glans, a stiff
bougie may  be used, and the whole may be made to taper gradually,
because a short bougie will always have  sufficient strength  for any
pressure that is necessary; but if the stricture be more deeply seated,
as about the bulb, where the passage begins to take a curve, the bougie
must be a little thicker in its body to support the necessary pressure.
If the stricture be anywhere in the bend of  the  urethra, or near  the
bladder, the bougie should be very flexible (though this is contrary to
our general position), because in this case it must bend in order to
adapt itself to the curve of the passage, which it  ought to  do with
ease; for when it bends with difficulty it does not make its pressure
upon the stricture, but upon the back part of the urethra, and therefore
does not enter so easily, which circumstance makes it more  difficult to
enter a stricture near the bladder than near the glans.  In the compo-
sition of the bougie the consistence is the most material thing to be
considered, the medical properties, so  far as known, being of little
consequence.  The  materials of which they are  commonly made  are
wax,  oil, and litharge.   The litharge gives them smoothness, and takes

by a metallic sound, and forwards, in front of the  suspensory ligament, when it is
produced by a flexible bougie.
  In this region, sounds may sometimes be the cause of strictures following the bad
effects which they produce, or they may keep up fistulous passages,  when we persist
in trying to make them cure them.  Beneath the symphysis  pubis, the ulcerations and
inflammation which they produce are less formidable.  Finally, on the  inferior wall
of the membranous and prostatic portions of the urethra, these instruments produce
the  same effects, but commonly without any inconvenience resulting from them.  M.
Mercier has shown that in cases of engorgement of the transverse portion of the pros-
tate with valvular elevation of the posterior border of the  neck of the  bladder, the
pressure of an instrument depresses the affected parts and hollows out  a furrow, or
destroys them by ulceration, which in this case is very beneficial, and may be requi-
site for a cure.
  But besides these direct effects, we also meet with sympathetic phenomena, either
nervous or of a true febrile character; among the latter, the most common are attacks
of intermittent fever, either quotidian or tertian, but rarely of any other type, which
recur or cease, according as we continue the instrument in the bladder or withdraw it.
—Ricord.] 
200                      STRICTURES.
off the adhesive quality which they would have if made of wax and
oil only.  A composition which answers well is three  pints of oil of
olives, one pound of beeswax, and a pound and a half of red lead,
boiled together upon a slow fire for six hours.
   [Ricord.—Since  Hunter's time, practitioners have  been far from
agreeing on  the requisite form for bougies.
   Conical bougies have the inconvenience of dilating the sound parts
of the canal more  than the diseased parts, and, if large enough, of
fatiguing the meatus.   Again, when they are inflexible, or very rigid,
they expose the patient to the danger of false passages  more than any
other instruments.  But when we  have a  stricture of some size, for
which a small instrument is necessary, very pliable cortical bougies are
undoubtedly to be  preferred even to Ducamp's conductors, or to the
ingenious method recently proposed by B^nique, which consists in
introducing  into  the urethra a bundle of small independent bougies,
which are pushed upon successively until the one corresponding to
the opening in the stricture is introduced.
   The bougies which I employ, the cone of which does not begin till
near the extremity designed to pass the stricture, have the necessary
solidity, and are so readily introduced, that I often pass them with ease,
where cylindrical instruments of a much less caliber are stopped. They
give to the  anterior portion of strictures the form of a tunnel, into
which they  are introduced  without violence, by  pressure which is
gradually increased, and which is infinitely less painful and dangerous
than that of cylindrical bougies  of an  equal diameter.  Moreover, if
my personal experience in a large hospital  had not taught me all the
advantages that may be derived from bougies of this shape, Dupuytren's
opinion would suffice to lead me to recommend them, in spite of those
theorists who would have us believe that they are generally abandoned
at the present day.
   As I said before, both conical  and cylindrical bougies, when they
reach a  certain size, necessarily fatigue the sound parts of the canal,
and  especially the  meatus urinarius, and the  portion of the urethra
included within the glans, or immediately back of it.   To obviate this
inconvenience, fusiform or bellied bougies have been proposed, and
they are very properly recommended by Ducamp.  They undoubtedly
have the advantage of dilating  only  the constricted  part.   The prin-
cipal objection that has been made to them, viz.: that their introduction
is difficult, and attended with violence to the  meatus  and the  sound
parts of the canal  in  front  of the stricture, is not tenable;  for'since
the  utmost  volume of their enlarged portion  does not exceed the
diameter  of such cylindrical bougies as would be used in the same
case, it is seen at  once  that those parts of the canal which we desire to
spare, will receive less injury from the momentary passage of this  en-
larged portion than from the permanent dilatation exercised by cylin-
drical bougies.
   Conical bougies  terminated  by a small bulb, or olive-shaped end,
are very useful, and I  must  confess that at first I did not fully appre-
ciate them.  I now use them more than any others.  They can be
made to pass strictures which are impervious to other instruments. In 
USE OF  BOUGIES.
201
most cases they have the advantages of conical bougies, without the
inconvenience of their point.
  M. Leroy d'Etiolles has derived great advantage from twisted bou-
gies, or bougies rolled  into  a  spiral, in certain eccentric strictures.
They are made by rolling small bougies of India rubber or gutta percha
round a large knitting-needle, or  any other cylindrical body.  With
time, patience, and a light touch, strictures may be overcome by these
instruments, which at first appear insurmountable.  When you have
succeeded in passing one of these bougies, and the urine flows between
it and the canal, it must be left in place twenty-four hours, when it can
be easily replaced by a larger one.
  Flexible bougies are in common use, and  many  surgeons  prefer
bougies of wax; but though these have the advantage, when properly
made, of taking an impression of  the diseased parts, and of moulding
themselves to the natural or accidental curves of the canal, it often
happens, when we wish to introduce them, that they are either too stiff
for some patients, or  that they become too flexible, after we have been
trying to pass a stricture long enough for them to soften.
  Bougies of  gutta percha have recently been proposed.  These bou-
gies, which are at first stiff, but which become flexible when slightly
warmed, are not affected by contact with the  urine, and may become
valuable instruments at  a future day, when they are farther perfected.
  For myself, I prefer the so-called  gum-elastic bougies.  But  stiff
bougies are still frequently employed; and lately, the use of metallic
sounds has very properly been revived.  I am well aware, as Desault
remarks, that their feeble weight  adds nothing to ordinary dilatation
made with softer instruments, which are more  easily borne;  but I
would beware of stigmatizing with empiricism, as some persons have
done, those who have recommended them as a simple and economical
means for the poor and for hospitals,  where  many patients use them
with  great ease and without  danger.  They  are especially adapted to
cases where it is only requisite to maintain a cure.
  Stiff bougies have also been recommended, but they are not abso-
lutely or permanently stiff; such  are  the whalebone  bougies, that M.
Lallemand (of Montpellier), recommends, catgut bougies, and the more
recent bougies of flexible ivory. The latter, composed  of ivory, reduced
to a semi-gelatinous state by depriving it of a portion of its phosphate
of lime, have  the advantage of producing a solid instrument to which
a suitable curve is given, according to the case, and which, under the
influence of the moisture of the urethra, afterwards softens  and swells,
adapting itself to the shape of the canal, and tending  to dilate it more
and more.  The faults found  with whalebone bougies, and especially
with those of catgut, may also be found with these.  Their chief in-
convenience is owing to the fact that the instrument swells  in the con-
stricted part, so as to become fixed, and adheres with so much force
that it cannot be withdrawn  without  considerable violence, which  is
not always free from danger.   However, we may obviate  this  defect
by soaking the instrument in  water, and ascertaining beforehand the
extreme dilatation of which it is susceptible; and thus we may  derive 
202
STRICTURES.
great advantage from this German invention, which has been so happily
naturalized in France by M. Charriere.—Ricord.]

             § 1.  Of a New Passage formed by Bougies.

  The greatest evil arising from the improper use of the bougie and
the most dangerous, is where it makes a new passage.1  I mentioned
before, that this generally rose from an attempt to  produce ulceration
by the application of the end of the  bougie  to the stricture in cases
where a bougie could not pass; for, in those  cases where  a bougie
passes, there can be no danger of such an effect.
  This  new passage is seldom carried so far  as  to produce  either an
increase of the present disease or a  new one,  although sometimes this
happens; yet it prevents the cure of the original disease; for it renders
both the application of the bougie and caustic  to the stricture  so uncer-
tain that a continuance of either is dangerous, as it may increase the
mischief, and at last produce very bad consequences.
  This  new passage is generally along the side of the old one when in
that part  of  the urethra which is  on this side of the bend, and it is
made in the spongy substance of the urethra; but when it is made at
the beginning of the  bend, it passes on in a straight  line through the
body of the urethra, about the beginning of the membranous  part, and
goes through the cellular substance of the perineum towards the rec-
tum.  When the new passage is made between the glans and the bend
of the urethra, it may take place  on either side of the canal equally
in the  spongy substance of the urethra; between the  canal and the
skin of the penis  or  scrotum; and it may be between the canal and
the body of the penis.  The situation of it will make some difference
in the operation necessary for the cure of this complaint.
  When a new passage is made, I know of no other method of cure
than to open the part externally; and the opening must be made  in
that part  of  the urethra which is most convenient for coming at the
stricture, regard being had to the other external parts, such as the scro-
tum.  If the stricture be before the scrotum,  the new passage will be
there also, and, therefore, the operation must be made of course before
that part;  but if the stricture is opposite to  the scrotum, the bottom
of the new passage may also be opposite to this part; but if the new
passage is of a considerable length, its bottom or termination may be
in the beginning of the perineum; and  in either situation, the opera-
tion must  be begun behind the scrotum, or, indeed, may be made  a
little way into it.  But if the stricture and new passage are in the peri-
neum, then the operation is to be performed there.
   The method of performing this operation is as follows: Pass a staff,
or any such instrument, into the urethra as far as it will go, which will
probably be  to the bottom of the  new passage, and that we may be
certain  is beyond the stricture.  Feel for the end of the instrument
externally, and cut upon it, making the wound about an inch long if
the disease be before the scrotum, and an inch and a half, or more, if
1 Vide Plate II. 
USE OF  BOUGIES.
203
in the perineum.  If the new passage be between the urethra and the
body of the penis, then you will most probably get into the sound
urethra before you come to the instrument or new passage; if so, it is
necessary to go farther in order to get into the bladder, as we  may be
certain that this part of the urethra is behind  the stricture.  Having
proceeded so far, take a probe, or some such instrument, and introduce
it into the urethra by the wound, and pass it towards the glans, which
will be passing it forwards towards the stricture.  If it meet with an
obstruction there, we may be certain it is the stricture, which is now
to be got through, and which will afterwards be easily enlarged.  To
complete the operation, withdraw the probe, and introduce in the room
of it a hollow canula forwards to the stricture; then take another
canula, and introduce it from the glans downwards till the two  canulas
oppose each other, having the stricture between them, an assistant lay-
ing hold of the urethra on the outside, between the finger and thumb,
just where  the two canulas meet, to keep them in their places; then
through the upper canula introduce a piercer, which will go through
the stricture, and pass into the lower canula; this done, withdraw the
piercer, and introduce a bougie into the same canula in the same way,
being careful  that it passes into the lower canula; then withdraw the
lower canula, and the  end  of the bougie will  appear in  the wound;
lay hold of the bougie there, and withdraw the upper canula over the
bougie, leaving the bougie in the urethra;  now the lower end of the
bougie is to be directed into the urethra leading on to the bladder, and
pushed on  to that viscus.  It may be farther necessary to lay the whole
of the new passage  open, that  it may all heal up; for it is possible
that this new passage may often receive  the bougie, to be applied in
future, which would be troublesome, and  might prove an obstruction
to the cure.
  If the new passage be between the skin and the canal of the urethra,
after cutting down to the instrument, you must go farther on in search
of the  natural canal, and, when you have found it, introduce  a probe
into it  towards the glans, to find the  stricture;  and when this  is done,
go on with the operation as above described.
  The bougie  must be left in the passage, and as it may be found dif-
ficult afterwards  to  introduce another readily  into the  bladder, the
longer the  first is allowed  to remain, so  much the more readily will
the second  pass.  I am not certain but that it would be better to push
on the hollow  canula at first, and keep it there for some days, at least
till the inflammation  is over, and  the parts have adapted themselves
to that body, which will make a bougie  pass more easily afterwards.
The bougies must be gradually increased in size, and continued  till
the wound is healed up.
  The first case of a new passage formed by a bougie which I ever saw
was at the  hospital of the third regiment of guards, about the year
1765.  A young soldier had a stricture, for the  cure of which he had
bougies regularly passed for near half a year without any relief.  The
bougie had gone farther  than at first by two inches, and therefore
seemed to have gained ground on the stricture.  This seemed to justify
the continuance of the practice; but it being suspected that there was 
204
STRICTURES.
something more than was then understood, I was consulted; and,
without foreseeing what was really the case, I proposed that an open-
ing should be made into the urethra where the obstruction was, and
carried farther back if necessary, in search of the sound urethra.  This
was accordingly done in the following manner: the grooved staff was
first passed as far down as it could go, which was  to the bottom of the
new passage; the scrotum was pulled up upon the penis, when the
end of the staff was prominent towards the skin a little way above the
perineum, and there an incision was made on the end of the staff about
half an inch long; this  disengaged the end of  the staff, which was
pushed out at the wound;  then search was made  for the other orifice
which led to the bladder, on the supposition that  that  orifice was the
stricture ; but none being found, we tried to trace it by blowing with
a blowpipe into the bottom and lower part of the wound; but no orifice
could be observed.  We then began to suspect  that we were not in
the urethra.   To determine if we had been in the urethra, I began to
dissect with care the parts at the bottom of the wound, and laid bare the
musculi acceleratores.  I then made an incision into the body of the
urethra and came to the true  canal, which was easily discovered.
When this was done we passed a probe on to the  bladder, then with-
drew, turned, and passed it from this wound towards the glans penis,
but found that it went not much more than two inches  that way, and
then stopped.  This struck us with a new idea of  the case, for we were
now sure that the end of the staff had not been in the urethra, but in
a new passage made in the spongy part of the urethra, for two inches
beyond the stricture.  We now passed a staff from the glans down the
urethra, and another up from the last wound, to see at what  distance
the ends of the two instruments were, which would give us the length
of the stricture.   We found, by taking hold of the urethra  between
the finger and thumb on  the outside, that the two ends were  close
together.  What was to be done next was our consideration; it im-
mediately struck us that we might force our way through the stricture
with safety.  The gentleman who assisted me in the operation passed
a blowpipe  one-fifth of an inch in diameter (being not sufficiently
furnished with instruments) from the wound forwards to the stricture;
and then I took a silver canula, open at both ends, which had an iron
piercer longer than itself, and passed it down to the stricture from the
glans; and now the end of the canula opposed the  end of the blowpipe,
and they were almost close upon  one another.   They were  kept in
this position, with the finger and thumb applied on the outside of the
penis, like splints on a broken bone.  I then introduced the piercer
and pushed it on, which went through the stricture into the hollow of
the blowpipe.   Great care was taken not to push  too forcibly, lest the
two ends of the hollow tubes should slip by  one  another, which they
would do if not held firmly, as actually happened twice in this case;
but we succeeded the third time. I then pushed on the canula through
the stricture, and with it pushed out the blowpipe.  The next object
was to pass a hollow bougie along  the urethra to the bladder, to do
which the small end of it was introduced into the canula, which, being
pushed on, forced out the canula  at  the wound; we  then passed  a 
USE OF  BOUGIES.
205
director into the other orifice of the urethra, leading on to the bladder,
and put the end of the bougie into the groove of the director, and
pushed it along the groove to the  bladder;  and before we withdrew
the director we turned it round with its back to the bougie, that the
end of the bougie might not stop against the end of the groove, and
so be pulled out again.  After all this was done one stitch was made
in the urethra, but the external wound in the skin was left for the
passage of the urine, that it might not insinuate itself into the cellular
membrane.  We dressed the wound superficially, and applied the T
bandage, which was slit to go on each side  of the scrotum, and just
where it came to the scrotum we tied  the two ends together, which
supported the scrotum and kept it forwards on the penis ; and the two
ends that came from this knot on each  side of the scrotum were tied
to the circular part that came round the body.  The patient had  some
slight fever for a day or two, and the urine came  partly through the
bougie and partly by the side of it, through  the wound.  A swelling
of one testicle came on;  likewise a swelling of the glands of the groin,
pain in the belly, sickness, and at times vomiting, all which symptoms
were  owing to sympathy, and entirely went off in five or six  days.
The  water,  in nearly the same  time,  came entirely by the natural
passage.  The bougie was changed from time to time till the cure was
completed.
   [Ricord.—After reading what Hunter says of false passages, any
one will be convinced that if this  accident was not rarer,  much less
was known about it in his time than at the present day.
   Since all parts of the urethra, without exception, are capable of be-
coming the seat of strictures, false passages may consequently be made,
or may be found already existing, in any portion of this canal.   Both
the fixed and movable  portions present  numerous examples of it.
Thus, Hunter speaks of false passages in the  spongy portion of the
urethra; and Charles Bell and many others mention instances, without
counting all those which have not been reported.  However, it is very
certain that false passages are found most frequently in the curved or
membranous part of the canal, although they may also occur in the
prostatic portion  both within the  substance of the gland  and at the
neck  of the bladder. They are most commonly made in the inferior
wall of the  canal, especially in the membranous portion, but they may
also occur on all sides of the urethra, as, for  instance, in the superior
wall,  at a point corresponding to the suspensory ligament, when the
surgeon, in passing a catheter, forgets the direction which the canal
follows in this region, from above downwards and from before  back-
wards, and depresses the handle of his instrument  too soon. Yariable
in their size and length, they may terminate in a cul-de-sac, or may
enter a neighboring organ, as the rectum; or else, after having made
their  way through the tissues for some distance, they may reach the
bladder, either passing through its anterior wall, or more  frequently
by the natural passage posterior to the  stricture, or again by piercing
the substance of the prostate; fistulas may also enter the bladder be-
hind this gland, and perforate its sides or bas-fond.  In the latter case
the instrument which makes the false passage may pass  between the 
20.6
STRICTURES.
 bladder and the rectum, or may reach the bladder after entering and
 again emerging  from  the intestine,  as in  the case reported  by
 Deschamps.
   Hunter has not dwelt on the circumstances which favor the produc-
 tion of false passages.  They may be found in the situation of certain
 strictures, in the  fixed  position of the parts  of the  urethra beneath
 the pubis, and in the changes in direction which the canal undergoes
 arising especially from abnormal or pathological states of the prostate
 the accumulation  of fecal  matter in the rectum, and the consequent
 distension of this intestine at the time of catheterization for certain
 deep strictures;  but, in addition to these causes, we must  seek for
 others in the character of the strictures,  in the condition of the tissues
 situated in front of them, in the nature of the instruments employed to
 pass or force them, and in  the prudence and ability of the surgeon.
   The harder, more callous, tougher, and less dilatable strictures are,
 the more easily false passages are made; the narrower the passage is
 the more this accident is  to be feared; this is especially true if the
 stricture is very long, or if many strictures follow each other, so that
 the first interferes with passing the instrument through the second, and
 so on.  When the tissues in front of a stricture are softened by chronic
 inflammation or otherwise, perforations  may easily occur without the
 stricture necessarily being  very large.
   The instruments employed have a great influence in the production
 of false  passages.  Supple and flexible instruments are the least dan-
 gerous,  and rigid instruments the most dangerous.   Their volume
 should  be adapted to the  size of the opening in the stricture.  Yet
 in soft or spasmodic strictures, it is better that they should be a little
 large.  But, as a general rule, the less the diameter of the instrument,
 the greater the danger.  Straight and rigid instruments, used in the
 portion  of  the urethra posterior to the suspensory ligament of the
 penis, have occasioned frequent accidents.
   Though instruments produce false passages with the greater ease in
 proportion as they are pointed—as, for instance, conical sounds, which
 have  been too highly praised, and perhaps too much  censured also—
 the lesions which they cause in this case are less serious than those
 which result from the use of larger instruments, whose volume is not
 proportioned to the stricture.   In fact, in the first case you often have
 merely  a simple perforation, a kind of acupuncture; whilst in the
 second case you bruise the parts, lacerate them extensively, and even
 tear out  fragments of the canal.
   Pressure  on the front of strictures,  in the cure by ulceration, as
 Hunter calls it, and cauterization, more particularly when applied from
 before backwards, also give rise to false passages; the same is true of
 the various cutting operations of which we have spoken.
  However, the most fruitful cause  of false passages  is perhaps the
 hand of the operator.   An imperfect acquaintance with anatomy, want
of practice, and too great haste, have caused accidents where they might
have been avoided, in spite of all other causes combined.  Take hold of
the sound as low down as possible, so as to better judge of the obstacle
to be overcome and the route to pursue; draw the penis towards the 
USE OF  BOUGIES.                    207
instrument, so as to stretch the urethra and obliterate so far as possible
the cul-de-sac in front of the stricture; follow the instrument with the
finger externally in its course to the end of the perineum;  introduce
one finger into the rectum, so as to accompany it  at its entrance into
the prostatic portion, and prevent its  deviating from its course;  take
the more time for the  operation the more difficult it is; use well-
directed efforts to push the sound forwards only when you feel its point
grasped by the tissues, and thus know that  it is  engaged within the
stricture; these are the rules for the surgeon to follow, which, added
to the choice of good instruments, will protect him from accidents that,
alas! are too common, when  a desire to shine by  a rapid operation is
joined to ignorance.
   Hunter, as has been seen, says nothing of the signs by which false
passages may be recognized.  A flow of blood at the moment the
sound or bougie is introduced is of little value  in this respect.  In
some patients, the  urethra  bleeds with great facility without the in-
strument deviating from the natural passage.  In  others, the bleeding
is owing to a softening of the mucous membrane.   It is not true that
the first passage of a sound in any person is generally followed  by a
flow of blood, even if there  be no morbid change in the canal.  The
feelings of the patient are equally  deceptive.  Some exaggerate their
suffering, and think themselves  wounded every  moment,  especially
about the fossa navicularis, the bulb  and the neck of the bladder;
hence, even  those  who  have nothing the matter with them may be
made to believe  that these  regions are the seat of disease; whilst
others, because they suffer less than they expected, will let you pierce
the walls of their urethra without any expression  of pain.   However,
when patients complain of a tearing  or  pricking sensation, we must
redouble our attention  and  care.   Generally, they suffer more when
the urethra  is torn than when the instrument passes the stricture; the
sensibility of the latter not being always so great as has been asserted.
Nevertheless, I must add, that when once engaged in a false passage,
a sound or bougie is less painful than when  it remains  in a stricture.
With regard to  the amount of  resistance, it is very certain that in
most cases the sound parts resist less than the diseased parts, and that
in some cases we might be deceived by the ease with which we pierce
the tissues.   The tearing sensation, which surgeons and  patients detect
immediately, may be due to  the rupture of a band, or to a sudden
bruise of the constricted part, and also to the division of the tissues in
front of it.   But when we have entered a stricture which offers some
degree of resistance, the instrument is grasped by it, which does not
take place when a false passage is made.  The coincidence of the in-
strument with the axis of the urethra; the possibility or impossibility
of rotating curved instruments, which are supposed to have entered
the bladder; the flow of urine from the catheter, when one is used—
are often deceitful signs.  Indeed, we may have made a false passage,
at the same  time following very nearly the axis of the canal, and the
instrument may have reached the bladder by one of those  accidental
routes, of which we have spoken, without our knowing it, except from
subsequent symptoms, which fortunately do not always  arise.  On the 
208
STRICTURES.
other hand, without departing from the natural  passage, the instru-
ment may be grasped by the constricted part, be inclined  to  one side
or the other in eccentric  strictures, and,  impeded  by the  bladder,
whose capacity  is decreased by thickening and contraction of its
walls, may lead  us to believe that it has taken a wrong course, espe-
cially if the eyes of the catheter are plugged up with mucus or blood,
so as to prevent the urine from escaping.  But, in addition to  the
symptoms which I have just examined,  I must mention, as of greater
value, the impressions that may sometimes  be taken  by means of
Ducamp's exploring sound, or by bougies of soft wax; also a digital
examination through  the rectum, and especially the amount of con-
striction that the instrument undergoes.
  If what Hunter says were true, most false passages would be serious
affairs, and would require operations still more serious, but it is  not
so.   When there is no complete retention  of urine, and patients can
empty their  bladder;  when the false passage is made by an instrument
of small  diameter, and when it has not reached the bladder  back of
the stricture, it is commonly a slight accident, which patients, and some-
times inexperienced surgeons, do not detect.  When it is known, it is
sufficient to let  the patients  rest a few days before introducing new
instruments, and then the parts  contract and cicatrize;  the urine, on
account of the position,  and  especially  the direction of the  passage,
tending rather to approximate its walls than  to introduce itself  between
them unless there be a false passage returning on itself as may occur
when a bougie bends and forms a hook in front of the stricture.
  Local inflammatory symptoms or general sympathetic reaction may
supervene in cases of bad ruptures, violence by large instruments, or
destruction of the tissues by cauterization, &c.  But so long as  the
false passage does not communicate with the reservoir of urine, either
when first made  by the instrument or by a subsequent process of ulcer-
ation, and the patient  can pass his water, we have still much  to hope,
if we will wait and meet the symptoms with suitable treatment.  It is
only when ruptures  are  large and extended, the  retention of urine
complete, and  prompt evacuative catheterization urgent, that we  are
to expect the most unpleasant results, and are forced to have recourse
to operations  analogous  to those of which Hunter  speaks, or to
puncture the bladder, or  finally to contend  against symptoms arising
from effusion of  urine.  However, in some cases, when the instrument
has made a false passage into the bladder,  and  patients are. able aud
especially are desirous of retaining it, everything goes on  well, and a
new  canal soon forms, provided  with a false mucous membrane.  In
all cases when a  false passage is made, its direction should be remem-
bered, or, when  another  surgeon has sounded before you, its course
should be ascertained by  taking impressions of the canal, so as to give
the instruments a curve and direction which will prevent their falling
into it a second time.—Ricord.] 
CONSEQUENCES  OF  STRICTURES.            209
                      CHAPTER VI.

OF DISEASES IN CONSEQUENCE OF  A PERMANENT STRICTURE
                       IN THE  URETHRA.

   Strictures in the urethra produce almost constantly diseases in the
parts beyond them; that  is,  in the part of the urethra between the
stricture and the bladder.   They bring on in most cases a gleet, as has
been described, and often  a considerable distension of the part of the
canal beyond  the stricture; also inflammation and ulceration, and in
consequence of them diseases in the surrounding parts, as in Cowper's
glands, the prostate, and the surrounding cellular membrane, forming
abscesses there, and at last ulceration, for the purpose of making a new
passage for  the urine.   The bladder is  also often affected, and some-
times the ureters, with the pelvis of the  kidneys, and in some cases the
kidneys themselves.  All these are effects of every permanent obstruc-
tion to the urine; some of them  are methods which  nature  takes to
relieve the parts from the immediate complaints; such are the increase
of the urethra beyond the stricture, and  the enlargement of the ureters
and pelvis of the kidneys, which are only to be considered as the parts
accommodating themselves to the immediate  consequence of the ob-
struction, which is the accumulation of  urine.  Of these complaints I
shall take notice in their order.


               §1.  Of the Enlargement  of the Urethra.
   The urethra  beyond the  stricture I have  observed is  enlarged,
because it is more passive than the bladder, and yields to the pressure
of the urine.  It is naturally passive while the bladder is acting, by
which means it becomes  distended in  proportion to the  force  with
which the bladder acts, and the resistance of the stricture.  Its internal
surface toften becomes  more irregular  and fasciculated.   It is also
more irritable, the distension becoming  often  the immediate  cause of
spasms in that part, and these spasms are most probably excited with
a view to counteract the effort produced by the action of the bladder.
   [Ricord.—When there are several strictures, an enlargement of the
canal is rarely observed, except behind the one which is nearest to the
bladder.   Between the  others the urethra often appears  contracted
without  its  walls being affected.   The  latter are even free from the
chronic inflammation and  morbid  secretion which are met with back
of the posterior stricture.
  These dilatations have been justly compared to aneurismal enlarge-
ments, some of whose phases they resemble.]
       14 
210
STRICTURES.
        § 2. Of the Formation of a New Passage for the Urine.

  When the methods recommended above for the removal of a stric-
ture have either not been  attempted or  have not  succeeded, nature
endeavors to relieve herself by making a new passage for  the urine,
which, although it often prevents immediate death, yet, if not reme-
died, is productive of much inconvenience  and misery to the patient.
through life.   The mode by which nature endeavors to procure relief
is by ulceration on the inside of that part of the urethra which is en-
larged and within the stricture.   The ulceration  commonly begins
near or close to the stricture, although the  stricture may be at a con-
siderable distance from the bladder;  therefore we must suppose that
there is some circumstance besides the distension of the urethra by the
urine which determines the ulceration to a particular part.  This cir-
cumstance most probably arises immediately out of its vicinity to the
stricture, and may be called contiguous  sympathy.   The stricture is
often included in the ulceration, by which  it is removed, the disease
cured, and a stop sometimes  put to the farther ulceration; but un-
luckily this is not always the case.  We may observe that this ulcera-
tion is always on the side next to the external surface, as is  common
in abscesses.
   As this ulceration does not arise from preceding inflammation, and
as it cannot be said that the urine acts exactly as an extraneous body,
because it is in its natural passage, we find that there is but very little
inflammation of the adhesive kind attending these ulcerations.  We
must allow, however, that the urine produces the ulcerative disposition
here, like matter on the inside of an abscess, although not  so readily.
   Whenever,  therefore, the internal membrane and substance of the
urethra are removed by absorption, the water readily gets  into the
loose cellular membrane of the scrotum and  penis, and diffuses itself
all over those  parts, not having been previously united by the adhesive
inflammation; and as the urine has "considerable irritating powers
when applied  to the common cellular membrane, the parts inflame and
swell.   The presence of the urine prevents the adhesive inflammation
from taking place; it becomes the cause  of suppuration wherever it is
diffused; and the irritation is often so great, more  especially in cases
where the urine has been  allowed to become very stale, that it pro-
duces mortification, first in all the cellular membrane, and afterwards
in several parts of the skin, all of which, if the patient live, slough
away, making a free communication between the urethra and external
surface, and produce fistulas in perinaso.
   We may observe, however, that the want of the adhesive inflamma-
tion in these  ulcerations  appears to be  peculiar to that part of the
urethra which lies between the membranous part and the glans penis;
for we find from experience that when this process takes place farther
back,  as in the prostate gland, a circumscribed  abscess is generally
formed.  This may arise from the difference in texture of the cellular
membrane of the parts, the first admitting of the diffusion of the urine
very readily from  the looseness of its  texture, the other producing 
CONSEQUENCES  OF  STRICTURES.
211
adhesions before the urine is allowed to pass, which adhesions after-
wards exclude it.
  It sometimes happens that the urine gets into the spongy substance
of the body of the urethra, and is  immediately diffused through the
whole, even to the glans penis, producing mortification of all those
parts, as I have more than once seen.
  When the  urine has made  its way into  the cellular membrane,
although the ulceration of the urethra is in the perineum, yet it gene-
rally passes easily forwards into the scrotum, that part being composed
of the loosest cellular membrane in  the body.  When the seat of the
ulceration is  in the membranous or bulbous part of the urethra, and
the pus and urine have found their way to the scrotum, there is always
a hardness extended along the perineum to the swelled scrotum, which
is in the tract of the pus.
   Ulceration cannot be prevented  but  by destroyiug the stricture;
but when the water is in the cellular membrane,  which is the state we
have been describing, the removal of  the stricture will in general be
too late to  prevent all  the mischief, although  it will be necessary for
the complete  cure; therefore an attempt should be made to  pass  a
bougie, for, perhaps, the stricture may be included in the ulceration
(as was mentioned before), and thereby allow a bougie to pass.  When
this is the case, bougies must be almost  constantly used to procure as
free  a passage forwards in the right way as possible.  When the bougie
will not pass, I am afraid that the caustic, as described in the  case of
a stricture, would in many cases be too slow in its  operation; and in
others it cannot be tried, as the situation of the stricture is often such
as will not admit of it.
   While we are attempting the cure of  the stricture, every method is
to be used that removes inflammation, particularly bleeding.   Great
relief may be obtained by exposing  the parts  to  the steam  of hot
water;  but this is merely a palliative cure.  The warm  bath, opium,
and  the turpentines, given by the mouth, and also by the anus, will
assist in taking off any  spasmodic affection; but all these are too
often insufficient, and therefore  immediate relief must be attempted,
both to unload the bladder and prevent any farther effusion of urine
into the cellular membrane.  This must be  done by an operation,
which consists in making an opening  into  the urethra somewhere
beyond the stricture, and the nearer to the stricture the better.
   The method of performing the operation is first to pass a director or
some such instrument into the urethra as far as the stricture; then to
make the end of the instrument as prominent externally as possible, so
as to be felt, which in  such a case is often  difficult, and sometimes
impossible.   If it can be felt, it  must be cut upon, and  the incision
carried  on a little farther towards the  bladder or anus, so as to  open
the urethra beyond the stricture; this will be sufficient  to allow the
urine to escape and to destroy the stricture.   If the instrument cannot
be felt at first by the finger, we must cut down towards it, which will
bring it within the feel of the finger, and afterwards proceed as above
directed.1

       1 This is the operation which Mr. Syme has lately revived.—Ricord. 
212
STRICTURES.
   If the stricture in the urethra be opposite to the scrotum, it being
 impossible to make the opening there, it must be made in the perineum,
 in which case there can be no direction given by an instrument, as one
 cannot be made to pass so far; therefore we must be  guided by our
 knowledge of the parts.  The opening being made, the stricture  is to
 be searched for as described in  the operation, in cases where a  false
 passage has been  made, by passing a probe from the wound forwards
 towards the glans.  The other steps of the operation will be nearly the
 same.  In whichsoever way the operation is performed a bougie must
 be introduced, and  the wound healed up over it.  In my opinion a
 catheter answers this purpose better.1
   Great attention should be still paid to the inflammation, which arises
 in consequence of the urine having been diffused in the cellular mem-
 brane, as before described.  Where the inflammation is attended with
 suppuration and mortification, it will be necessary, as well in this  case
 as in that where no operation is required, to scarify the parts freely,
 to give an opening both to the urine and pus.   Where mortification
 has  taken place on the skin, the scarifications should be made in  the
 mortified parts, if it can be done with equal advantage, and this with
 a view to prevent irritation.
   In total suppressions of urine, from whatever cause, the urine should
 never be allowed to accumulate, and should either be drawn off  fre-
 quently  or  a catheter should  be kept continually in the urethra  and
 bladder, because we should on no account  allow the  bladder  to be
 distended beyond an easy state; for if it  be, it  always brings on  de-
 bilitating and  alarming symptoms, as  paralysis of  that viscus.  In
 many suppressions of  urine, as in cases of strictures, it is impossible
 to draw off the water.  In some cases, where the urethra is ulcerated,
 and the  urine gets into the cellular membrane of the penis and pre-.
 puce, so  as to  distend them much, producing a phimosis, it becomes
 impossible to find the  orifice of the urethra.  The following case illus-
 trates most of the preceding doctrines:—
   A gentleman, of a scrofulous habit, had often had venereal gonor-
 rhoeas, which, being severe, commonly produced swellings, or knobs,.
 along the  urethra, upon which account he was advised to avoid  this
 disease as much  as possible.  When in the country, in November,
 1782, he was attacked with a slight  cold  or fever, and a  small  dis-
 charge from the urethra, which he could not determine to be venereal.
 In this state he set out for London, but was seized on the road with a
 suppression of urine, which detained him two days at an inn.  On  his
 arrival in London, I found him feverish.  He spoke to me only of a
 discharge from the urethra; but as I did  not conceive that the fever
 could arise from that cause, I desired him to be easy on that account.
 He was  taken with  a  shivering fit, which made us  suspect it might
 terminate in an intermittent, and we  waited for the  result. He still
complained of the discharge, and mentioned a soreness in the perineum,
both when he made water and when he  pressed it  externally.   On

  1 Puncture of the bladder above the pubes should often be preferred.—Ricobd.
  [Puncture of the bladder through the rectum, except in case of an enlarged prostate.
should be preferred to puncture above the pubes.__Ed.] 
CONSEQUENCES  OF STRICTURES.            213
 examining the perineum, I found a fulness there, from which I sus-
 pected a stricture, and inquired particularly how he made water .in
 common;  he declared very well, which led me from the true cause.
 This swelling was regarded as the effect of an inflammation, either in
 consequence of the fever, the disposition of the part, or both, increased
 by sitting in a postchaise for several days.   The part was fomented
 and  poulticed, and  leeches  were applied several  times.  He  had
 another shivering  fit three days after the first, which, if his disease
 had been  an intermittent, would have constituted  a  quartan;  but he
 had another some hours after, which made us give up our suspicions of
 an intermittent.  We now began to suspect that matter was forming
 in this part, although I could  not feel anything like a fluctuation; nor
 was the pain of the throbbing kind, or so acute as we commonly find
 it in  the suppurative inflammation.  What in some degree surprised
 me was that the swelling came forwards along the body of the penis
 towards the  os  pubis,  while it seemed  to be diminishing  in the
 perineum.  He now began to find a difficulty in making water, with
 a frequent desire, which  increased  till there was a total suppression.
 I pressed  on the lower part of the belly to determine whether or not
 the urine was secreted and accumulated in the bladder;  but I could
 not feel any fulness;  nor did he then feel  pain on pressure; however,
 about twenty-four hours after, he began to complain of a great desire
 to make water, and a pain in the lower part of his belly, and, the hand
 being placed there, a fulness of the bladder was readily felt.   It was
 now clear  that the water ought to be drawn off; but, as I still  sus-
 pected mischief in the urethra as a cause  in his complaint, I took the
 necessary precautions.  I provided myself with catheters and bougies
 of different sizes; and, to be  as  much upon my guard  as possible, I
 introduced a bougie of a small size first, and found a full stop about
 the bulbous part of the urethra;  I then took a smaller, which  passed,
 but with difficulty.  I afterwards passed a small catheter on  to the
 stricture, where it  stopped; but, as it was absolutely necessary that
 the water should  be drawn off, I used more force than  I otherwise
 should have done;  it went on, but with difficulty, and I was not cer-
 tain whether it was in the natural passage or was making a new one.
 When the  bougie had gone so far as certainly (if in the right passage)
 to have entered the bladder, I found that  no' water came; I therefore
 pressed the lower part  of the belly, and the water immediately came
 out through the catheter, whence it appeared that the bladder had lost
 its power of contraction.   The water was drawn off three times every
 day, that is, every eight hours, to give  as much ease to the bladder as
 possible; but still, it  was necessary to press the belly, to'assist  the
 discharge of the urine;  and it was upwards of a fortnight before the
 bladder began to recover its power of contracting.  The swelling in
 the perineum still continued, advancing along the body of the penis,
 and spreading a  little on the pubes;  it seemed to extend along the
 projecting part of the penis, and at last filled the whole cellular mem-
 brane of the prepuce,  but did not  in the least affect the scrotum. This
swelling appeared to be owing to  the urine having found its way into
the cellular membrane of the perineum, and from  thence proceeding 
214
STRICTURES.
along the side of the penis.  When the prepuce became much loaded
with water, a very considerable phimosis took place, which made the
introduction of the catheter into the orifice of the  urethra very un-
certain, so much did the swelled prepuce project over the glans.  I
was obliged to squeeze the water back into the body of the penis, and
introduce a finger and feel  for the glans, and on this finger introduce
the catheter;  and in a few minutes I generally found the orifice.
  The nature of the case was now plain; for ulceration had taken place
beyond the stricture, and the swelling had arisen from the urine having
insinuated itself into the cellular membrane of the perineum; and as
the urine escaped from the urethra, it was pushed forwards where the
cellular membrane was loosest, till it got to the very end of the pre-
puce as before mentioned.
  By this time he was become extremely low and irritable; his pulse
quick and small; his tongue brown, dry, and contracted; his appetite
gone, with great drought, bad sleep, and the first stages of a delirium
coming on.  This discovery of the true state of the case gave a change
to the mode of treatment.   Instead of evacuation to  lessen inflamma-
tion, the bark and cordials were given, with as much food as his stomach
would bear.   Their effects on the constitution were almost immediate,
and he began to recover, although but slowly.  I made two punctures
in the phimosis at the extremity, with a view both to take off the ten-
sion  and to evacuate  the urine from the cellular membrane, between
the penis and the skin.
  Blisters began to form on the skin of the penis, and at last mortifi-
cation took place in several parts, especially on the  prepuce, which I
divided at the mortified  parts, and thereby the glans became exposed,
so that the catheter could now be introduced easily.
  Upon squeezing the swelling, from the perineum forward along the
penis, I could force out at the mortified parts, air, water, and some mat-
ter.   The cellular membrane under the skin was almost wholly morti-
fied.  When bounds were set to the mortification, the sloughing cellular
membrane began to separate; and a good deal was cut away to keep
the parts clean, and to allow of a freer vent for the matter. Now that
separation was taking place, it was clear that no more  water from the
bladder could insinuate itself any farther into the surrounding cellular
membrane; therefore it was not necessary to pass the catheter any more,
and  the patient was allowed to  make water whenever  he had  a call,
which, when he did, the water came both ways, through the urethra
and  through the cellular membrane, at the openings where the skin
had  sloughed off.  As the sloughs separated they came forwards from
behind, at the side of the scrotum, so that I could draw them out; and
when most of the mortified cellular membrane was removed, I  saw a
part, about the size of a  sixpence, of the tendinous covering of the cor-
pus  cavernosum dead, which was allowed to slough off.   Most of the
water now came through the sore.  The parts became more painful; he
was more restless, and one  morning he had a shivering fit.  I endea-
vored to pass a bougie down the sore, between the skin and penis, but
could not; in the evening of the same day a gush of matter and blood
came out of the sore, which immediately relieved him, and he began to 
CONSEQUENCES OF  STRICTURES.
215
mend again, and continued to do so, both in the parts and his general
health, the water coming both ways, but often varying in quantity be-
tween the two passages; more and more, however, came the right way,
till at last the new passage closed up entirely.
  While the external parts were healing I passed a bougie occasionally,
to keep the passage clear and open.  To find out the situation of the
internal opening, I ordered the patient to press on different parts of the
perineum while he was making water, by which means  he found that
by pressing upon a particular spot he could stop the water from flowing
through the new passage.  He was directed, however, not  to press too
hard, for  fear of forcing together the sides of the natural passage.
Upon erections, the penis was bent to the side that had suffered; but in
time the parts gradually recovered their natural form.

      § 3. Of Inflammation in the Parts surrounding the  Urethra.

   Inflammation arising from distension and irritation of the urethra
often extends considerably farther than  the surface of that canal, for
the surrounding parts become the seat of inflammation, the situation of
which will commonly be according to the  situation of the stricture,
producing the distension.  Thus, we find the inflammation affecting the
prostate glands, the  membranous  part  of the urethra, the bulb, and
probably  Cowper's glands, with other parts of the urethra between the
bulb and the glans.   But inflammation in the surrounding parts of the
urethra is not always a consequence of distension or stricture; it arises
often from other irritations in this canal, such as violent  gonorrhoeas
and very irritating injections. When inflammation attacks these parts
it is of the true adhesive kind, and therefore when suppuration takes
place an abscess must be formed, unless the inflammation be resolved.
The matter,  according to a  general principle in abscesses, points  ex-
ternally ; when the seat of the abscess is either in the prostate gland,
membranous part, or in the bulb, the matter will point in the perineum;
or the abscess may be formed forwards in the scrotum, or before it, ac-
cording to the situation of the stricture.
   The seat of these abscesses is generally so near the inner surface of
the urethra that the partition between them often gives way, and they
open internally, as frequently happens in an abscess by the side of the
rectum, so that the matter is at once discharged by the urethra, or car-
ried back into the bladder to be discharged with the urine.  When the
internal opening only takes place, I believe it is owing to the ulceration
on the inner surface of the urethra, as has been already described; and
in these cases also the stricture is sometimes involved  in the abscess
and ulceration, by which means the water will find a free passage for-
wards ; but the urine has also a free passage into the abscess, which we
may suppose retards its  healing, and often  becomes the cause of its
opening externally;  but here, from the adhesive inflammation having
taken place, the urine cannot insinuate itself into the surrounding cel-
lular membrane, so as to produce the consequences mentioned in treat-
ing of the way in which Nature endeavors to relief herself.  In such
cases we find that upon pressing the abscess externally the matter is 
216                      STRICTURES.
squeezed into the urethra, and so out by the glans.  It sometimes hap-
pens that a catheter  can be introduced into the opening of such an
abscess, by which means it can be washed by injecting something
through the catheter,  whereby probably it may be sooner healed.  It
more frequently happens that such abscesses open both internally and
externally, discharging themselves both ways.
  These ulcerations and suppurations, of both kinds, are to be con-
sidered as efforts of nature, or, to speak more physiologically, as a
natural consequence arising from such irritation, by which, as the urine
cannot pass by the old passage, a new one is made to prevent farther
mischief.
  Both these  diseases,  when they open externally, if not properly
treated, often lay the foundation for the complaint commonly called
the fistula in perinaso, which  is owing to  the  bottom of the  abscess
having a less disposition to heal than the external parts.  It may be
farther supposed that  the urine, passing into the abscess by the inner
orifice, and making its escape into  the  external, keeps up a constant
irritation in the sore, which in some measure may prevent a union of
the sides, and rather dispose them to form themselves into a hard cal-
lous substance, the inner surface of which loses the disposition to union,
and assumes the nature of an outlet.
  But it is more than probable that the cause which prevents these
abscesses from healing depends upon their first action often continuing
in full force; that is, a diseased state of the internal parts, as will be
farther illustrated when we shall treat on  the fistula in perinaso.  They
often heal up at the orifice in the skin, especially if the water has a free
passage forwards; but if the  internal opening is not perfectly consoli-
dated, some water will insinuate itself into the old sore, become the
cause of fresh inflammations and suppurations in the surrounding parts,
which frequently open externally in different places, not following the
old canal,  although they sometimes communicate with  it and form
branches, as it were, from the principal trunk.  I have seen the scro-
tum, perineum, and inside of the thigh, full of openings, which were the
mouths of so many sinuses leading to the first-formed abscess.  When
the abscess opens only externally, which  is  seldom the case, it is to be
considered as a common abscess.
  When these inflammations arise from  stricture, the difficulty in
making water is increased in the  time of the inflammation, which is
generally so great as to compress the sides  of the urethra together for
some way; besides, the stricture itself will  become tighter from being
inflamed. _ Inflammation in these  parts, even when it does not arise
from a stricture, brings on a suppression  of urine; but in such cases a
bougie or catheter can be passed, the latter of which, in cases of ob-
struction arising from contiguous swellings, as tumors, inflammations,
and swelled prostate gland, is the proper instrument, as the sides of the
urethra would be pressed together immediately upon withdrawing the
bougie, by which the  urine would be as much as ever prevented from
following. 
CONSEQUENCES OF STRICTURES.
217
  § 4.  Of the Treatment of the Inflammation in the surrounding Parts.

 ^ The inflammation of these parts is to be treated like other inflamma-
tions.  Resolution is much to be wished for; but it is almost impossible
it should take place where stricture is the cause.  When the stricture
is removed, either by ulceration or a bougie, we have only the inflam-
mation to contend with; but this seldom happens, for the inflammation
is but too often accompanied with suppuration.
  When suppuration takes place, the sooner the abscess is opened ex-
ternally the better, as that may in  some cases be the  means, though
seldom, of preventing its opening internally; yet it may prevent the
inner opening from becoming so large as it otherwise might be.  The
opening externally should be large; and if the stricture is not involved
in the  suppuration, then it must be destroyed, because there can be no
cure while the water passes through the new opening.  I have succeeded
with the caustic even in strictures of long standing.
  When the stricture will admit of the passage of a bougie through it,
it is to be kept almost constantly in the urethra, and to be withdrawn
only at the time of making water;  this will allow the urine  to pass
more freely through the  urethra without escaping  through the sore.
The sore must be healed from the bottom.1
  Hollow bougies are recommended in such cases, after the stricture
is destroyed, to prevent the urine passing  through the wound.  This
instrument  admits of a constant dribbling  of urine through it; but
the bougie may be occasionally stopped up,  and the urine permitted
to pass when there is a desire to  make water.  It becomes, under cer-
tain circumstances, the worst  instrument possible; for if  its canal is
not of a size sufficient to let the water pass as freely as the contraction
of the bladder requires,  the water will pass easily by  the side of the
bougie to the abscess, and, not getting forwards beyond the stricture,
flow out at the abscess; to avoid this effect as much as  possible, the
hollow bougies should be as large as the strictured part will allow, and
its  sides should  be as thin as possible, that its passage may be the
larger.   The elastic gum  has these two properties in a higher degree
than the spiral wire covered with waxed cloth. But, as I doubt very
much that the passage of the urine may be a hindrance to the healing
of the sore, I am the less solicitous  about  such practice;  for we find
that after lithotomy the parts heal very readily; and even in this ope-
ration the external parts which are not diseased heal up very readily.
I suspect that the want of disposition to heal arises from the  strictures
not  being sufficiently subdued, or the deeper parts not being in a
healthy state.
  When  these suppurations are left to themselves, and no method
tried to remove the stricture,  and of course  nothing introduced into

  1 Added: " In many such cases of abscess in perinseo, where the stricture has been
destroyed,  the passage at that part is so irregular that the catheter is the best instru-
ment to use ; and where the parts are much contracted, a flexible catheter may be
readily introduced down to the stricture, and then a curved stylet passed into it, which
will admit of its being directed into the bladder. In this way I have sometimes suc-
ceeded when all other attempts have failed."—Home. 
218
STRICTURES.
the urethra, the stricture sometimes closes entirely, so that no water
can pass forwards through the urethra;  and, therefore, before  any at-
tempt can be made  to heal the fistulous orifices, a passage must be
made through the united parts.  This cannot be done with a bougie;
and if this union of the parts is before the bend of the urethra, which
most commonly it is, nothing but the caustic can be applied with any
prospect of success, as we shall mention more fully in treating of the
fistula in perinaso.
  [Ricord.—Since  Hunter's time, the subject of infiltrations of urine
has advanced only in proportion  as our anatomical knowledge has
increased, and especially our knowledge of the surgical anatomy of
the genito-urinary organs, the pelvis, and particularly the perineum.
There is no doubt but that our acquaintance with the arrangement of
the fascias which lately have been so carefully studied, has thrown light
on the course which the urine may pursue, according to the situation
of the  rupture, and that in some cases  we may arrive at a more cer-
tain diagnosis.  But, on the  whole, recent investigations have made
but little change in our knowledge of this subject.
  As may be seen from what Hunter says, and especially as numerous
facts in pathological anatomy have since taught, there  is no part of the
urinary passages which may not afford an abnormal outlet to the urine.
The accidental openings through which this fluid escapes are produced
either by  a sudden rupture of the canal or by the gradual progress of
ulcerations, commencing in the interior of the urinary passages, or
involving  them from without.  In  the first instance, they may result
from operations, such as lithotomy, the boutonnilre operation, the open-
ing of abscesses, the introduction  of sounds,  and the production of
false passages; or else they may occur in consequence of efforts made
by the bladder, and the muscles which co-operate with it, to overcome
a stricture, behind which the  tissues are generally morbidly affected,
and« finally give way.  In the second case, the accidents in question
often occur even when the patient passes his water tolerably well, and
evacuates  his bladder  without any  great  effort.  In all cases, the
rapidity and extent of the infiltration are proportioned  to the size of
the accidental opening, and especially to the severity of the stricture
which obstructs the course of the urine.   When the opening is  narrow,
the urethra tolerably free, and the urine oozes away rather  than is
forced into the tissues, effusions become circumscribed  and confined
by the  inflammation which precedes or accompanies them, or by the
anatomical arrangement of the tissues, and particularly of the fasciae.
In  these  cases, the abscesses which are formed maintain their com-
munication with the rupture, and are emptied into tne bladder or ure-
thra, according  to  their situation  and  the freedom  of the canal, or
finally  open externally, and give rise  to complete fistulas.  But in
some cases, to which Hunter does not refer, the urine having  escaped
through small openings, which afterwards close,  the succeeding ab-
scesses, although on being opened  they present all the characteristics
of urinary abscesses, do not afterwards  transmit the urine or form fis-
tulous passages.
   However,  in  considering the production of inflammations in the 
CONSEQUENCES OF STRICTURES.
219
neighborhood of the urethra and bladder, we must take into account
the influence  exercised by instruments which are employed to over-
come strictures.   These are often the only cause of accidents, even
when we should least expect it, judging from the degree of dilatation
already obtained.—Ricord.]
  [Editor.—Besides the abscesses which form in the neighborhood of the
urethra in consequence of rupture of its walls and  infiltration of urine into
the cellular tissue, others sometimes occur which are entirely independent of
any escape of this fluid, or even any obstruction to its free evacuation. Such
abscesses  commonly depend on irritation of the canal, especially in its deeper
portions, and about the neck of the bladder.  Thus they are sometimes seen
to occur during the use of a permanent catheter, when worn in  consequence
of paralysis of the bladder, although the urine escapes with perfect freedom
through the instrument.   Again, in treating strictures of the canal, they are
often formed after using bougies, even though no violence has been employed,
and though the patient passes his water with  comparative ease.
  The swelling preceding the formation of the abscess will frequently subside
if the irritating cause be removed.  If the  abscess be opened, pus escapes,
without any admixture with the urine.   Its situation, at some distance from
the urethra, and even in front  of the stricture, as in a case reported by Cm-
ale, often renders any connection between it  and the canal extremely impro-
bable ; and numerous cases are reported by Charles Bell, Civiale, and others,
in which a post-mortem examination  could discover no trace of such connec-
tion.
  The existence of these abscesses,  independent  of any effusion of urine, is
clearly recognized by  Hunter, who  compares them to the  abscesses which
form in the neighborhood of the rectum.   They are also analogous to the
collections of matter in the vicinity  of the larynx, and to those which some-
times arise about the vagina after irritation of the sexual organs in women
by excessive coitus, etc.
  Like other inflammations of the parts about the urethra, as inflammation
and abscess of the prostate, they frequently react on  the canal, rendering it
exceedingly sensitive, and compelling us to abstain from the  use of all instru-
ments.   Such was the case in  a patient recently under my care, affected with
several strictures, two of which were situated in the spongy portion of the
urethra, within  three inches  of the  meatus.  After successfully dilating the
anterior stricture, by simply.introducing  bougies, and keeping them in con-
tact with the stricture at intervals during a fortnight, suddenly the stricture
appeared to retrograde, the urethra became extremely sensitive, the passage
of the urine was difficult, but  not impossible, febrile action followed, and an
abscess formed in the perineum and another above the root of the penis, com-
pelling me to  suspend the use of instruments for several weeks.   Still, this
extraordinary sensibility is not a constant attendant on the formation of these
purulent collections.
  The prognosis  of these abscesses is generally not serious, if we suspend 
220
STRICTURES.
 the treatment in time.  But sometimes they excite severe constitutional reac-
 tion, and when deep seated, and scarcely perceptible externally, they may be
 a source of great perplexity to the surgeon.  In such cases, when their situa-
 tion can  be discovered, they should  be opened  early and freely.—See M.
 Civiale's  Traite sur les Maladies des Organes Genito-urinaires, t. i. p.  497.
 —Editor.]

 § 5. Q/*  the Effects of Inflammation in  the surrounding Parts upon the
                              Constitution.

   The effects which these attempts to form a new passage for the urine
 have upon the constitution are very considerable;  much more so than
 what one would at first suspect.   Those cases appear to  be most  for-
 midable which begin by ulceration on the inner surface of the urethra,
 and where the water diffuses  itself into the cellular membrane of the
 scrotum and penis.
   Those where the inflammation is circumscribed are more of the true
 abscess, and  therefore do much less  mischief to the parts than when
 the urine is diffused  in  the cellular membrane.   In these last, if  not
 soon relieved, the patient  sinks,  and  a  mortification comes on.   If)
 before the patient sinks, a  separation of the  slough takes place, this
 separation  performs  the operation of  opening, and the patient may
 recover.  We should not, I believe, wait for such separation of  the
 mortified part, but make an opening early, upon  the first knowledge
 of a diffusion  of water into the cellular membrane;  and we should be
 guided as to situation by introducing a staff into the urethra on to  the
 stricture.   But in some  cases this cannot be done;  for when the urine
 gets into the corpus spongiosum it produces mortification  of all  these
 parts, and renders the whole so indistinct that often no urethra can be
 found.1
   The effects  that the circumscribed  inflammation has upon the con-
 stitution is generally not so serious as the above;  for mortification as
 seldom takes place in  this as in  abscesses   in general.  When  the
 abscess is from the bulb backwards, there is generally a sharp sympa-
 thetic fever, because the abscess will  be of considerable size before it
 gets to the  skin of the perineum, and is generally attended with great
 pam; but this pain goes off by the formation of the matter, especially
 if opened early.
   As there is  a great disposition to violent action attended with great
 weakness, in such cases,  more especially in those of the first kind, it is

  ' A staff will not always serve to direct the knife in making incisions into infiltra-
tions of urine  or urinary abscesses.  The rule to be followed is to incise wherever yon
find collections of urine and  matter: open freely,extensively, and  deeply, and  the
more so, when crepitation is felt in the cellular tissue, when the parts are erysipelatous
and threaten gangrene, when  the infiltration is not circumscribed, when the obstacle
to the courseof the urine is complete, and when constitutional symptoms have already
appeared.  We can only temporize, in some cases, when the abscesses are circum-
scribed, and the patient still urinates with ease.  A wise hardihood is a requisite for
success in all  cases ; for the sooner we succeed  in freeing the tissues from the urine
which bathes and destroys them, the sooner we put  an end to the supervening
symptoms.—Ricokd.                                             r 
CONSEQUENCES OF STRICTURES.
221
advisable to give the bark early, and in considerable quantity; but I
apprehend it is  necessary to give along with it sudorifics, as some of
the preparations of antimony, there being generally a  good deal of
fever. . The bark gives strength,  and also in some degree  lessens
irritability; but it should be assisted by other medicines.1

                    §  6. Of Fistulce in Perinceo.

   It often happens that the new passages for the urine do not heal on
account  of the strictures not being  removed; and even when the stric-
ture is removed they frequently have no disposition to heal.  In both
cases they become  fistulous, and  produce fresh inflammations  and
suppurations, which do not always open into the old sore, but make
new  openings externally.   These sometimes arise from  the  first
external openings  not  being sufficiently large, so  that  they  heal up
long before the bottom, or long before the diseased urethra, and even
when the external opening  has been made as large as possible, it will
often heal sooner than the bottom,  and become fistulous at last.
   It is very common for these diseases to affect the constitution so as
to bring on complaints of an intermittent kind.  I have seen several
affected  with regular agues, where the bark has produced no effect;
but whenever the obstruction has been got the better of, or the fistu-
lous orifice opened and in a state of healing, these complaints have
entirely gone off.                             ■,-,■,
   To cure this disease, it is necessary first to make the natural passage
 as free as possible, that no obstruction may arise from  that  quarter;
 and sometimes this alone  is sufficient; for the urine, finding a free
 passage forwards, is not forced into the orifice, and the fistulas heal up.
 The bougie may bring on an inflammation on the urethra at this part,
 and produce  adhesions there;  but if this effect is not produced early,
 the bougie will rather do harm if  applied too often, and too long at a
 time  as will be more fully  explained.   But the  dilatation  of the
 stricture is not  always sufficient;  it is often necessary to perform an
 operation on the fistulas, when they alone  become the obstacle to the
 cure, which I shall now describe.

              § 7. Of the Operation for Fistulce in Perinceo.

   When the before-mentioned treatment is not sufficient for the cure
 of the new passages, a method should be followed similar to  that used
 in the cure of fistulas in other parts, by laying them freely open to the
 bottom, and  even making the  orifice in the urethra a fresh  sore if
 possible.  This will be difficult  in  many situations of the internal
 orifice; and  the mode of opening, and other circumstances attending
 the operation, will vary according to  the situation.
   That as little of  the sound  part of the inner surface  of the urethra

   " In addition to the  facts which Hunter mentions, and the characteristic urinary
 fever symptoms of purulent absorption sometimes occur, such as articular abscesses
 and purulent coUections in different organs, as in the lungs, the liver, and other parts,
 which are beyond the reach of direot infiltration.—Rioobd. 
222
STRICTURES.
may be opened as possible, and that the diseased part may be fully
exposed, it is necessary  to be well directed to the inner orifice, for
which we have commonly  two guides;  one is a staff introduced into
the urethra  as far as is thought necessary, or as far as it  will go
(which will only be to the  stricture, where the stricture still exists, or
it may pass on to the bladder in cases where the stricture has been
destroyed); the other guide is a probe passed into the fistulous orifice.
The probe should be first  bent, that it may more  readily follow the
turns of the fistula, and be  introduced as far as possible; if it could be
made to meet the staff, so much the better, as then the operator could
cut just what is necessary.  If the fistula is tolerably straight,  so as to
admit the passing a director, it is the best instrument for operating
upon.  If neither the probe nor the director can be made to  pass on
to the staff, we must open as far as they go, and begin searching anew
after  the  remainder of the passage with  the same instrument,  and
pursue it  till  the whole fistulous canal is laid open.  If there  are any
sinuses, they are to be laid  open if possible ; but it frequently happens
that they cannot be followed  by the knife, some running along  the
penis, where  the scrotum is attached, others passing  on towards  the
pubes, round the penis, while others are about the membranous part
of the urethra.  In such cases  some degree of violence may be used,
and I have several times introduced my finger into these sinuses, and
have  torn the parts so as to produce a considerable inflammation, by
which means they often suppurate, granulate, and unite.
   If the situation of the internal orifice is opposite  to  the scrotum, it
will be  difficult to get to it; but I imagine we may use great freedom
with the external parts, whatever they are, for they are generally in a
state of callosity.  However, this requires judgment.
   In cases where the  disease is before the membranous part and the
stricture is not removed, a  staff cannot be made to pass on to the inner
orifice.  In such, the fistulous opening must be followed by the intro-
duction of a probe or director into it, and by dilatation  upon the in-
strument till  the urethra beyond  the stricture is found; and then a
probe must be passed _ on towards the glans, to  meet  the end of the
staff at the stricture, similar to what is done in the operation where a
false  passage has been made by the mismanagement  of the  bougie.
The stricture  must then be destroyed, and a bougie passed, as was
recommended in that  operation.
   If either the ulceration or the abscess is formed in or near the pros-
tate gland, then probably the stricture is near that part.  In that case
a staff must be passed as far as possible, and a probe or director intro-
duced into the external  orifice, and the  operation  is  to be directed
accordingly.   The difference  of  the operation in  this  case from the
former will be that we shall most probably be obliged  to cut into the
urethra  on both sides of the stricture, therefore more of the canal must
be exposed.
  As this operation is the opening of all the fistulous canals, and also
the destruction of the stricture, if there has been one, an instrument
can afterwards, in every case, be passed into  the  bladder.  It will
most probably always be proper to introduce an instrument into the 
CONSEQUENCES  OF STRICTURES.
223
bladder, and keep it there almost constantly, so  as  to  preserve the
passage of the urethra in a regular form, while the openings made are
healing ;  and probably the catheter will be by much the best instru-
ment, because  it is not necessary to be withdrawn whenever the neces-
sity to make water comes on, which a bougie must; and its introduction
again is often  not practicable, for its  end will be apt to get into the
wounds.
  In such cases as require a hollow canula to be left in the bladder for
the purpose of drawing off the water, whether a catheter or hollow
bougie, it is absolutely necessary it should be fixed  there, or else  it
will in common come out by  the actions of the part.  To effect this, it
is necessary to fix that  end of the  instrument out of the penis to some
part of the body that is  the  least movable.  What will answer ex-
tremely well is the common belt-part of the bag-truss, with only two
thigh-straps fixed behind and made to tie or buckle  before; and two
or three very  small rings or short tapes  fixed to those  straps where
they pass between the  thigh and scrotum;  they should not be at a
great distance from  one  another where  they are fixed behind  to the
belt, for otherwise they are much altered in tightness  by  the motion of
the thigh.  If they have a flat spring  in them so much the better.1
  The common bag-truss for the scrotum answers extremely well, first
by fixing two or three rings  on each side of it along the side of the
scrotum;  and with a piece of small tape the ring of the canula can be '
fastened to any one  of those  rings  that is  most convenient from its
situation.
  Whatever instrument is used for the purpose of keeping the passage
clear and open while the sores are  healing,  whether  the sores are in
consequence of this  operation, or in consequence of the  causes of the
fistulas which I have described, there is  a limited time in many cases
for its continuance;  for if it be continued beyond a certain period, it
frequently acts contrary  to what was intended;  at first, it often assists
the cure, but  towards 'the last it may obstruct the healing of the sores
by acting at the bottom of the wound  as an extraneous body.  There-
fore, whenever the sores become stationary,  I would  advise the with-
drawing of the instrument, and the introducing  it only occasionally.
The catheter will probably be still the  best instrument for this purpose,
as it will pass the more readily, and draw off the water at the same
time;  however, I have often used a bougie, and by  great care have
passed it with success; and probably it will be proper to use it every
now and then, even when all is healed, in order to determine whether
or not the passage is free from disease.
  The sore and the wound are to be at first dressed down  to the bottom
as much as possible,  which will prevent the reunion of the parts just
divided, and make the granulations shoot from the bottom, so  as to
consolidate the whole by one bond of union.
  When the urethra has suffered  so much that abscesses have formed
beyond the scrotum, the patient should  ever after take  great care to
avoid a fresh gonorrhcea, for he seldom in that case escapes a return of
1 Mr. Vanbutchell's springs would answer very well. 
224
STRICTURES.
the same complaints; and, indeed, if he is  not careful in many other
respects, he is liable to returns of the same  disease.  If, notwithstand-
ing this precaution, he should contract a gonorrhcea, everything heat-
ing is to be carefully avoided, particularly irritating injections.
  The following case shows that keeping  extraneous bodies  in  the
urethra prevents wounds made into that canal from healing.
  A man, aged twenty-six, came into St. George's Hospital, March 2,
1783.  He had labored under a fistula in perinaso for nearly two years,
arising  from a stricture,  attended with great pain and  difficulty in
making water.   Four fistulous orifices were to be observed  in  the
perineum and scrotum.  The smallest bougie could not be made to
pass into  the bladder after repeated trials.  The caustic was then
applied, but without  success.
  The operation for  the fistula in perinaso was performed September
19. A catheter was first introduced as far as it would go, as a director,
and all the sinuses were laid open to that catheter, which exposed near
an inch in length of  that instrument; then the catheter was in part
withdrawn to expose that part of  the urethra which was laid bare.
The blood being  sponged off, the  orifice in the stricture was next
searched for, and when found it was dilated.  The catheter was now
pushed on to the bladder, although  with some difficulty, and the end
of it was then fastened to a roller which  went round the thighs; and
the wound was  distended with lint. He took  an anodyne» draught
after the operation, and another at night.  September 20, he had some
pain in the head from the  opiates; his pulse was natural, and he had
slept tolerably well.   On the 21st day the  catheter slipped out, and
the second introduction of it gave considerable pain.  The anodyne
was repeated.  October 1. The catheter was still to be felt by intro-
ducing a probe into the wound.  From this time to the 25th nothing
material happened, excepting a piece of lint of the first dressing coming
away through the urethra.  November 20. The wound  having  for
some time been stationary, and showing no  disposition to heal, I con-
ceived that the catheter was now acting as an extraneous body at the
bottom of the wound, and therefore desired that it might be withdrawn,
and passed occasionally;  and no sooner was the wound free from it
but it put on a healthy look, and by the 10th of December no urine
came through the wound, but  passed tolerably  well  through the
urethra; and on the  12th the wound was quite  healed, and the water
came from him rather in a full stream and without  pain, although  we
could never pass either catheter or  bougie  afterwards, probably from
the new and old passages being irregular.
  [G. G. B.—It is possible that some cases  may occur where the ope-
ration which is described by the  author may be required, but such
cases are undoubtedly very rare.   The complete removal of the stric-
ture is in almost all  instances followed by the spontaneous closure of
the sinuses in the perineum. Until the strictured portion is dilated to
the same size with the rest of the urethra, there is little improvement.
As  soon as  that is effected, the urine is no longer diverted into  the
sinus, but takes  the  more ready course of  the  natural passage; and
the cause which maintained the fistula being thus removed, the opening 
                CONSEQUENCES  OF STRICTURES.            225

gradually contracts, and in a short time heals, without any surgical
treatment whatever.]
  [Ricord.—The subject  of urinary fistulas  is so important that it
would doubtless be well in this place to fill the gaps which Hunter's
short chapter leaves;  but this task, to be  complete, demands more
space than I have allotted to myself, and I will therefore indulge only
in the following considerations.
  Urinary fistulas may take  their rise  in  any part of the passages
through which  the  urine flows.  They are incomplete or complete,
according as they terminate in  a cul-de-sac or open externally.  They
have rarely  more than one  internal orifice, whilst externally they
often present several.  The most common situation of the latter is
over the course of the urethra, proceeding, in order of frequency,
from the perineum to the neighborhood of the frasnum.  Yet there is
no  part in the  neighborhood which may not become the terminus of
a fistulous passage; thus,  they often terminate in the rectum in man,
and in the vagina in woman.
  There may be one or more fistulous passages; they may be direct
or oblique, straight or sinuous.  When  they open into  the bladder,
the  urine flows through them  incessantly, as it is secreted.  When
they open into  the canal, it  escapes only during voluntary emission.
Some circumstances, however, may deceive us  on  this point.  When
the internal orifice within the bladder is very near its neck, and this
organ habitually contains but little urine, the liquid often accumulates
in the bas-fond, and is discharged only during voluntary contractions.
It may also happen, in cases  analogous  to  the one  observed in a
woman by my learned friend, M. Jobert, surgeon of Hotel-Dieu,1 that
the  internal orifice, situated at the base of the trigonum, does not
permit a continual flow of urine.  Pockets, or cul-de-sacs, in the course
of  the  fistulas and retention of the urine in the rectum or vagina may
also deceive us.  Wherever the situation of  the internal orifice  of a
fistula  in the rectum is, the urine is generally discharged only with
the stools, although its presence  irritates  and often excites constant
and insurmountable tenesmus.   As  to the vagina, although the urine
remains there during the recumbent posture, it soon escapes in any
position which renders the  vulva  inclined  downwards, and in  the
various efforts  which depress  the  uterus,  approximate the vaginal
walls, and thus diminish the capacity of the vulvo-uterine canal, whose
entrance is much less frequently contracted than some theorists have
asserted. The arrangement of the fasciae, the  length and  sinuosities
of  some fistulous passages, and the suppuration which  they furnish,
may also in some cases give rise to apparently continuous discharges
of  urine.  In  all cases, the  more numerous fistulas are the greater
alteration the tissues which  they traverse undergo;  the skin grows
thin, is undermined, ulcerates, or else hardens and becomes carnified;
gangrene also destroys the cellular tissue wherever adhesive inflam-
mation does not oppose a barrier to the urine; the aponeurotic sheaths
exfoliate; the bones themselves are sometimes denuded, become carious
15
1 Traite de Chirurgie Plastique, Paris, 1849. 
226                      STRICTURES.
 or perforated, and finally  degenerations, generally  of a  malignant
 nature, may occur in a part where,  at  first, there was only simple
 engorgement.
   So long as any obstacle obstructs the discharge of the urine through
 the urethra, fistulas have little or no tendency to heal; but  so soon as
 the canal becomes free again, their cure is the more rapid the shorter
 time they have lasted; a fact which should be recollected in the treat-
 ment ; for recent fistulous passages are not  furnished with those false
 mucous membranes which become organized in the passages through
 which the urine has flowed a long time.
   The temporary use of bougies is often sufficient to cure fistula3.  As
 the normal calibre of the urethra is re-established, the urine is less and
 less inclined to pass  through the accidental passages, and  in  a large
 number of cases a cure soon follows.   But this mode of treatment, to
 which Hunter seems to accord the preference,  is not, however,  the
 mode which succeeds the best and the  most frequently.   A large
 number of fistulas yield only to the permanent use of catheters. The
 urethra must  not only be restored to  its  natural size, but  it is also
 necessary to prevent  the urine from entering the fistulas during emis-
 sion.   But when solid bougies are used, the urine may make  its way
 between them and the surface of  the urethra, and thus gain the fistu-
 lous orifice, or may enter it still more  readily when the  bougie is
 removed  for  the  purpose of urinating.  Hence, most practitioners
 prefer permanent catheters,  which are left  open, and  which, without
 violently stretching the canal, fill it with sufficient exactitude to make
 the urine escape through an easy and  permanent passage rather than
 by the fistula.   But when a certain degree of dilatation is attained, if
 we go on increasing it, as Dupuytren  used to remark, we often inter-
 fere  with cicatrization  of the internal orifice, by keeping  its edges
 apart, and can effect  a cure only by  gradually returning to  smaller
 instruments, or by ceasing to use them altogether.
   In some cases practitioners have thought that they could  favor the
 complete evacuation of the urine through the catheter by furnishing its
 beak with a piece of sponge, or, better still, with threads, which, passing
 through the eyes of the instrument, might act by capillary attraction.
 They have also attempted to apply the principle of the siphon; but
 they have not always obtained satisfactory results even with M. Soyer's
 instrument, in which a continuous current of water tends to  produce a
 vacuum and suck up the fluid.  Yet, in all cases where an open cathe-
 ter is permanently worn, the free admission of air should be prevented,
 to a certain degree, by means of a bladder attached to its  outer ex-
 tremity.
   But instruments sometimes irritate the parts and excite inflammation,
 various degrees of suppuration, and even ulcerations; and if we continue
 to use them, the disease, far from being ameliorated, becomes compli-
 cated and aggravated.  In this case we must either suspend  the treat-
 ment entirely until the symptoms subside, or at least pursue it only at
intervals so far as is necessary to preserve the advantage already gained.
 In accordance with what Mr. Babington  says, and  as I myself have
already had occasion to remark, the operations of which Hunter speaks 
                CONSEQUENCES OF STRICTURES.            227

are of rarer application than we should be led to suppose from what
he says.   However, without making a common mode of treatment out
of these operations, which are often useless or even dangerous, perhaps
we do not have recourse  to them often enough in  those cases which
resist other more simple means, and which leave patients for months or
years a prey to a disgusting infirmity which is fatal in the end.  Let it
be recollected that it is not  always enough to restore the urethra to its
former size, but that to effect a cure it is also necessary to destroy the
organized fistulas. These passages should be laid open like other fistulas,
so as to substitute for them  simple wounds susceptible of cicatrization.
However, before having recourse to an operation, the execution of which
may present great difficulties, we should make a trial of caustics.   In
this case, cauterization should be applied not only to the external ori-
fice,1 which has naturally a  sufficient tendency to close, but it should
be made to act chiefly on the deeper parts.  I have succeeded in some
cases by cauterizing the urethra within and behind  the stricture with
nitrate of silver, so as to endeavor to  reach the internal orifice of the
fistula, and then injecting the fistulous passage with a strong solution
of this salt; thirty grains or more to an ounce of distilled water.  When
the fistulous passages  have been tolerably large, I have introduced
within them a director, with its groove filled with this caustic; or else
I have employed a probe, with a thread wound round it, and impreg-
nated with acid nitrate of mercury.  I have sometimes obtained favor-
able results  by the actual  cautery,  which, however, rarely succeeds,
except when the fistulas are direct and of small extent.
   But many fistulas, situated in front of the scrotum, and at different
points of the spongy portion  of  the urethra, resist all these means.
Some of these fistulas consist of simple openings, whose passage between
that skin and  canal is scarcely perceptible.   Others, on the contrary,
are due  to losses of substance of various sizes, and are, in  a measure,
cases of hypospadias, to which the name of fistula is  inapplicable, since
there is  only a single opening without a fistulous passage.
   One must treat such cases to get an idea of the difficulties in the way
of their cure; difficulties which arise from the want of thickness of the
cellular  tissue, which is very lax in these parts, and from the disar-
rangement which the process of cicatrization undergoes from the fre-
quent changes in the volume of the penis during erection and collapse.
   In three patients at the Hopital des YeneYiens, I have tried the suture
recommended by my learned friend Dieffenbach, which consists in  sur-
rounding the short passage of the fistula with a thread passed between
the skin and the canal, like a purse-string.  In  these three cases the
operation failed, although performed with all possible care.  Nay, more,
two of the patients were operated upon three times, and the third twice!
Each time I introduced some new modification in the operation, with-
out, however,  attaining entire success.   Sometimes the passage was
previously refreshed with tincture of cantharides, sometimes with acid
nitrate of mercury, or nitrate of silver.  In one patient I previously

  1 Brodie recommends that the external orifice should be cauterized with potassa fusa,
so as to keep it open, while nitrate of silver is applied internally.—Ed. 
228                      STRICTURES.
introduced a catheter, and left it open; then, a second time, I uncorked
it only when it was necessary for him to  pass his urine; and, finally,
at the third operation, I left the canal free from  any instrument, with-
out any better success.  Since the first edition of this  work, I have
operated upon two new patients by the same method, and have suc-
ceeded each time.
  The cases of M. Yiguerie, of Toulouse, and the happy results  ob-
tained by M. Segalas1 in losses of substances, or fistulas of the urethra in
front of the scrotum, induced me to have recourse to urethroplastic
operations in three patients; two of whom had complete division of the
canal  near  the peno-scrotal angle, the result of ligatures which they
applied to themselves in their childhood at the age of seven and eight
years; the  third had lost nearly two-thirds of the spongy portion of
the urethra in front of the scrotum.   In the first  two patients, I first
performed the boutonniere operation, and introduced a catheter through
the opening into the bladder, so as to draw oft'  the  urine  during  the
time necessary for the success of the operation.   In the  third, I made
use of a previous fistula in the perineum, as  M.  Segalas  did, to intro-
duce a deflecting catheter.   I succeeded  in the three  cases.  The first
operation is recorded  in  my Iconographie de VHopital des Veneriens;
the Academy of Sciences  accorded me one of the Montyon prizes for
it; the last is found in the Memoires de la Societe  de Chirurgie de Paris.
Alion, Astley Cooper, and M. Jobert, the ingenious surgeon of Hotel
Dieu,  have succeeded without turning aside  the urine; but there  are
some cases like those I have met, an account of  which is given in  the
works cited, where the boutonniere  operation, or the employment of a
perineal fistula seems requisite to give the happy results  which I have
obtained.
  The little success attending the various sutures employed to remedy
different degrees of hypospadias is well known;  the results have been
similar when they have been applied to accidental losses  of substance.
Four  years ago,  in  a  patient who had lost two-thirds of the inferior
wall of the spongy portion of the  urethra between  the  scrotum and
the glans, and  in whom  G. Breschet had already twice tried simple
sutures without success, I was equally unsuccessful with one of Dief-
fenbach's methods, which consists in dividing the skin on each side of
the abnormal opening, at a certain distance  from  its refreshed edges,
so as to form two bands of integument, which may be approximated
without danger from  traction.   In  the  same  patient,  I afterwards
had recourse to a urethroplastic operation, by means of a flap taken
from the scrotum; but the operation failed in part, union taking place
in only two-thirds of the opening;  this was owing to a  circumstance
which it may be well to mention, viz., that the edge of the borrowed
flap was ecchymosed.  Finally, with regard to the method, which con-
sists in covering the accidental opening with a collar of the skin, bor-
rowed from the sheath of the penis, I do not think we are yet prepared
to form an  opinion.—Ricord.]

  1 A Letter to Dieffenbach on the Urethroplastic Operation, Paris, 1843 ;  Memoir on
the Urethroplastic Operation, in the Memoirs of the Academy of Medicine, Paris, 1845,
vol. xi. 
SOME OTHER AFFECTIONS OF THE URETHRA.
229
                     CHAPTER  VII.

        OF SOME OTHER AFFECTIONS  OF THE URETHRA.

  The substance of the urethra is muscular, and it is therefore capable
of contracting its  canal, similar  to  an intestine, so as to shut it up
entirely.   This makes it subject to diseases peculiar to muscle in gene-
ral; which is, indeed, the only proof we  have of its being muscular.1

            § 1.  Of the Spasmodic Affections of the Urethra.

  In a sound state of the  parts  these muscles  are never excited  to
violent actions, acting simply as sphincter muscles;  but when irritated
they are capable of acting violently, as is best seen  in some cases upon
the first use of injections, the  urethra often refusing the injection en-
tirely.  This seems rather  to  be a salutary motion to hinder  things
from getting into the bladder; but there  are often spasmodic contrac-
tions of these muscular fibres in different parts of the canal, shutting
up  the passage and obstructing the  course of the urine, often not
allowing a drop to pass.  That this also is owing to spasm  upon the
muscular fibres is evident, because a large bougie will sometimes pass
when it is at the worst.  When the contraction is near the bladder it
is called a strangury, and is often  produced  in  a sound state  of the
parts by irritating medicines, the power of which falls upon these parts,
as cantharides; and when this part is in  an irritable state, the  spasm
may be brought on by a vast number  of things, such as most of the
peppers, fermented liquors of all kinds, violent exercise, &c.
  The urethra, in cases of spasmodic stricture, is more irritable than in
the true stricture, which irritation, indeed, is in a  great measure the
cause of the spasm.   Spasmodic strictures often bear  so strong a re-
semblance to the cramp, that one would be apt to attribute them to the
same cause as that which  produces cramp.   In  such  cases the spasm
also goes off by tickling the part, similar to the removal of cramp.
  In all cases of  very irritable  urethras, where  spasms very readily
take place, the patient should never long retain his urine when  he has

  1  The  conclusion which Hunter draws from pathology as to the structure of the
urethra, is far from being good reasoning.  There is no need of muscular tissue  for
spasmodic affections to take place in the urethra.  The tonicity of the spongy tissue is
sufficient for that.  However, Hunter's ideas have been partially realized ;* for anatomy
has  proved that the so-called membranous portion of the canal is formed of muscular
fibres, and that it is generally in this region, and  at the neck  of the bladder, that  we
meet with that kind of stricture, which J. J. Rousseau is supposed to have had.—Ricord.
 * The researches of KolHker and Mr. Hancock have shown that the urethra is surrounded by muscular
fibres throughout its whole extent, thus fully realizing Hunter's ideas.—Ed. 
230
SPASM.
an inclination to void it; for I have  seen  cases where this  alone  has
brought on the spasm;  and indeed these parts, when in perfect health,
will be thrown into a spasmodic affection if the urine is too long con-
fined in the bladder;  while at the same time a certain fulness of the
bladder, or a small degree of retention of the urine, will  make  the
bladder contract with more force, and the  urethra will, for the same
reason, relax more freely;  therefore, in cases where there is a tendency
to strangury, there is seldom  any harm in waiting a little after  the
inclination comes on.
   I may be allowed here to caution surgeons who have not had oppor-
tunities of seeing many of these cases, when they meet with permanent
strictures which  are  becoming troublesome, attended with  frequency
in making water, and a difficulty in passing it often threatening stran-
gury, not to  advise, or rather not to allow, their patients  to take long
journeys either on  horseback  or in  carriages, more especially in  the
winter.  I have known  many patients laboring under such complaints
taken  ill in the middle  of  a journey,  and obliged to stop for days upon
the  road, and who have  continued  in misery the  remainder of the
journey; and after having arrived at the  place  of their destination,
have been laid up for months,  and have suffered from most of the be-
fore-mentioned complaints.
   [Ricord.—Spasmodic strictures, which we must of necessity admit,
have these peculiarities, which distinguish them from other strictures,
viz.: that they do not remain permanently confined to one point of the
canal;  that they are found at different depths, often at short intervals
of time, in the same subject;  that  impressions  taken of them at  dif-
ferent times are not identical; that  they disappear and  reappear at
intervals; that their duration also cannot be fixed; and that they are
generally overcome better with rather a large-sized instrument.]

       § 2. Of the Cure of  the Spasmodic Affection of the Urethra.

   It may not be improper to premise, that in diseases of the actions
only of the  urethra  and bladder, whether spasmodic and  proceeding
from too great irritability, or paralytic (although two opposite diseases),
irritations on other parts have often wonderful effects, equally dimin-
ishing the action in the one and increasing it in the other.   The proof
of this will appear when we shall treat of  the irritable and paralytic
urethra and bladder; for, in either  part,  and in  either case,  we find
blisters applied to the lower part of  the small of the back or the peri-
neum, as also many other applications to this part, often produce great
effects.1
   As  spasm simply is not an alteration of structure, but is only a dis-

   1 That the parts ooncerned in the expulsion of  the  urine (as the bladder and
urethra) sympathize strongly with the skin  of the perineum, I believe is commonly
supposed, from applications being often made to that part in cases of stoppages of
urine.
   A gentleman, who had  no complaint in these parts, had a small fistula at the side
of the rectum,  for which  he  often had occasion to  sit over the steam of warm water
and vinegar ; and this application to the perineum never failed of making him void
his urine. 
         SOME  OTHER  AFFECTIONS OF THE URETHRA.     231

eased or preternatural action arising from some irritation, it may be
made to cease instantaneously. , In whatever part of the urethra the
spasm is, if time will allow, it is proper to try internal medicines, and
also external applications, to remove it.   The internal medicines that
may be  said  to act immediately are opiates and turpentines,1 given
either by  the mouth  or the anus; but  they are more immediate in
their  effects in  the form  of clyster, especially the  opium.  Bark is
often had recourse to in spasmodic affections, in which it  is thought
to be of  service; but in such affections of the urethra I think I have
seen it frequently do harm.
   The external applications are the steam of warm water with spirits,
the pediluvium, the warm bath, bladders of warm water applied to the
perineum, and similar applications.  The crumb part of a  new-baked
loaf, warm from the oven, applied  to the perineum, has been found to
give ease.
   I have known a  blister applied to the loins in  a great measure
remove the  spasm  from the urethra; it is equally effectual when
applied to the perineum.  But in most  cases these methods are  too
tedious;  therefore, when the case has been  of  some standing, before
assistance has been called  for, and requires immediate relief, recourse
should be had to the catheter or bougie immediately.
   If  the  contraction is near the bladder, the  catheter will answer
best; but in most cases the bougie will be sufficient, and  is a much
safer  instrument; for in many hands the catheter is a very dangerous
one, requiring a dexterity only to be acquired by a thorough know-
ledge of  the course of the  canal, and  a habit of passing it.  The
bougie has likewise this advantage that, in many cases, where the part
spasmodically affected will not allow it to pass,  it may be  allowed to
lie close to the stricture; for it is not always necessary for  the bougie
to  pass through the constrictured part;  for a bougie which has only
passed a very little way in the urethra has sometimes been effectual,
if suffered to stay there  till the desire of making water is perceived.
   In  such cases, even when the bougie passes into the bladder, it is
necessary  to  let it  stay in  the passage  till the inclination to make
water comes on.  If the water does  not follow on the first attempt, it
will be proper to make another; or if only part follows the bougie, it
will be necessary to introduce it again.  This circumstance, of  the
water following the bougie with more certainty if it is allowed to stay
till the inclination comes on, is a  proof that the disposition in  the
bladder to contracting removes in some degree the disposition to con-
traction in the urethra.
   Some  attention is necessary with respect to the passing  of  the
bougie in these cases; for the urethra, being more irritable than com-
mon,  it often resists the bougie before it reaches the true spasmodic
part.   When this is the case, force is not to  be used; but we should
rather wait a little with patience, and then make another  attempt to

  1 Dr. Home, in his experiments on this medicine, found that large doses brought on
the strangury in women.
  Strangury is the frequent effect of spirit of turpentine taken for some time. 
232
EXCRESCENCES.
push  it on.  Dipping the end of the penis in very cold water often
removes the spasm, and the water flows immediately and freely.
  In most cases there is an uneasy sensation at the end  of the penis,
which leads the patient to rub  those parts; aud  sometimes, though
rarely, during  the friction,  the  water will pass.   Gently  irritating
injections, thrown in only a little way, often give ease.   They may be
supposed  to act in a manner somewhat similar to  a bougie that does
not pass, and by irritating one part of the urethra to produce a relaxa-
tion in the other.  They act in some cases as a preventive.1


                § 3. Of the Paralysis of the Urethra.

  In opposition to the foregoing disease, there is the want of power of
contraction of the urethra;  but this is not so  frequent a case  as the
former.. This disease is attended with symptoms contrary to those of
the foregoing;  the bladder is hardly allowed to be filled so as to give
the stimulus of repletion, but the water dribbles  away insensibly as
fast as secreted by the  kidneys; or if the bladder is  filled  so as to
receive the  stimulus for  expulsion, then it immediately takes place,
and the water flows, if the person  does not  act  with the musculi
acceleratores; but sometimes in  such cases the power of contraction
of  these muscles  is lost, and then the water  will  flow whether the
person will or not, there being little or no power of retention.  There
is great difference in the degrees of violence of this disease.2


               § 4. Cure of the Paralysis of tlie  Urethra.

  It is to  be cured by stimulants, as a blister to the loins, or a  blister
to the perineum.  It may be useful-to immerse the feet in cold water.
Tincture of cantharides, taken internally, fifteen or twenty drops once
or twice a day,  according to the effects, are of singular service in some
cases.
  A man came to St. George's Hospital with this complaint. I ordered
him the before-mentioned medicine, and  it had  such an effect as to
bring on the contrary disease, or a spasmodic affection of the urethra,
so that he could not make water when he had the inclination; but an
injection of opium removed this complaint, and he was then well.  In
this case, a few drops less, probably, would have effected a cure with-
out any inconvenience.

           § 5.  Of Caruncles or Excrescences in  the Urethra.

  Strictures  are not supposed to be the only causes of obstruction to
the passage of  urine in  this canal; excrescences or  caruncles are like-
wise mentioned by authors as happening  frequently.  From  the fami-
liarity with which they  talk of them, and  the  few  instances  in which

  1  See pages 162 and 189.
  2  The affection which Hunter here refers to the urethra should be attributed to
functional disturbance or organic lesions of the neck of the bladder.—Ricobd. 
SWELLING  OF  THE  PROSTATE.
233
they really oecur, one would suspect that this cause of obstruction was
originally founded  in  opinion, and  not observation, and afterwards
handed down as matter of fact.  If caruncles had been at first described
from actual  examination of cases, the language would  have accorded
with the appearances, and they would have been considered as seldom
the causes of obstruction compared  with strictures.  However, they
do sometimes happen, although but rarely.  I have, in all my examina-
tions of dead  bodies, seen only two,  and these were in very old  stric-
tures, where the urethra had suffered considerably. They were bodies
rising from the surface of the urethra like granulations, or what would
be called polypi in other parts of the body.  It  is possible they may
be a species of internal wart;  for I have seen warts extend some way
into the beginning of the urethra, having  very much the appearance
of granulations.  Most probably it will not be  possible, in the living
body, to distinguish caruncles, excrescences, or risings  in the urethra,
from a stricture; for I cannot conceive that they can produce any new
symptoms or peculiar feel to the examiner.

            §  6. Of the Cure of the Excrescence or Caruncle.

  I should very much  suspect that this disease  is not to be cured by
the bougie;  at least dilatation in such cases is not to be attempted, as
there is no contraction.   If, therefore, the bougie is of any use, it  must
be in making the carnosity ulcerate from its pressure, which  probably
may be done by a large bougie  pressing  upon it with considerable
force.  But if this should not have the desired effect, I should certainly
recommend  or use the caustic, if the parts  are so situated as to admit
of the  application; and from  such practice, I should not doubt  of a
cure.  But  the  difficulty lies  in distinguishing the disease  from the
true stricture;  for although authors talk of caruncles as common, and
give us the method of treatment, yet they  have not  told  us how we
are to distinguish them from strictures.
  I have never met with a caruncle in women.1
                    CHAPTER  VIII.

             OF THE SWELLED  PROSTATE GLAND.

  Another disease of the parts  surrounding  the urethra, which is
often very formidable, is a swelling of the prostate gland.  This is of
more serious consequence  than any of the former causes of obstruc-
tion, because we have fewer methods of cure; for we cannot destroy
it as we do the stricture, nor can  Nature relieve  herself by forming

  1 Vegetations of the urethra are more common in women than in men.  (See pages
163, 179, 188, and 193.—Ricobd. 
234
SWELLING  OF  THE PROSTATE.
new passages.  We have, however, often the means of temporary relief
in our power, which is not the case  in  the stricture;  for most com-
monly we can draw off the water by  the catheter.
  The swelling  of the prostate gland is most common in the decline
of life.   The use of this gland is not sufficiently known to enable us
to judge of the  bad consequences  that  attend its  diseased  state,
abstracted from swelling.   Its situation is such, that the bad effects of
its being swelled must be evident, as  it may be said to make a part of
the canal of the urethra, and, therefore, when so diseased as to alter
its shape and size, it must obstruct the passage of  the urine.  When
it swells, it does not lessen the surface of the urethra at the part like
a stricture;  on the contrary, it rather increases it; but the sides of the
canal are compressed together, producing an obstruction to the passage
of the urine, which irritates the bladder, and brings on all the symp-
toms in that viscus that usually arise from a stricture or stone.  From
the situation of the gland, which is principally on the two sides of the
canal, and but little, if at  all, on the fore  part, as  also very little on
the posterior side, it can only swell laterally, whereby it presses the two
sides of the canal together, and at the same time stretches it from  the
anterior edge or side to the posterior, so that the canal, instead of being
round, is flattened into a narrow groove.  Sometimes the gland swells
more on one  side than the other, which makes an obliquity in  the
canal passing through it.
  Besides this effect of the lateral parts swelling, a small portion of it,
which lies behind the very beginning of the urethra, swells forwards
like a point, as it were, into  the  bladder, acting like a valve to  the
mouth of the urethra, which can be seen even when the swelling is
not considerable, by looking upon the mouth of the urethra from  the
cavity of the bladder in a dead body.  It  sometimes increases so much
as to form a tumor,1 projecting into  the bladder some inches.  This
projection turns or bends the  urethra forwards, becoming an obstruc-
tion to the passage of a catheter, bougie,  or any such instrument; and
it often raises the sound over a small stone in the bladder, so as to pre-
vent its being felt.  The catheter should,  for this part, be more curved
than is necessary for the other parts of the  urethra.  In such cases, I
have frequently passed first a hollow elastic catheter till it has reached
this  point, and afterwards a stylet or brass wire properly curved, so
as to go over the prostate gland.   The advantages of this method  are
that, if the hollow catheter passes, no more  is  necessary; and, if it
does not, the  curved wire will  pass  along the hollow bougie much
easier, both  to the surgeon and patient, than it would have done if it
had  been introduced at first  with the hollow bougie  over it;  for it
would endeavor  to adapt the urethra to  the curve; whereas, when
introduced afterwards, the stylet acts only on the inside of the hollow
bougie, which the patient hardly feels.
  A gentleman had been often sounded  for a stone, and yet no stone
could be found; but it afterwards appeared that there was a stone,
which, together with the swelling of the  prostate gland, had  been  the
cause of his  death.
1 Vide Plates V. and VII. 
SWELLING  OF THE  PROSTATE.
235
  John Doby, a poor pensioner in the Charter-house, had been several
years afflicted with the stone in the bladder, and was relieved from all
the symptoms by an enlargement of this part of the prostate gland,
preventing the stones from falling down upon the neck of the bladder
and irritating those parts.  A twelvemonth after that the symptoms of
the stone had gone off, he was attacked with a strangury, to relieve
which many  ineffectual attempts  were made, both with the bougie and
catheter; but it soon proved fatal.   Upon examination of the parts in
the dead body, the prostate gland was found  enlarged  to a size six
times  greater than what it is in common, and the urethra,  passing
through it, was a slit about an inch and a half in length, the two sides
of which were close together, the  upper end towards the pubes and the
lower towards the rectum. This slit was formed by the sides of the
prostate gland only swelling, and the right side was the most enlarged,
having its  surface next the urethra rounded or convex,  and the  left
side was exactly fitted to it, having its surface  hollowed  in  the same
proportion.   The small projecting point.of the gland was  so much
enlarged as to come forwards  into the cavity of the bladder, and  fill
up entirely the passage at the neck of it.  The bladder itself was very
much enlarged and thickened in  its coats, and contained about twenty
stones, most of them lying behind the projecting process of the prostate
gland, and the rest lodged  in small sacs, made by the internal mem-
brane being pushed some little way between the fasciculi of muscular
fibres.
   The prostate gland, when swelled, generally becomes firmer in its
consistence.  The effects of these swellings are very considerable, for
they squeeze the sides of the urethra close together, and the projecting
point hinders in some degree the urine from  entering the passage, and
in many cases stops it entirely.  Farther, the increased firmness of the
substance of the gland  hinders  it from yielding to the force of the
urine, so that little or none can pass.  It will be unnecessary to relate
the particular symptoms which this disease occasions; they are such
as arise from any stoppage of urine, producing au irritable bladder.
   When a difficulty in making water takes place, a bougie is the in-
strument which the surgeon will naturally have recourse to, and if he
finds the passage clear, which he often will, in such cases he may very
probably suspect a stone.  If search  is made, and  no  stone  felt, he
should naturally suspect the prostate gland, especially if the sound or
instrument used meets  with a full stop, or  passes with some difficulty
just at the neck of the bladder.  He should examine the gland.  This
can  only be done by introducing the finger into the anus, first oiling
it well, placing the forepart of the finger towards  the pubes; and if
the parts, as  far as the end of the finger can reach, are hard, making
an eminence  backwards into the rectum, so that the finger is  obliged
to be removed from side to side, to feel  the whole  extent of such a
swelling, and it also appears to go beyond the reach of the finger, we
may be certain the gland is considerably swelled, and is  the principal
cause of those symptoms.
   I  have known cases where the common catheter has been  pushed
through the projecting part of the gland into the bladder, and the water 
236
SWELLING  OF THE  PROSTATE.
then drawn off; but in one patient the  blood from the wound  passed
into the bladder and increased the quantity of matter in it.  The use
of the catheter was attempted a  second time, but, not  succeeding, I
was sent for.   I passed the catheter till it came to the stop, and then
suspecting that this part  of the prostate projected  forwards, I  intro-
duced my finger into  the anus, and found  the  gland very much en-
larged.  By depressing the handle of the  catheter, which of course
raised the point, it passed over the projection; but,  unfortunately, the
blood had coagulated  in the bladder, which filled up the holes in the
catheter, so that I was obliged to withdraw  it, and clear  it  repeatedly.
This I practised several days;  but suspecting that the coagulum must
in the end kill, I proposed cutting him as if for the stone; but he died
before it could be conveniently done, and the dissection, after death,
explained the case to be what I have now described.
  In some of those cases where this part of the gland swells into the
bladder in form of a tumor, the catheter has been known not to bring
off the water  at times  when it appeared to have passed;  and upon the
death of the  patient,  when the  parts have  been  examined,  it was
imagined that the catheter, in the living body, had made its way into
the tumor so  as to have been buried in it at those times.'
  From the knowledge of the above-mentioned facts, whenever I find
the urine does not flow immediately upon introducing the catheter into
the bladder, I have pushed it on  and depressed the handle, so  as  to
reach the fundus of the bladder with the end of the catheter, and have
always succeeded.  For the more ready introduction of the instrument,
a catheter made flexible at the point only for about an inch, is perhaps
best, as it is more under the command of the hand than when wholly
flexible.
  If the bougie be used, it should be first warmed, and  then very much
bent at the point, and allowed to cool in this position, and passed quickly
with the concave side upwards, before it loses the bend in  its passage.
But the bougie does not answer so well as the catheter, because, upon
withdrawing  the bougie the sides of the  gland soon close again.  I have
known where the water has passed by the side of the bougie with more
freedom than when it was pulled out, because the bougie gave a straight-
ness to this part of the canal,  which it  had  not when  the  bougie was
withdrawn.   The following case is a strong instance of the inconveni-
ences arising from such a disease of the prostate gland.
   A gentleman was attacked with a suppression of urine; a catheter
could not be  passed; but a bougie relieved him.   He continued well
for five years; but the same complaint returning, the bougie could not
be passed, and the disease was supposed to be a stricture.  A catheter,
however, passed, although with a good deal of difficulty, and the bougie,
though often tried, could  not be passed, excepting once, just after using
the catheter.   I was sent for, and tried the bougie with as little success,
and was obliged to have  recourse to the catheter.  I passed it with
great ease, and the water  was drawn off.  The late Mr. Tomkyns, who
had Daran's bougie, was called; but he was not more successful, and
was obliged to have recourse  to the catheter; but  such violence was
1  Vide Plate VII. 
SWELLING  OF THE  PROSTATE.
237
used as caused a good deal of blood to come from the urethra, and after
all it did not succeed.  I was again consulted, and  passed the catheter,
but with much more difficulty than before, which made me believe that
the passage had been a good deal torn.  Upon taking out the catheter,
I passed a large bougie into the bladder with great ease; this I  allowed
to remain for three days, and the  patient made water tolerably freely
by the side of it.  The moment I drew out the bougie I attempted to
pass another, but did not succeed, although I  gave it the natural bend
of the passage.  Upon withdrawing those bougies that did not pass, I
observed that all of them had a bend at the point, contrary to the direc-
tion of the passage; this made me suspect that the  place which stopped
the bougie was on the posterior surface, and that, by being pushed on,
it bent forwards into the passage, and of course the point turned back.
I therefore took a thick bougie, and before I  introduced it I bent the
point almost double, so that it could not catch at the posterior surface
of the urethra, where I supposed the stop to be; this point of the bougie
rubbed all along the anterior and upper surface of the urethra, by which
means it avoided catching on the  posterior surface, and it passed with
great ease into the bladder.  He made water by the side of the bougie,
as before.  He had been for some time troubled with fits of an inter-
mittent, which at first were very irregular, but became afterwards more
regular.  In one of the cold fits, the bougie, being  in the urethra, gave
him great pain, and obliged him at last to  pull it out, on which he had
immediate ease.  The sensation was as if it stretched the passage too
much, and it seemed to come out with difficulty. This looks as if there
was a contraction of the urethra,  as well as of the vessels of the skin,
in the cold fit; so that this disposition runs deep. By giving the bougie
this bend he was able for the future to pass them with great  ease.   I
may just observe that, by introducing the finger into the anus, I found
the prostate gland much enlarged.
   Many patients, while laboring under any  of the before-mentioned
diseases of the urethra, and sometimes even after they had been cured
of them, find  great  pain  in  throwing forwards the semen, having a
sensation as if it  scalded.  This arises from the very irritable state
which the muscles of this part are in, giving  great pain  by their own
action.
   [Ricord.—Since the time of Sir Everard Home, to whose work Mr.
Babington does right in referring for all that  relates to diseases of the
prostate, anatomists have disagreed on the conformation of this gland-
ular body, and particularly on the inferior portion of it, which Home
considers as forming a middle lobe.  But however it may be with this
portion, whether its apparent separation is only due to the furrow hol-
lowed out by  the ejaculatory ducts, or whether it  is really distinct  as
some facts in comparative anatomy or some arrests of development
would seem to show, it is important, as  Hunter observes, to be aware
of the pathological states which may be confined to it alone.  On the
other hand, I will recall a  remark made  by Sir E. Home, which I have
had an opportunity to  verify, viz.: that the  left  side, or, if you will,
the left lobe of the prostate, is more frequently affected with hyper-
trophy or morbid  alterations than the right; a fact important to  be 
238
SWELLING  OF  THE  PROSTATE.
known, so as to give the requisite curve to instruments in catheteriza-
tion.
  I will add, that in cases of disease of this organ, or in operations to
be performed around or within it, we cannot too well bear in mind both
the pathological changes to which it is liable, and also some anatomical
varieties, which have lately been better described than formerly. The
prostate may be wanting, or else be very small, whilst sometimes it is
seen  to acquire a large  development, without morbid alteration.  In
some subjects it does not completely envelop the urethra and the neck
of the bladder, and then the part which is wanting beneath is replaced
by muscular fibres,  according to M. Amussat.  M. Senn has described
another anomaly in which the superior portion of the prostate is thicker
than the inferior, so that the urethra and the neck of the  bladder are
situated much nearer the rectum than in the normal  state.  Lisfranc
had two beautiful anatomical specimens belonging to this variety, which
he often showed in his operative courses.  However, for the anatomy
and pathology of the prostate, I think I cannot do better than  to refer
to the work on this subject published by M. Mercier.1—Ricord.]


         § 1. Of  the Treatment of the Swelled Prostate  Gland.

  The methods practised in the above cases  afforded only temporary
relief, yet such must be had recourse to in order to prevent the conse-
quences of retaining the urine too long.  As a temporary relief from
pain, as also to remove spasm, opiate clysters should be thrown  up once
or twice a day.  A  certain cure, I am afraid,  is not as yet discovered.
  I have seen hemlock of service in several cases. It was given upon
a supposition of a scrofulons habit.   On the same principle, I have re-
commended sea-bathing, and have seen considerable advantages from it,
and,  in two cases, a cure of  some standing.
  In one case in  which I was consulted, the surgeon had found that
burnt sponge had reduced the swelling of the gland very considerably.
  This disease, like the stricture, produces complaints in the bladder;
but in this the bladder  is generally more irritable, perhaps from the
cause being nearer to that viscus.
  Diseases of the vesiculas  seminales  are  very familiarly talked  of;
but I never saw one.   In cases of very considerable induration of the
prostate gland and bladder, where the surrounding parts have become
very much affected, I have seen  these  bags also involved in the
general disease; but I never saw a case where it appeared  that they
were primarily affected.
  In a case of a swelled prostate gland, with symptoms of an irritable
bladder, in a young gentleman about twenty years of age,  Mr. Earle
tried a blister to the perineum; but not finding the desired effect, and
conceiving a greater irritation and discharge to be necessary, he passed
a seton in the direction of the perineum.  The orifices were about two
inches distant from each other.   The symptoms of irritability in  the

  1 See the valuable work of Mr. Henry Thompson, entitled: The Enlarged Prostate,
its Pathology and Treatment; London, 1858.—Ed. 
TREATMENT.
239
bladder began to abate, and in time went entirely off.  Upon examina-
tion of the prostate gland, from time to time, it was found to decrease
gradually till  it was nearly of the natural size.  The seton was  con-
tinued some months, and upon its being withdrawn the symptoms
began to  return.  It was advised to  introduce  it again, which was
accordingly done, but without the former good effects.
  [G. G. B.—The  enlargement  of the prostate gland, as it occurs  in
old people,  seldom,  if ever, yields  to surgical treatment; yet much
may be done to prevent or alleviate  the distressing effects  which it
produces on the neighboring  organs.  In fact, it  is these effects  only
which give any importance to the malady.  The disease of the pros-
tate in most cases  occasions no  symptoms which are referable to the
gland  itself.  But it may  impede  the flow  of  the  urine, or excite
chronic inflammation of the  bladder, and ultimately disease of the
kidneys, or give rise to painful  irritability of the rectum.  The mode
in which these consequences are produced, and the treatment by which
they are to be obviated, are  best detailed in the observations of Sir
E. Home, on diseases of the prostate gland, to which work the reader
is referred.]
  [Ricord.—Lesions of the vesiculas seminales are perhaps more com-
mon than is supposed.  These sacs  are always more or  less affected,
in what I call successive epididymitis, that is to say, epididymitis  in
which the spermatic passages are involved from the urethra,to the
epididymis.  Among the cases reported of their pathological anatomy,
I will recall those  presented by M. Gaussail,  and  those which I myself
showed to the Academy of Medicine.  It results from my observations
that the vesiculas seminales are susceptible of the most varied morbid
changes, from simple inflammation  and suppuration to different de-
generations, one of the most common of which is tubercular degenera-
tion.  The tubercles are either developed alone in  these organs,  or
they  are  also found at  the  same time in other regions, and  more
particularly in connection with scrofulous sarcocele.   A fine  instance,
taken from the wards  of my  learned colleague,  M. Cullerier, was
published in the Bulletin de la Societe Anatomique, and I have shown
several  similar cases at my clinique.
  I will here quote the summary of an interesting essay on oblitera-
tions of the spermatic passages, which M. Gosselin, chief anatomist of
the medical faculty of Paris, read to the Academy of Medicine, June
29, 1847.
  1. The vas  deferens may be  obliterated, and  cease to convey the
semen to thevesicula seminalis.
  2. The canal of the epididymis may be obliterated at a point cor-
responding to the cauda of this organ; and in this case also the  pas-
sage of  the semen into the vesicula is prevented.
  3. In these two cases, the  canal  forming the  epididymis may be-
come dilated and varicose, or  preserve its normal state.
  4. The  testicle, in these cases, does not invariably become atrophied;
it continues to secrete semen,  and its swollen vessels  are unloaded by
absorption. 
240
DISEASES  OF  THE  BLADDER.
  5. Obliterations of the epididymis, at the point where the cauda is
given off, are sometimes incomplete or temporary.
  6. Obliterations may take  place in the head of the epididymis, but
they do not obstruct the  flow of the semen.
  7. The seminiferous vessels of the testicle  may become wholly or
partially obliterated.—Ricord.]
                     CHAPTER  IX.

 OF THE DISEASES OF  THE BLADDER,  PARTICULARLY FROM
  THE BEFORE-MENTIONED OBSTRUCTIONS  TO THE  URINE.

  All the diseases of the urethra, as also the diseases of the prostate
gland, I have  now  treated of, and  shall next consider the effects of
them  upon the bladder, as also the diseases of that viscus, independent
of affections of the urethra.
  The disease of the bladder arising from obstruction alone is increased
irritability  and its consequences, by which the bladder admits of little
distension,  becomes quick in  its action, and thick and  strong in its
coats. * But prior to the description of the effects of the diseases of the
urethra on the bladder, it will be necessary, for the better understand-
ing of the  whole, to make some remarks upon those diseases of the
two parts, in which we  find that each affects the other; and these I
shall consider without having  any regard to the cause, but only to the
general effects, when they  are  diseased.  It may be observed  that
every organ in  an animal  body is made up of  different  parts, the
functions or actions of which are  totally different from each other,
although all tend to produce  one ultimate effect.   In most, if not in
all,  when perfect, there is a succession of motions, one naturally arising
out of the  other,  which in the end  produces the ultimate effect; and
an irregularity alone in these  actions will constitute disease, at least
produce very  disagreeable effects, and often totally frustrate the final
intentions of the organs.
  I may be allowed also to premise that the natural width of  the ure-
thra gives  such a resistance to  the force or power of the bladder in
expelling the urine as is easily overcome by the natural action of the
bladder; but  when the canal is lessened, either by stricture, spasm,
swelled prostate  gland, or any other means, this proportion is lost, by
which means  the bladder finds  greater difficulty than natural, and is
of course thrown into an increased action to overcome the  resistance,
which becomes a cause  of  the  irritability and  increased strength of
this viscus  in such diseases.
  It is to  be understood that in a sound state of  these two parts, the
bladder and urethra, the contraction of the one  produces a  relaxation
of the other, and  vice versa;  so that their natural .actions  are alternate,
and they may be considered  as  antagonist muscles to  one another. 
DISEASES OF THE BLADDER.
241
 Thus, when the stimulus of expulsion of the urine takes place in the
 bladder, which immediately produces  contraction in it, the urethra
 relaxes, by which means the urine is expelled from the bladder, and
 allowed to pass through the urethra;  and when the action ceases in
 the bladder, the urethra contracts again, like a sphincter muscle,1 for
 the purpose of retaining the urine which flows into the bladder from
 the kidneys, till it gives the stimulus for expulsion again.   But in
 many diseases of these two parts, this necessary alternate action is not
 regularly  kept up, the one not obeying the summons of the other.
 This irregularity arises, perhaps, oftener from disease in the urethra
 than in the bladder, for the action  of  the  urethra depends upon the
 actions of the bladder; and if it is not disposed to obey the notices of
 the bladder, then there must be an irregularity as to time, which pro-
 duces very troublesome symptoms.
   We find, in many diseases of the urethra, such as strictures and
 spasms, as also in diseases of certain parts belonging to this canal, such
 as the prostate and Cowper's glands, that there is a greater disposition
 in this canal for contraction than common, so that when the bladder
 has begun to act, the water is not allowed to flow, the urethra not im-
 mediately relaxing; and the moment  such a symptom takes  place,
 every other power takes the alarm, and is brought in to assist the blad-
 der, such as straining violently with the abdominal muscles, and mus-
 cles of respiration, from all which there  is violent  pain in the  parts
 immediately concerned, especially in  the glans penis.2
   This disease has different degrees of violence. When slight, the dis-
 tance  in  time between the contraction  of the bladder and the relaxa-
 tion of the urethra is but short, only giving a momentary pain and
 straining before the urethra relaxes, and the water flows according to
 the dilatation of the urethra, which, in many of these cases, is but very
 small.  In others, the distance of time is very long, many straining for
 a considerable time before a drop will  come; and what does come is
 often  only in  drops;  and sometimes, before the whole  urine can be
 expelled  in this way, the spasm of the urethra comes  on again, and
 there is a full stop, which gives excruciating  pain for a while; but at
 last, the bladder is, as it were, tired, and ceases to act.  But, as the
 urine in such cases is seldom all discharged, and often but a very little
 of it, the symptoms soon recur; and in this way, with a call to make
 water perhaps every hour out of the four and twenty, the patient drags
 on a miserable life.
   The bladder, in all cases  of obstruction, whether constant, as in the
 permanent strictures or swelled prostate gland, or only temporary, as
 in the spasmodic stricture, is generally kept distended, but much more

  1 It may be remarked that many sphincter muscles have two causes of action ; one
 which may be called involuntary, depending  on the natural uses and actions of the
 parts ; the other is voluntary, where a greater degree of action can be produced by
 the command of the will;  and when a diseased  action takes place, it is probably of
 this voluntary action, for it is an increased action over the natural, which the volun-
 tary is.
  2 Added: " A gentleman, whose bladder was in  an irritable state, found  that by^
passing a bougie a little way into the urethra the irritation was taken off from the
bladder, and he could retain the urine several hours."—Home.
       16 
242
DISEASES OF  THE BLADDER.
  so in the permanent stricture; and when the irritation of fulness comes
  on, which is very frequent, the contraction of that viscus becomes vio-
  lent in proportion to the resistance; the sympathetic contraction of
  the  muscles of the abdomen takes place,  and is also violent; yet the
  water, at such times, shall only dribble, and be  discharged in small
  quantity; and in the  spasmodic stricture, often not a drop shall pass,
  so that the bladder is never  entirely empty; and what does pass is no
  more than what is sufficient to take off  the  irritation of fulness, by
  which means these actions  become more frequent, and consequently
  there is  almost always a constant  oozing of urine from the penis
  between the times of making water.  This, however, is not always the
  case, for the bladder sometimes is so irritable as not to cease acting till
  it has evacuated the whole water; and even then it is not at ease, but
  still strains, though there  is nothing  to throw out, the action of the
  bladder becoming a cause  of its own continuance.
    In all such affections of the bladder, there is a sensation of pain and
  itching combined in the glans penis.1
    If the  symptoms are more urgent than what can be accounted for
  upon the supposition of a  stricture or disease  of  the prostate gland, a
  stone is to be suspected.


  § 1. Of the Treatment where the Actions  of the Urethra and Bladder do
                         not exactly alternate.

    The  cure, where the disease arises from spasm alone, consists in
  removing the disposition to over-action in  the  urethra, and the irri-
  table disposition of the bladder when the urethra does  not obey it.
  Perhaps opiate clysters, as a temporary means of relief, are the very
  best medicines  that can be administered.   I have known a blister to
  the  loins, or to the perineum, remove the spasm, in a great measure,
  from the urethra.
    When the circumstance of the  ultimate actions  of these parts not
  being regular arises from stricture,  swelled  prostate  gland, or any
  mechanical obstruction to  the urine, then that cause must be removed,
  as has been fully described in the treatment  of these diseases.


  § 2. Of the Paralysis of the Bladder from Obstruction to the  Passage of
                              the  Urine.

    We may observe that the bladder  is a part easily deprived of its
  power of contraction; for we find in many debilitating diseases and
  long illnesses from any cause, as fever, gout, and  considerable  local
  diseases which debilitate, that the bladder often becomes paralytic, and
  the water must be drawn off. We may also observe, when the bladder
  has  been distended considerably, from whatever  cause, so  as to  have
  its contractile power destroyed, that there is a considerable extravasa-

#   ' Added: "In diseases of the bladder, the constitution is sooner affected by symp-
  toms of dissolution than from the same apparent degree of disease in other parts ; the
  patient becomes drowsy, insensible, and soon dies."—Home. 
PARALYSIS.
243
tion of blood from the inner surface of the bladder, so that the water
which  is evacuated is often extremely bloody.  I have seen, in cases
where  the  patient has died  with  this obstruction upon him, that the
inner membrane of the  bladder has been almost black, being loaded
with extravasated blood; but this symptom of bloody urine goes off,
as the bladder acquires again its power of contraction.
   In the diseases of the urethra, before described, when not properly
or in time attended to, and in cases of stricture, where Nature has not
been able to relieve herself, the water must of course  be  retained in
the bladder, which is perhaps always productive of another disease,
that is, the loss of the power of contraction of that viscus.   Although
this one effect, the retention of urine, arises from very different causes,
as before related, yet immediate relief must be given  in all of them,
which can only be effected by the evacuation of water.   According to
the nature  of the obstruction, the mode of the evacuation will  be
different, and  will  be of two  kinds—one by the natural passage by
means of a hollow tube, the other by an artificial opening made into
the bladder.
   If the causes of suppression are either spasmodic affections of the
urethra,  a swelled prostate  gland, inflammation in the surrounding
parts of the urethra, or tumors pressing upon it,  as happens in preg-
nant women, immediate relief may be procured by means of a catheter,
because under such circumstances a catheter will most probably pass,
the sides of the canal being merely forced together by spasm or ex-
ternal pressure.
   A bougie, although it will also pass under such circumstances, will
not answer so well, because a bougie must be withdrawn before the
water can flow, which will allow the cause of  the obstruction to exert
again its full force;  and if the spasm should not  now exist, yet the
bougie will not answer, unless there be a  power of action  in the blad-
der ; for it is with difficulty that the urine can be made to pass through
the urethra by pressing the abdomen only.
   When the catheter is passed, it will be necessary to make the patient
strain with his abdominal muscles, as also with his muscles of respira-
tion, to squeeze out  the water, the bladder having no  power of con-
traction ;  and even this will  not be sufficient, for it will be necessary
to press on the region of the pubes with the hand to make the water
flow.
   In cases where there is a considerable degree of  debility in the
bladder, or in those cases where there is a considerable strangury, and
of long standing, and where a small quantity of urine in the bladder
gives the stimulus of fulness to that viscus, which is always attended
with considerable urgency to make water, and where only very small
quantities are evacuated, the bladder not  being emptied at  each time
of making it, and when a catheter, either rigid  or flexible, can with
readiness be passed, the question is—What is the best way upon the
whole to evacuate the water ?  There are three ways in which it can
be done; one, by allowing the parts to do their own business as much
as they can, and this, at first sight, might be supposed  to  be the very
best;  but it is in some cases the very worst; for the frequency of the 
244
DISEASES  OF THE  BLADDER.
 inclination to make water, arising from  the  water not being wholly
 evacuated each time, the evacuation not readily taking place, increases
 the effort, and for a few minutes produces excruciating pain, keeping
 up  a  considerable and almost constant irritation  in all those parts,
 which few can bear.  Another method is to  draw off the water each
 time with a catheter, but this, in many cases, is next to  impracticable;
 for, supposing the operation to be performed only twice or three times
 in the day, we shall find that this is oftener than what should be done.
 The third method is, to  leave the catheter almost constantly in the
 bladder.
   Which of these three methods is likely to give, on  the whole, the
 least irritation must depend  upon circumstances attending different
 cases.   Where frequency and the urgency is great, and the flowing of
 the water difficult, either the second or the third is to be pursued; and
 when the symptoms are such that a catheter must be passed very often,
 I believe it  had better be left in, only taking it out occasionally.  I
 think this is  supported by observation and experience.
  It sometimes happens, in cases  of swelled  prostate gland, that the
 catheter cannot be passed without the utmost difficulty,  and when this
 has been the case I  have left it in  the bladder for fear of not being
 able to pass it again, and  continued  it there till the bladder has suffi-
 ciently recovered its tone, which is known by its being able to throw
 the urine through the catheter; after which that instrument  maybe
 withdrawn.
  If the spasm, in  such cases as  arise from  that  cause, should still
 continue after the bladder has recovered its  tone, we must continue
 the  use  of the catheter. .  But it often happens that the spasm leaves
 the urethra before the bladder recovers its  power of contraction, the
 disease becoming then simply a paralysis of that viscus.
  One of  the first symptoms  of the bladder beginning to regain its
 power of contraction is the sensation of fulness, or an  inclination to
 make water, and when that sensation comes  on the patient should be
 allowed to make water, but not to force it, for  that circumstance alone
 will bring on the spasm if the urethra is not very ready to dilate.  I
 have seen, however, in some cases, that a  slight sensation is not alto-
 gether to be depended  upon, for it required a little retention more
 effectually to stimulate the bladder to action, and then the water has
 passed more freely.
  The spasmodic contraction of the  urethra does not appear to give
 up  its action simply upon the stimulus or inclination to make water,
 nor  till the bladder begins to have the power of contraction; for in
 cases where the bladder is  paralytic, and yet sensible of the stimulus
 arising from  being full, as it does not contract, the urethra does not
 relax, and the water cannot be made to pass.
  It would appear that, as the bladder recovers of the paralysis, it is
 not able to contain so much water as usual.   Therefore, the patients are
obliged to make water often, and of course in small quantities. 
TREATMENT OF PARALYSIS.
245
 § 3, Of the Cure of the Paralysis of the Bladder, from Obstruction arising
                     from Pressure or Spasm.

   The removal of the causes of the paralysis of the bladder was fully
 described when we were treating of the diseases which produce  that
 complaint, and the immediate relief, when the bladder is rendered in-
 active, has just now been considered; the paralysis itself is therefore
 the only remaining thing to be attended to.  In this disease there are
 often contrary indications of cure, for a spasm is very different from a
 paralysis;  and if the suppression is  from spasm, and that still  con-
 tinues, then what may be good for the paralysis, may be bad for  the
 spasm.   As  in such cases the water can  be drawn off, the bladder
 should be first attended to.  Stimulants and strengtheners  are useful;
 blisters to  the loins to rouse the bladder to action, and blisters to  the
 perineum,  to take off the spasm from the  urethra, often succeed.
 Electricity is sometimes of singular service, when applied in such
 cases to the perineum.  Through the whole of the cure the urine must
 be drawn off frequently, because the bladder should not be allowed to
 be distended, which  otherwise would be  the  consequence; and  the
 sensation arising from the distension  of  that viscus is a very oppres-
 sive one.
   A gentleman was at times attacked with a difficulty in making water,
 which he paid no attention to, as it had always gone off; but at last
 he was obliged to  have recourse to the catheter, which afforded only a
 temporary relief.  The spasm continued, and I was sent for.  When
 I passed the  catheter, I was obliged  to  press  the  lower part of the
 abdomen, to squeeze out the water, for the bladder appeared to give
 but little assistance.  I ordered a blister to the loins, which gave some
 power of contraction to the bladder, and took off some of the  spasm
 in the urethra, but still he was very little relieved.  I then directed a
 blister to be applied to the perineum, which immediately removed his
 complaint.
   [Ricord.—I have often succeeded, in cases of inertia of the bladder,
 with injections of  cold water or aromatic infusions; and  have  some-
 times obtained favorable results from cauterizing the neck of this organ.
 But, in some cases, I have only succeeded in restoring its contractility,
 by leaving an open catheter in  its cavity for some time.   The latter
 method is  often advantageous when the bladder has lost its elasticity
 in consequence of  long distension; we thus  prevent the urine from
 accumulating in the viscus, which collapses for the time being, and soon
 reacts when the instrument is withdrawn, and a quantity of fluid, to
 which it is no longer accustomed, stimulates it anew.
  In many cases of retention of urine, where there is no stricture  of
 the urethra and no swelling of the prostate—cases which are attributed
 to inertia or essential paralysis of the bladder, so called—M. Mercier
 has shown, by means of his  explorator, that there exists  a peculiar
 prominence of the vesico-urethral or pyloric valve.
  When this prominence is due only to spasmodic contraction of the
muscular fibres surrounding the neck of the bladder, which are excited
by inflammation of the prostatic  region of the urethra, cauterization 
246
SUPPRESSION  OF URINE.-
of the neck of the bladder, among other means, may give  favorable
results.   But in cases where the pyloric prominence is produced by a
permanent contraction of these fibres, which finally undergo various
degrees of fibrous degeneration, consequent on deeper and longer-con-
tinued inflammation, we should have recourse to section.—Ricord.]
                     CHAPTER  X.

OF  A SUPPRESSION OF URINE,  AND OPERATIONS FOR THE
                         CURE  OF IT.

  In  cases of total suppression of urine  arising from  strictures, or
other  causes where a catheter cannot be passed, and where every other
method recommended is impracticable, an  artificial opening  must be
made  into  the  bladder  for the evacuation of the water.  There are
three  places where this opening may be made, and each has had its
advocates.  This operation has not been considered in all its circum-
stances in different patients, so as to direct  the young surgeon  in the
variety of cases that  may occur; for under some  circumstances the
operation is more advisable in one place than another; and, indeed, it
may sometimes be next to impossible to perform it in a particular part.
  The opening  may be made first in the perineum, where we now cut
for  a  stone; secondly,  above the pubes, where cutting for  the stone was
formerly practised; and thirdly, from within the rectum, where the
bladder lies in contact with the gut.
  The first question which naturally occurs  is, which of those situa-
tions  is the most proper for the safety of the  patient, the  evacuation of
the water, and the conveniency of operating, when no particular cir-
cumstance forbids either of the situations ?
  On the first view of the subject, one would  be apt to prefer that
above the pubes, or from the rectum, as the bladder is nearer to either,
and the parts more adapted to an operation than from the perineum,
where we must cut at random.  These two  situations,  although the
most  proper in this respect, under certain circumstances, yet may be-
come  the most improper, for they are subject to greater changes than
the perineum.
  The reasons that may render it very improper above the pubes are,
the persons being very fat, or the bladders not distending sufficiently
so as  to rise above the pubes, which is common enough in diseases of
those parts.
  In  very fat people,  it will be found  that  the  substance to  be cut
through  may be  three or four inches, which will not only make the
operation very unpleasant, but often improper; for  such thickness of
parts  will make the swell of the bladder very obscure and uncertain;
in many, the bladder is so diseased as to allow of but little distension,
and in such the symptoms of fulness come on very early, perhaps when 
SUPPRESSION OF  URINE.
247
there are only a few ounces of water collected.  But if the retention
has been for some considerable  time, as twenty-four hours, then we
may suppose that the bladder has allowed of distension to a much
greater degree, which may in some cases be ascertained by introducing
the finger into the rectum.
  But where the bladder distends, and the parts are so thin that it can
be  plainly felt above the pubes, I see  no material objection to this
situation; and it has this advantage over the operation by the rectum,
that a catheter can more easily be introduced, and kept in, which will
be necessary to be done till the cause is removed.
  It may be necessary here to mention some  precautions respecting
the keeping the instrument in the bladder; as also the best kind to be
used.  It  must be a  hollow tube, and should reach as far as the pos-
terior surface of the bladder, for, upon the contraction of that viscus,
its anterior part recedes backwards and downwards from the abdomen
towards its fixed point, which may draw the bladder off from the tube.
But as the distance  between the skin of the abdomen and posterior
surface of the bladder cannot be exactly ascertained, the canula may be
either too long or too short; if too long, its end may press upon the
posterior surface of the bladder and produce ulceration there, and in
time work its way into the  rectum.  To avoid this mischief, as also
the inconveniences arising from its being too short, and  the  bladder
slipping off from its  end, I would  recommend the tube to be made with
a curve, and to lie with its  convex side on the posterior part of the
bladder, which, being a large surface, and following nearly the same
curve as the canula, less mischief is to be  expected.  The openings
into the canula may be made on the concave side.
  It would probably be both safer and easier for the patient  to  have
the curved end of the catheter introduced into the urethra from the
bladder.   The passing of it into  the urethra is very practicable; and
we know  that such a body lying in the urethra is  not productive of
any mischief.  A common catheter passed in this way enters so far as
to bring the handle almost flat  to  the belly; at  most only a  little
bolster between the catheter and belly  is necessary, and  then with  a
piece of tape fixed to the handle  of the catheter it might be fastened
to the body; or a short catheter might be made with ears to fix the
tape to.1   In cases where the canula has remained  in the urethra some
time, the artificial passage will become in some degree permanent, so
that it may be  taken out  occasionally, and  cleaned from any stony
matter that may be attached to it.  To avoid this part of the operation
it has been recommended to have two canulas, one within the other,
that by drawing out the inner it may be cleaned, and again introduced;
but in most cases it will also be necessary to withdraw the outer one,
as its external surface will contract a crust.

  1 Where this operation is performed in consequence of a stricture, I have conceived
that, by passing a catheter into the urethra from the bladder till it comes to the
stricture, and then passing another straight canula from the glans down the urethra,
the two may nearly meet, only having the stricture  between them;  and a piercer
may be passed down and forced into the end of the one from the bladder, and after-
wards either a bougie or hollow catheter introduced. 
248
SUPPRESSION  OF URINE.
   The second method, or puncture by the anus, will more  commonly
 admit of being performed than that above the pubes;  for it does not
 require that distension of the bladder which the other does, and is
 therefore not so often impracticable from that cause ; and perhaps the
 only obstacle here is a swelled prostate gland. In many of these cases
 of diseases of the urethra, the prostate gland is very much  swelled,
 which I  can conceive  may make  the proper place for the puncture
 very uncertain; for the prostate gland, in such cases, will  be pressed
 down towards the anus, before the bladder, and  will be the first thing
 felt by the finger.  Care  must therefore be taken to distinguish the
 one from  the other, which can only  be  done by getting  the  finger
 beyond  the prostate gland, Avhich may not  be practicable; and, if
 practicable, it may not be an  easy matter to distinguish the one from
 the other, as a  thickened and distended bladder may seem to be a
 continuation of the same tumor.  However, if the objections given to
 the performing it above the pubes exist, I should prefer operating by
 the rectum ; for although the  probability  of succeeding here  may not
 be apparently greater than above the pubes, yet the chances are in its
 favor.
   I must, however, observe here that the objections which I  have
 started, are only raised in my own mind  from my knowledge of the
 diseases of those parts, and  not from cases of suppression of urine
 under all  the before-mentioned circumstances having occurred to me
 in practice.
   A case of total suppression of urine arising from  stricture, where
' no instrument could  be passed by the natural  passage, and  where a
 puncture was made into the bladder, from the rectum, with success, is
 related in the Philosophical Transactions, by Dr. Hamilton, of Kings-
 Lynn in Norfolk.1
   What  led Dr. Hamilton to do it here was a difficulty which was
 found in passing the clyster-pipe into  the rectum, which induced him
 to introduce his finger into the anus, and he found the  bladder so
 prominent in the rectum  as to give the hint of performing the opera-
 tion there.
   The man was put into the same position as in the operation for the
 stone, and a trocar was introduced upon the finger into the anus, and
 thrust into the lower and most prominent  part of the tumor, in the
 direction of the axis of the bladder, and upon withdrawing  the piercer
 the water flowed out through the canula.
   A straight catheter was then introduced through the canula, lest the
 orifice in the bladder should be drawn off from the canula.
   Then the canula was pulled out over the catheter, which was left in
 till the whole water was evacuated, and was then withdrawn.
    The bladder, notwithstanding this perforation, retained the water as
 usual, till the inclination  to make it came on;  and when he performed
 the action of making water, the orifice in the bladder seemed to open,
 and it rushed out by the anus.  This continued  about two  days, when
 the water began to find its natural passage, and a bougie was introduced

         1 Philosophical Transactions for the year 1776, vol. lxvi. p. 578. 
SUPPRESSION  OF URINE.
249
into the bladder, through the urethra, which gave a free passage for the
water, and of course less came by the anus;  so that on the sixth day
after the operation the whole came by the natural passage.  The man
continued the use of the bougie till the  stricture was  dilated.  Dr.
Hamilton farther remarks that, in those cases of suppression of urine,
in general, he has found that calomel and opium, in large doses, answer
better than anything he  has tried.  He is convinced, from repeated
trials, that the specific efficacy is in the calomel, as large doses of opium
alone have proved ineffectual; but he does not say that calomel  alone
will answer.  He orders ten grains of calomel with two of opium, to be
repeated in six hours if it has not answered in that time; and he says
he has seldom been obliged to give a third dose.
  This  method of tapping the  bladder was first suggested by Mons.
Fleurant,  surgeon  to the Charite*, at Lyons, in the year 1750.   The
operation was performed  at that  time, and an account of it was  after-
wards published by Mons. Pouteau, in 1760, with the history of three
cases, in all which the operation was  performed by Mons. Fleurant.
The propriety of performing the operation in this part occurred to him
in a manner similar to that before related of Dr. Hamilton; for  in in-
troducing the finger into  the rectum to examine the state of  the blad-
der in a case where he was going to puncture in the perineum, he found
the bladder so prominent there, and  so much within the reach of his
instrument, that he immediately altered his intention, and performed it
in this part.  He very readily drew off the water, and kept the canula
in, with a T bandage, till the urine came the right way, and then with-
drew it, and all terminated well.  But there was a  good deal of trouble
on account of the canula  being left in on going to stool, as also from
the constant dribbling of the water through it; all of which was pre-
vented  in Dr. Hamilton's case, by removing the canula immediately
upon the evacuation of  the water.  This was  productive of another
good effect, which was the retention of the urine till the stimulus of
fulness was given, and then it passed through the  artificial as it would
through a natural passage.  Should this be a constant effect in conse-
quence of performing the operation here, I think it must be owned to
be an unexpected circumstance which at first could not have been ima-
gined.1
  In another patient of Mons. Fleurant's, the canula was kept in the
anus and bladder thirty-nine days without any inconveniency; so that
the objection to this part of the operation cannot be material.  Pouteau
mentions  one case where he performed this operation, in the year 1752,
and the man died.2  He says:  "I was called to visit a poor  man suf-
fering under a retention of urine, so obstinate  and violent that it had
already the symptoms of what is called a reflux of urine into the blood;
and the complaint had continued more than three days.  An empiric,
to whose care he had been intrusted, after having very improperly given
him the most powerful diuretics, had  likewise the rashness  to search
him.  It appears probable that these attempts,  which were made with-

  1 A history, with a description of this operation, was published by Mr. Reid, surgeon,
of Chelsea, in 1778.
  2 Pouteau, Melanges de Chirurgie, printed at Lyons, 1760, pp. 506-508. 
250
SUPPRESSION OF URINE.
out success, must have increased the mischief.  A catheter could not
be passed into such parts  by unskilful hands without increasing the
inflammation.  I only made three slight efforts to effect a passage into
the bladder by the urethra, which appeared to be much diseased,  as
well by the effusion of blood as the extreme pain which these attempts
produced.  I determined at once to do as before, and plunged my trocar
by the rectum into the  bladder.   The success was exactly the same;
the bladder was entirely emptied, and I allowed the canula to remain
there a whole night and a day, during which time the urine flowed
without intermission. Everything went on without any accident which
could be supposed connected with the operation; and death, which
happened next day, was entirely independent of it."
  One must suppose, with Pouteau, that the death of the patient could
not having arisen  from this operation, but from the preceding diseases.
  The  bags called vesiculas seminales, and the hemorrhoidal vessels,
have been  mentioned as  parts in danger of being wounded in the
operation,  and thereby proving troublesome; but if either of them are
wounded, no inconvenience can arise.  To avoid the vesiculas seminales,
it is recommended to perforate high up, and directly in the middle of
the bladder, between the two sides;  and this situation is, at the same
time, the one where the hemorrhoidal vessels are the smallest, and there-
fore it is of less consequence if they are wounded.
  It must appear from the following case, sent me by a gentleman, that
a communication being kept up between the bladder and rectum is only
inconvenient, and  not so much so as might be expected:—
  " With respect to the sailor who passed his urine by the rectum, I
have examined  the few papers  by me, but cannot find the particular
remarks I made; however, as the case was singular, I recollect the man
told me that, a few years before (this was at Madras Hospital, in De-
cember, 1779), he  had  the venereal disease, very bad  and very long;
that the urine came by the anus, but this passage healed up, and it came
by the  penis, and  continued  to do so till  he caught the disease again,
when the urine found its way a second time by the anus, and came that
way for years.  When he first came under my care, in the hospital at
Bombay, February, 1779, he felt no uneasiness or inconvenience from
this manner of  passing his urine; whenever  he had an inclination  to
make water he  sat down.   I often made him lie upon his breast, with
his legs drawn up, and the stream came through the  anus with great
force."1

  1 Added:  "John Conway, a seaman belonging to St. Antonio, was  admitted into
Haslar Hospital on the 24th November, 1770, for the lues venerea.  Besides the usual
symptoms of that disease, he had a communication between the bladder and rectum,
which had continued  four months.  When he endeavored to make water, the water
flowed both from the urethra and anus, coming from the anus in a small stream, often
to the quantity of a pint.  It also flowed freely from the anus when he went to stool,
although none was voided by the urethra.  In the beginning of the complaint, some
portions of dead flesh, he said, had come away from the rectum,  but when  admitted
into the  hospital there was not any soreness remaining, or discharge of matter from it,
and the  urine passed  without pain; externally, he never had any fistula penetrating
either into the bladder or rectum, and when disturbed with flatulence in the bowels,
did not perceive any wind to escape from the urethra."—Home. 
SUPPRESSION  OF  URINE.
251
  In  other  cases, in consequence of abscesses forming between the
bladder and rectum, where they have not healed up, there has been a
reciprocal passing of the contents of these cavities from the one to the
other.
  It only remains to speak of the puncture in the perineum.  An ob-
struction to the urine taking place in the natural passage prevents us
from  introducing an instrument in most of those cases, and deprives
us of all the advantages we could receive from it as a guide in the
operation; yet there may be cases of stricture where, by cutting into
the urethra beyond the stricture, the water will flow; but this must be
done  without any guide or direction, and requires a nice and accurate
knowledge of the parts. Or if the obstruction arises from the valvular
projection of the prostate gland, a staff may be passed as far as this
projection, and cut upon as for the stone, the surgeon only making a
similar incision, using a small gorget; or, in the room of that, a trocar
of a  particular form might be run along  it into the bladder; for,
although the staff does not enter the bladder, yet the distance to pass
through without  this guide is  but small.  If this  cannot  be done, a
small and deep incision may be made in the perineum with an impos-
thume lancet towards the  bladder; the  point of the trocar is to  be
introduced by this, the  surgeon  passing at the same time the forefinger
of the other hand into the anus, which will be a guide both for the
direction of the instrument, as  also to avoid its point passing into the
rectum.  With these precautions, the error cannot be great.
  I must own,  however, that I have not seen cases enough to enable
me to give all the varieties that commonly happen, and of course to
give all the advantages and disadvantages of each method.
  [G. G. B.—In cases of retention of urine from stricture, it is always
more safe  to open the urethra than to puncture the bladder.  The
bladder is imbedded in loose  cellular membrane, which envelops  it
everywhere, and  which must be wounded if the bladder is punctured,
whatever part  be chosen for  that  operation.   Now, such a  wound
cannot be made without  great danger,  because the urine is  thus
admitted into this loose cellular texture, and frequently diffuses  itself
through it, producing extensive sloughing and abscess.  This is by no
means a rare consequence  of puncture of the bladder, and when  it
occurs, is very generally fatal.  The opening of the urethra is not
attended with  the same risk, because the cellular membrane of the
perineum is generally loaded with fat, and the escape of the urine  is
in all cases direct and  easy; and even  if abscess should take place, it
will be near the surface, and can be laid open with the greatest facility.
  Under ordinary circumstances, the urethra is collapsed, and is not
easily found, unless some instrument is previously introduced  as  a
guide; but in  cases of retention of urine from stricture, it is  always
greatly dilated between the contracted part and the bladder, and there
is not the same difficulty.   As there is variety in the seat of stricture,
there  will be some variety also  in the operation which is required.
  When the obstruction is  situated before the bulb, the distension of
the urethra behind it may be distinctly felt in the perineum, especially
when  the patient is straining to pass water. Under such circumstances, 
252
SUPPRESSION OF  URINE.
nothing is easier than to open the dilated part of the passage with a
common lancet.
  But the stricture is much more frequently seated at the part where
the membranous portion of the canal enters the bulb.  In this case
the difficulty is greater.  Nevertheless, the dilated part of the urethra
may generally be felt through the rectum, and more or less distinctly
in the perineum; and if a previous incision be made, as in lithotomy,
through the superficial parts, it may be reached and  laid open.  The
operator may derive some assistance from the introduction of a sound
into the urethra as far as the stricture, which will point out the direc-
tion of the canal;  but his principal guide must be the position of the
pubes, since  in  this case the  part which  is  to be punctured will lie
immediately  below the symphysis.
  When the  contraction is still farther back, so as to be near the apex
of the prostate gland, it may be impossible to feel any dilatation; and
in this case the operation must be varied.   A staff should be first in-
troduced into the urethra,  and passed down  to the  stricture.  The
groove of the staff should then be laid open for a small extent near
its point, and this will enable the  operator to introduce a probe, which
may be passed on to the stricture, and, without much trouble, made
to penetrate it.  When that has been effected, it will not be difficult
to pass a catheter through the stricture into the bladder, and to draw
off the water.
  These operations are not  applicable to  cases where the obstruction
arises from an enlarged prostate gland.  In this case, the mouth of the
urethra is closed, and no urine is admitted into it; yet even here the
operation of  puncturing the bladder is more hazardous than the per-
foration of the enlarged prostate. A silver catheter  may be forced
forward through the prostate,  and carried into the cavity of the blad-
der;  and this has been done on several  occasions without  being
followed by serious consequences, or even by material inconvenience.
The opening thus made has sometimes been permanent;  at  other
times, it has  appeared to close, and the urine has been passed  in the
same manner as before the operation, and with equal facility.—G. G. B.]

   § 1. Of allowing a Catheter to remain in the Urethra and Bladder.

  In cases of debility  of the bladder, and where a  catheter passes
with difficulty, or with great uncertainty,  and in cases where it must
be used frequently, and for a  length of time, it will be  necessary to
keep an  instrument in the urethra and  bladder, so as  to allow the
water to pass through it freely.  A common catheter, or one made of
the elastic gum, is perhaps the best instrument; but it must be fixed
in the canal; this will be best done by its outer end being tied to some
external body, as I  shall now describe.   When the catheter is fairly
in the bladder, the outer end is rather inclined downwards, nearly ia
a line with the body.  To  keep  it in  this position, we may take the
common strap or belt part of a bag-truss,  with two thigh-straps either
fixed to it or hooked to it, and coming round each thigh forwards by
the side of the scrotum, to  be  fastened  to the belt where the ears of 
SUPPRESSION  OF  URINE.
253
the bag are usually fixed.  A small ring or two may be fixed to each
strap just where it passes the scrotum or root of the penis; and, with
a piece of small tape, the ends of the catheter may be fixed to those
rings, which will keep it in the bladder.  A bit of rag about four or
five inches long, with a hole at the end of it, passed over the exterior
end of the catheter, and the loose  end allowed to hang  in a basin
placed between the thighs, will catch the water which cannot disen-
gage itself from the catheter, and keep the patient dry;  or if another
curved  pipe  is  introduced into the catheter, it will answer the same
purpose.
  Under such treatment, the  bladder will never be allowed to be dis-
tended ;  and when the patient wants to have the bladder some degree
emptied, he has only to strain with his abdominal  muscles, by which
means he will be able to  throw out a great deal at each time.
  As the bladder begins to  recover its  actions, the patient will find
that an inclination to make water will come on, and at those times he
will also find that the water will come from him without straining with
the abdominal muscles;  when this  takes place readily, the catheter
may be taken out, and it will be found that he will be able in future
to make  water of himself.  If it is necessary to keep in the catheter a
considerable time, it will be  the cause of a great deal of slime  and
mucus being formed in the urethra and bladder; but I believe this is
of no consequence.  I have known a catheter kept in this way for five
months without any inconveniency whatever.
  In all  cases where  it is necessary to keep an extraneous body for a
considerable time in the bladder, whether in an artificial passage or the
natural one, it will be proper, a few days after its first introduction, to
withdraw it, and examine whether it is incrusting or filling up in its
cavity with the calculous matter of the urine.  If, after remaining in
the bladder for some days, it  has contracted none, we need be under
no apprehension of its doing it; but if, as frequently happens, it should
have collected a considerable quantity, then it will be necessary to have
it occasionally withdrawn and cleaned.   The best method probably of
doing this is to  put  it in vinegar, which will  soon dissolve the stony
matter.

            § 2. Of the increased Strength of the Bladder.

  The bladder, in such cases as have been described, having more to
do than common, is almost in a constant state of irritation and action;
by which, according to a property in all muscles, it becomes stronger
and stronger in its muscular coats;  and I suspect that this disposition
to become stronger from  repeated action is greater in the involuntary
muscles  than the voluntary;  and the reason why it should be so is, I
think, very evident; for, in the involuntary muscles, the power should
be  in all cases  capable of  overcoming the resistance, as the power is
always performing some natural and necessary action; for  whenever a
disease produces an uncommon resistance in the involuntary parts, if
the  power is  not proportionally increased, the disease becomes very
formidable; whereas, in the voluntary muscles there is not that neces- 
254
SUPPRESSION  OF  URINE.
sity, because the will can stop whenever the muscles cannot follow;
and if the will is so diseased as not  to stop, the  power in voluntary
muscles should not increase in proportion.
  I have seen the muscular coats of the bladder near half an inch thick
and the fasciculi so strong as to form ridges on the inside of that cavity;1
and I have also seen the fasciculi very thin, and  even wanting in some
parts of the  bladder, so  that  a  hernia of the internal coat had taken
place between  the fasciculi and formed pouches.2 These pouches arise
from the thin parts not being able to support the actions of the strong,
as happens in ruptures at the navel or rings of the abdomen.


                 § 3. Of the Distension of the Ureters.

  It sometimes happens that the irritation from th'e distension of the
bladder, and the difficulty in throwing out its contents, is so great that
the urine  is prevented from flowing  freely into that viscus from the
ureters, which become thereby preternaturally distended.  The pelvis
of the kidneys and infundibula are also  enlarged; but how far this
dilatation of the ureters and pelvis is really owing to a mechanical
cause, I am not so clear; or whether it is not a disposition for dilata-
tion arising out of the stimulus given by the bladder.  In some cases
of long standing, where the bladder had become very thick, and had
been for a long time acting  with  great violence, it had affected the
mammillas, so  that the  surface  of  these processes produced a matter,
and perhaps even the secreting organs of the kidneys, so that the urine
secreted was accompanied with a pus,  arising from the irritation being
kept up in all  these parts.
  The urine, in the above cases, is generally stale, even before it is
thrown out of  the bladder, which, when joined  with the circumstance
of the linen being  constantly kept wet, by the  almost continual dis-
charge of urine, becomes very offensive, and it is hardly possible to
keep the patient sweet.


§ 4. Of the Irritability in  the Bladder independent of Obstructions to the
                         Passage of the Urine.

  Another disease of the bladder, connected with the present subject,
is where that viscus becomes extremely irritable, and will not allow of
its usual distension.  The symptoms of this disease are very similar to
those arising from obstructions to the  passage of the urine in the ure-
thra, but with this difference, that in the present disease the urine

  1  This appearance was long supposed to  have arisen from a disease of that viscus;
but, upon examination, I found that the muscular parts-were sound and distinct; that
they were only increased in  bulk in proportion to the power they had to exert; and
that it was not a consequence of inflammation  ; for in that  case parts are blended into
one  indistinct mass.
r* ^hi|jiS' perna*)S>the cause of tne stone being often found in a pouch formed in
the bladder; for the bladder, in cases of stone, is often very strong, which arises from
the violent contraction of that viscus, caused by the irritation of the stone on the sides
of it; and also from the stone being often opposed to the mouth of the urethra in the
time of it making water. 
SUPPRESSION OF  URINE.
255
flows readily, because the urethra  obeys the summons and relaxes;
however, there is  often considerable straining, after the water is all
voided, arising from the muscular coat of the bladder still continuing
its contractions.
  This irritability of the bladder often arises from  local causes, as a
stone, cancer, or tumors forming on the inside, all which produce irri-
tability of this viscus.  In such cases the straining is violent, for the
cause still remains which continues to give the stimulus of something
to be expelled, and the bladder continues to contract till tired, as in
the cases of simple irritability, and  then there is a respite for a time;
but this respite is of short duration, for the urine is soon accumulated.
   This disease will in the end be fatal by producing hectic fever.


         § 5. Of the Cure of Simple Irritability of the Bladder.

   When the symptoms arise from irritability alone, and  not from a
stone or any local affection, the nature of the complaint may not at
first be  so obvious ; temporary relief may, however, be procured by
opium, which is most effectual in slight and recent cases; and if  it be
applied as near to the part as possible, its effects will be more evident;
and therefore it may be given by clyster as well as by the mouth.1
   I should, however, be rather inclined to rely on a blister applied to
the perineum, or to the lower part of the small of the back, or upper
part of the sacrum if more convenient, than to any other method of
cure.
   In all cases, where there is an irritation of the bladder, the patient
should never  endeavor to retain his water beyond the inclination to
make it.   It hurts the bladder and increases its irritability; and in-
deed I am apt to think that this circumstance, even in  sound parts, is
often a predisposing  cause of disease in this viscus  and its appendage,
the urethra; for I have known several cases where it has brought on
the spasmodic stricture in  the  urethra in sound parts, and it is fre-
quently an immediate cause of strangury in those  who have either a
stricture or a disposition to spasms in those parts.
   A gentleman in perfect health, from retaining his urine beyond the
inclination, in the playhouse, had all the  symptoms of an irritable
bladder brought on, which continued for several years, rendering him
miserable.

            § 6. Of a Paralysis of the Accelerators  Urinaz.

   In many irritations of the bladder,  the  urethra not only relaxes
directly on the stimulus to make  water being felt in that viscus, as
has been described, but" a paralysis sometimes takes place in the volun-
tary muscles of those parts, so that the will cannot  command them to
contract to hinder the inconveniences  that may attend an immediate
evacuation of that fluid.  If we attempt to stop the water, which is an

   1 Added: " I have known alum whey  given, under which treatment  the patient
got well."—Home. 
256                   SPERMATORRHOEA.
act of the will, it is in vain; the acceleratores will not  obey, and the
water flows.
  A blister applied to  the perineum will  have considerable effect in
removing this complaint.
                     CHAPTER  XI.

   OF THE DISCHARGE OF  THE NATURAL MUCUS OF  THE
                  GLANDS  OF THE  URETHRA.

  The small glands of the urethra and Cowper's glands secrete a slimy
mucus, similar to the white of  an egg not coagulated.   This  seldom
appears externally, or flows from the urethra, but during the indulgence
of lascivious thoughts, and is seldom or never attended  to, excepting
by those who  are either under  apprehensions of a gonorrhcea coming
on, or imagine that the last infection is not gone off entirely, and are
therefore kept in constant terror by this natural discharge.  They
often find it in such quantity as to leave spots on the shirt, but without
color; and often after  toying, the  lips of the  urethra are, as it were,
glued together by it, from its drying there, which  appearances alarm
the mind of the patient without cause.  Although this is only a natural
discharge, and is secreted, at such  times, under the same influence
which naturally produces it, it  must be owned that it is  commonly
much increased in those cases of debility arising from the mind, which
is probably not easy to  be accounted for.  It would  seem that the
contest between the mind and the body increases this secretion, for it
cannot be considered as a disease of the parts.

   § 1. Of the Discharge of the  Secretions of the Prostate Gland and
                         Vesiculce Seminales.

  This complaint is  imagined to be the consequence of the venereal
disease in the urethra; but how far this is really the case is not certain,
though most probably it  is not.   It is  a discharge of mucus by the
urethra which generally comes away with the last drops of urine,
especially if the bladder is irritable, and still more at the time of being
at stool, particularly if the patient be costive, for under such circum-
stances the straining or actions  of the muscles  of those parts are more
violent.  It has generally been  supposed that this  discharge is semen,
and the disease  is  called a seminal weakness; but it  appears, from
many experiments and observations, that the discharge is undoubtedly
not semen.  It is only the mucus secreted either by the prostate gland,
by those bag^s improperly called vesiculas seminales, or  both; and it
may not be improper to give here the distinguishing marks  between
these two fluids.  First, we may observe the discharge in question is
not of the same color with the  semen, and is  exactly of the  color of 
SPERMATORRHEA.
257
the mucus of the prostate gland  and of those bags.  It has not the
same smell, and indeed it hardly has  any smell at all.  The quantity
evacuated at one time is often much more considerable  than the eva-
cuation of semen ever is, and it happens more frequently than it could
possibly  do were  the  discharge  semen.  It is a disease that often
attacks old men, where one can  hardly suppose  much semen  to be
secreted; and we find that those who  are affected  with this disease are
no more  deficient in the secretion and evacuation  of the semen, in the
natural way, than before they had the disease.  If the mind be at ease,
this shall take place immediately after a discharge of semen as well as
before, which could not be the case were it  semen.  Farther, if those
that labor under this complaint are not connected with women, they
are subject to nocturnal discharges  from the imagination, as persons
who are perfectly sound; and,  indeed, most  patients,  when  made
acquainted with these  circumstances, become very sensible that it is
not the semen.1
   It is not clear what the diseased state of the parts is upon which this
discharge depends, whether there is a larger secretion of this mucus
than natural, or whether it is entirely owing to a preternatural uncom-
mon action of those parts; and if this last, why these parts should be
put into  action when the bladder, rectum, and abdominal muscles are
thrown into action to expel their contents, is not easily explained.  It
is plain that the most violent  actions of these parts are necessary to
produce  this  evacuation; for  it  does not  come  with the first of the
urine,  nor in general with an easy stool.
   As it was thought to be a seminal discharge, it was imagined to arise
from a weakness in the organs of generation;  and as frequent discharges
of semen in the natural way generally weaken, it was therefore imagined
that this discharge must also weaken very considerably;  and the ima-
gination will operate so strongly as to make the patients  believe they
really are weakened.  Whether the cause of such a discharge is capa-
ble of weakening, I will not pretend to say; but I  believe the discharge
simply does not.   Fear and anxiety of mind may really weaken the
patient.  In the cases I have seen of this kind the mind has been more
affected than the body.
   From  my own practice, I can hardly recommend any one medicine,
or way of life, for  removing this complaint.  In one case, I found  con-
siderable benefit from giving hemlock internally.
   The idea that has been formed of the disease leads  to the practice
generally recommended, such as giving strengthening  medicines of
all kinds;  but I never saw any good effects  from any of them, and I
should rather be inclined to adopt the soothing  plan to prevent all
violent actions.  Keeping the body generally open will in some degree
moderate the discharge, and probably may effect  a cure in the end.
   [Ricord.—Without indorsing Hunter's views  on the functions of
the vesiculas seminales, which, as all  researches  since his  time have

   1 Added : " A gentleman has often a discharge of mucus from the urethra with the
last drops of urine, and when he goes to stool.  But after having  connection with
women  it does not take place."—Home.
       17 
258
IMPOTENCE.
incontestably proved, are reservoirs of the semen, I adopt his explana-
tion of seminal  emissions  almost entirely.  Daily  observation has
proved to me that cases of true spermatorrhoea are much less frequent
than has lately been asserted.   I have had an opportunity of seeing a
very large number of these patients, or hypochondriacs, and most  of
them, I find, have only discharges of mucus, entirely free from animal-
cules and other characteristics of the semen.   I know that the contrary
may have  been observed in many cases; but has there not been a little
exaggeration ?
  Some men,  doubtless, lose their  semen with very great facility; a
lascivious thought, the slightest friction, timidity added to heightened
desires in the presence of women, and their first attempts at intercourse,
produce emissions, without intromission being necessary or even possi-
ble; also prolonged continence, dorsal decubitus, irritation of the in-
testinal canal,  etc., cause nocturnal  pollutions in many subjects.   But
there is a  great difference between this state of things and  the over-
drawn picture which has recently been given us; and works on sper-
matorrhoea  have  only confirmed what Montesquieu said:  " Though
physicians frighten us by the descriptions they give of disease, they
soon reassure us by proclaiming a specific."
  However, these remarks are applicable only to the exaggerated view
of the subject which has lately been made public, and which has  cre-
ated a true epidemic of spermatophobists, tormented  individuals, sad,
pettish hypochondriacs,  .in  whom  cauterization  of the neck of the
bladder does not always cure the brain.
  I will say in conclusion, that, without the authority of M. Lallemand's
distinguished name, and above all, without the remarkable observations
on seminal emissions1 which he has published, I should ask myself, as
Hunter did, if such writings be not more injurious  than useful.  But,
I repeat, in order that ideas  may not be attributed  to me which I do
not entertain, that although  I forbid these writings  to be read by men
of the world, I cannot recommend them too highly to the attention of
practitioners.—Ricord.]
                    CHAPTER  XII.

                        OF  IMPOTENCE.

  This complaint is by many laid to the charge of Onanism, at an
early age; but how far this is just, it will in many cases be difficult to
determine; for, upon a strict review of this subject, it  appears to me
to be by far too rare to originate from a practice so general.
  How far the attributing to this practice such a consequence is of
public utility, I am doubtful, particularly as it is  followed  most com-

          1  Involuntary Seminal Emissions.  Paris, 1836-1842, 3 vols. 
IMPOTENCE.
259
monly at an age when  consequences are not  sufficiently attended  to,
even in things less gratifying to the senses;  but this  I can say with
certainty, that many of those who are affected with  the complaint in
question are miserable from this idea; and it is some  consolation for
them to know that it is possible it may arise from other causes.  I am
clear in my own mind  that the books on this subject have done more
harm than good.1
   In the cases of this kind  that have come under my care, although
the  persons themselves have  been  very ready  to  suppose that the
disease has arisen  from the cause here  alluded  to, yet they did not
appear to have given more into  the practice than  common; and, in
particular, the worst case I have ever seen was where but very little of
this practice had ever been used, much less than is common among boys.2
   Nothing hurts the mind of a man so much as the idea of inability to
perform well the duty  of the sex.  If his scrotum hangs low it makes
him miserable; he conceives  immediately that he is  to be rendered
incapable of performing  those acts in which  he  prides  himself most.
It is certain that the relaxation or contraction of the scrotum is in some
degree a kind  of sign of the constitution; but it  is of the constitution
at large, not of those parts in particular.  Nurses are so sensible of the
contraction of that part  being a  sign of health in the children  under
their care, that they take notice of it.  The relaxation  of it in them
cannot be supposed to  arise from inability to perform those acts at one
time more than another.   The face is one of the signs  of the constitu-
tion, and has as much  to do with those peculiar acts  as the scrotum.
However, we must allow that  this part is much more lax than what we
should conceive was intended  by nature, even in young men who are
well in health; but as this is very general, I rather  suspect  that it
arises from the circumstances of the part being kept too warm  and
always suspended, the muscles hardly ever  being allowed  to act, so
that they have less force.  How far  it  is the same in  those countries
where the dress does not immediately suspend those parts, I have not
been able to ascertain.   Warmth appears to be one cause; for we find
that cold has generally an immediate effect; but this is perhaps owing
to its not being accustomed  to cold, which, if it were, it might possibly
become as regardless of as it is of warmth.  What the difference is in
this part, in a cold and warm climate, all other circumstances the same,
I do not know.  But  whatever may be the cause, if it is really in
common more lax than intended by  nature, it is of no consequence as
to the powers of generation.   The testicles will  secrete, whether kept
high or low.3

  1 There are, doubtless, many collegians who recollect the  little effect reading Tissot
had upon them in deterring them from this habit.  Since the work of this remarkable
author, nothing better has  been produced than M. Deslandes's book (Onanism and
Other Venereal Abuses considered in Relation to Health, Paris, 1835), which can cer-
tainly be recommended to be read, at least by physicians.—RiCoed.
  * Added: " Which is particularly  pernicious from the frequency of the repetition,
there being no want of opportunity."—Home.
  3 Sir E.  Home has here added a note, in which he expresses the belief that Onanism
is more hurtful than the author imagined;  and that its being practised before  the
parts have arrived at maturity in weakly constitutions, may prevent their ever attain-
ing their full power and development.  This opinion is not only in itself reasonable,
but seems also to foe confirmed by experience.—G. G. B. 
260                      IMPOTENCE.
              § 1. Of Impotence depending on the Mind.

  As the parts of generation are not necessary for the existence or
support of the individual, but have a reference to something else, in
which the mind has a principal concern, a complete  action in those
parts cannot take place without a perfect harmony of body and of
mind; that is, there must be both a power of body and disposition of
mind; for the mind is subject to a thousand caprices, which affect the
actions of these parts.
  Copulation is an act of the body, the spring of which is in the mind;
but it is not volition; and according to the state of the mind so is the
act performed.   To perform this act well, the body should be in health,
and the mind should be perfectly confident of the powers of the body;
the mind should be in a state entirely disengaged from everything else;
it should have no difficulties, no fears, no apprehensions; not even an
anxiety to perform  the act well; for even this anxiety is a state of
mind different from what should prevail; there should not be even a
fear  that the mind itself may find a difficulty at the time the act should
be performed.  Perhaps no function of the machine depends so much
upon the state of the mind as this.
  The will and reasoning faculty have nothing to do with  this power;
they are only employed in the act, so far as voluntary parts are made
use of; and if they, ever interfere, which they sometimes  do, it often
produces another state of mind, which destroys that which is  proper
for the performance of the act; it produces a desire, a wish, a hope,
which are all only diffidence and uncertainty,  and create in the mind
the idea of a  possibility of the want of success, which destroys the
proper state of mind, or necessary confidence.
   There is perhaps no act in which a man feels himself more interested,
or is more anxious  to perform well, his pride  being engaged in some
degree, which, if within certain bounds, would produce a degree of
perfection in an act depending  upon  the will, or an act in voluntary
parts; but when it produces a state of mind contrary to that state on
which the perfection of the act depends, a failure must  be the con-
sequence.
   The body is not only rendered incapable of performing this act, by
the mind being under the above influence, but also by the mind being
perfectly confident  of its  power, but conscious of an impropriety in
performing it;  this, in many cases, produces  a state of mind  which
shall take away all power.  The state of a man's mind, respecting his
sister, takes away all power.  A conscientious man has been known
to lose his powers on finding the woman he was going to be connected
with unexpectedly a virgin.
   Shedding tears arises entirely from the state of the mind, although
not so much a compound  action as the act in question; for none are
so weak in body that they cannot shed tears;  it is not so much a com-
pound action of the mind and strength  of body, joined,  as the other
act  is; yet if we are afraid of shedding tears, or are desirous of doing
it, and that anxiety is kept up through the whole of an affecting scene, 
IMPOTENCE.
261
we certainly shall not  shed tears, or at least not so freely as would
have happened from our natural feelings.
   From this account of the necessity of having the mind independent
respecting the act, we must see that it may very often happen that the
state of mind will be such as not to allow the animal to exert its natural
powers;  and every failure increases the evil.  We must also see, from
this state of the case, that this act must be often interrupted; and the
true cause of this interruption not being known, it will be laid to the
charge of the body, or want of powers.  As  these cases do not arise
from real inability, they are to be carefully distinguished from such as
do; and perhaps the only way to distinguish them is to examine into
the state of mind respecting this act.  So  trifling often is the circum-
stance which shall produce this  inability depending on the mind, that
the very desire to please shall have that effect, as in making the woman
the sole object to be gratified.
   Cases of this kind we see every day, one of which I shall relate, as
an illustration of this subject, and also of  the method of cure.
   A gentleman told me that he had lost his virility.  After above an
hour's investigation of the case, I made out the following facts.   That
he had, at unnecessary times, strong erections,  which showed that he
had  naturally this power;  that  the erections were accompanied with
desire, which are all the natural powers  wanted; but that there was
still a defect  somewhere, which  I supposed  to  be from the  mind.  I
inquired if all women were alike to him; his  answer was, no;  some
women he could have connection with as well as ever.   This brought
the defect, whatever it was, into a smaller compass; and  it  appeared
that there was but one woman that produced  this inability, and that it
arose from a desire to perform  the act with this woman well,  which
desire produced in  the mind a doubt, or fear of the want of success,
which was the cause of the inability of performing  the act.  As this
arose entirely from the state of the mind, produced by a particular cir-
cumstance, the mind was to be applied to for the cure;  and I  told him
that he might be cured if he could perfectly rely on his own power of
self-denial.  When  I explained what I meant, he told me that  he could
depend upon  every act of his will, or resolution; I then told him„if
he had a perfect confidence in himself in that respect, that he was to
go to bed to this woman, but first promise to himself that he would
not have  any connection with her for  six nights, let his  inclinations
and  powers be what they would, which he engaged to do, and also to
let me know the result.  About a fortnight after, he told me  that this
resolution had produced such a total alteration in the state of his mind
that the power soon took place; for instead of going to bed with the
fear  of inability, he went with fears that he  should  be possessed with
too much desire, too much power, so as to become uneasy to him, which
really happened; for he would have been happy to have shortened the
time; and when he had once broke the spell, the mind and powers
went on together, and his mind never returned  to its former state.1

  1 Added : " Several similar instances have come under my care, but there is an evi-
dent objection to multiplying unnecessarily cases of this kind."—Home. 
262
IMPOTENCE.
  § 2. Of Impotence from a Want of proper Correspondence between the
                   Actions of the different Organs.

  I lately observed, when treating of the diseases of the urethra and
bladder, that every organ in an animal body, without  exception, was
made up of different parts, whose  functions, or actions, were totally
different from each other, although all tending to produce one ultimate
effect.  In all such organs, when perfect, there is a succession of mo-
tions, one naturally arising out of the other, which in the end produces
the ultimate effect; and an irregularity alone in these actions will con-
stitute disease, at least will produce  very disagreeable effects, and often
totally frustrate the final intention of the organ.  I  come now to apply
this principle to the actions of the testicle and the penis; for we find
that an irregularity in the actions of these parts sometimes happens in
men, producing impotence; and something  similar, probably, may be
one cause of  barrenness in women.
  In men, the parts subservient to generation may be divided into two,
the essential and the  accessory.  The  testicles are the essential; the
penis, &c, the accessory.  As this  division arises from their uses or
actions in health, which exactly correspond with one another; a want
of exactness in the correspondence, or susceptibility of those actions,
may also be divided into two:  where the actions are  reversed, the ac-
cessory taking place without the first, or essential, as in  erections of the
penis, where neither the mind nor the testicles are stimulated to action;
and the second is where the testicle performs the action of secretion too
readily for the penis, which has not a corresponding erection.  The first
is called priapism, and the second  is what ought to be called seminal
weakness.
  The mind has considerable  effect on the correspondence of the ac-
tions of these two parts; but it would appear in many instances that
erections of the penis depend more  on the state of the mind than what
the secretion of the semen does; for many have the secretion, but not
the erection; but in such the want of erection appears  to be owing to
the mind only.
  Priapism often arises spontaneously, and often from visible irritation
of the penis, such as the venereal gonorrhoea, especially when violent.
The sensations of such erections is rather uneasy than pleasant; nor is
the sensation of the glans at the time similar to that arising from the
erections of desire, but more like to the sensation of the parts  imme-
diately after coition.  Such as arise spontaneously are of more serious
consequence than those from inflammation, as they proceed, probably,
from causes not curable in themselves, or by any known methods.
  The priapism arising from inflammation of the parts, as in a gonor-
rhoea, is attended with nearly the same symptoms; but generally the
sensation is that of pain, proceeding from the inflammation of the parts.
It may be observed, that what is said of priapism is only applicable to
it when a  disease of  itself, and not as a symptom of  other  diseases,
which is frequently the case.1

  1 Added: "A gentleman had a priapism for two years ; it originated from an irrita-
tion in the bladder, which went off at the time the priapism came;  it only takes place 
IMPOTENCE.
263
  The common practice in the cure of this complaint is  to order all
the nervous and strengthening medicines, such as bark, valerian, musk,
camphor, and also the cold bath.  I have seen good  effects from the
cold bath; but sometimes it  does not agree with the constitution, in
which cases I have found the warm bath of service.  Opium appears
to be a specific  in  many  cases, from which circumstance  I should be
apt, upon the whole, to try a soothing plan.
  Seminal weakness, or a secretion  and emission of the semen without
erections, is the reverse of a priapism, and is by much the worst disease
of the two.   There is great variety in the degrees of this disease, there
being all the gradations from the exact correspondence of the actions
of all the parts to the testicles acting alone;  in every case of the dis-
ease there is too quick a secretion and evacuation of the semen.  Like
to the priapism, it does not arise from desires and  abilities, although
when mild it is attended with both, but not  in a due proportion; a
very slight desire often producing the full effect.  The secretion of the
semen shall be  so quick  that simple thought, or even toying shall
make it flow.
  Dreams have produced this evacuation repeatedly in the same night;
and even when the dreams have been so slight, that there  has been no
consciousness of them when  the sleep has been broken by the act  of
emission.  I have known cases where the testicles have been so ready
to secrete that the least friction on the glans has produced an emission;
I have known the  simple action of walking, or riding, produce this
effect, and that repeatedly in a very short space of time.
   A  young man, about four or five and twenty years of  age, not so
much given to venery as most young men, had these last-mentioned
complaints upon him.  Three or four times  in the  night he would
emit; and if he walked  fast, or  rode on horseback,  the  same thing
would happen.   He could  scarcely have connection with a woman
before he emitted, and in the  emission there was  hardly any spasm.
He tried every supposed strengthening medicine, as also the cold bath
and sea-bathing, but with no effect.  By taking twenty drops of lauda-
num, on going to bed, he prevented the night emissions; and by taking
the same quantity in the morning, he could walk or ride  without the
before-mentioned inconvenience.  I directed  this practice to be con-
tinued for some time, although the disease did not return, that the parts
might be accustomed to this healthy state of action;  and I  have reason
to believe the gentleman is now well.  It was found necessary, as the
constitution became more habituated to the opiate, to increase the dose
of it.
  The spasms upon the evacuation of the semen in such cases are
extremely slight, and a repetition of them soon takes place; the first
emission not preventing a second; the constitution being  all the time
but little affected.1  When the testicles act alone, without the accessory

in the  night, and mostly in his sleep, and immediately awakens him; having connec-
tion makes it worse."—Home.
  1 It is to be considered that the constitution is  commonly affected by the spasms
only, and in proportion to their violence, independent of the secretion and evacuation
of the  semen. But in some cases even the erection going off without  the spasms on
the emission shall produce the same debility as if they had taken place. 
264                      IMPOTENCE.
parts taking up the necessary and natural consequent action, it is still
a more melancholy disease;  for the secretion arises from no visible or
sensible cause, and  does not give  any visible or sensible effect, but
runs off similar to involuntary stools, or urine.  It has been observed
that the semen is more fluid than natural in some of these cases.  '
  There is a great variety in the  diseased  actions, of these parts, of
which the following case may be considered as an example.
  A gentleman has had a stricture in the urethra for many years, for
which he has  frequently used a bougie, but of late has  neglected it.
He has had no connection with women  for a considerable time, being
afraid of the consequences.  He has often in  his sleep involuntary
emissions, which generally  awake  him at  the paroxysm; but what
surprises him most is, that often he has such without any semen pass-
ing through the penis, which makes him think  that at  those times it
goes backwards into the bladder.  This is not always the case, for at
other times the semen passes forwards.   At the time the semen seems
to pass into the bladder he has the erection, the dream, and is awaked
with the same mode of action, the  same sensation, and the same plea-
sure, as when it passes through the urethra,  whether/dreaming  or
waking.  My opinion is that the  same irritation takes place in the
bulb of the urethra without the semen, that takes place there when
the semen enters, in consequence of all the  natural preparatory steps,
whereby the very same actions are excited as  if it  came into the
passage; from  which one  would  suppose that either semen is not
secreted, or if it be, that a retrograde motion takes place in the action
of the acceleratores urinas.   But if the  first be the case, then we  may
suppose that in the natural  state the actions of  those muscles do not
arise simply from the stimulus of the semen in the part, but from their
action being a termination of a preceding one making part of a series
of actions.   Thus they may depend upon the friction, or the imagina-
tion of  a friction on the penis, the testicles not  doing their part, and
the spasm in such cases arising from  the  friction, and not from the
secretion.
   In many of those cases  of irregularity, when  the erection is not
strong,  it shall go off without  the  emission; and at other times  an
emission shall happen almost without an erection; but these arise not
from debility, but affections of the mind.
   In many of the  preceding  cases, washing the penis, scrotum, and
perineum with cold water is often of service; and to render it colder
than we find it in some seasons of the year, common salt may be added
to it, and the parts washed  when the salt is almost dissolved. 
ATROPHY  OF THE TESTICLE.
265
                    CHAPTER  XIII.

              OF THE DECAY OF  THE TESTICLE.

   It would appear, from some circumstances, that the parts of genera-
tion are not to be considered as necessary parts of the animal machine,
but only as parts superadded for  particular purposes, and therefore
only necessary when those particular purposes  are to be answered;
for we may observe that they are later in coming  to maturity than any
other parts, and  are more liable to decay.  Thus far, in their natural
properties, they are different  from most other parts of our body, the
teeth only excepted, which are similar in  some of those circumstances.
   The testicles appear to be more subject to spontaneous disease than
any other part of the body; but what is the most singular thing of all
is the wasting of those bodies.  One or both testicles shall wholly dis-
appear, like to the thymus gland, or membrana pupillaris, &c, in the
infant.  This we do not find in any parts of the body which are essen-
tial  to its  economy, excepting the parts are of no farther use,  and
might become hurtful in the body,  as in the instance of the membrana
pupillaris.   But the testicles do not undergo this change as if in con-
sequence of an original property stamped upon them, as is the case of
the thymus gland, whenever the age of the person is such as to render
them useless, but are liable to it at  any age; and therefore the disposi-
tion is in the testicles themselves, independent  of any connection with
the animal economy.  An  arm or leg may lose its action, and may
waste in part, but never wholly.
   Testicles have  been known to waste in cases  of rupture, probably
from the constant pressure of the intestine.  Mr. Pott has  given us
cases of this kind.  I have seen in  the hydrocele the testicle almost
wasted to nothing, probably  from  the compression of the water;  but
in all  these the causes of wasting are obvious,  and would probably
produce similar effects  in other parts of the body under the same cir-
cumstances ; but a testicle without any previous disease wastes wholly;
or, at other times, it inflames, either spontaneously or from sympathy
with the urethra,  becomes large, and then begins  to subside, as  in the
resolution of common inflammation of the body,  but does not stop at
the former size, but continues to decay till it wholly disappears.  The
following cases are instances of this:—
   Case I. A gentleman, about nine years ago,  had a gonorrhoea with
a bubo, which suppurated.  A swelling of one of the  testicles came
on, for which he  used  the common methods of producing resolution,
and seemingly with success.   All the  other symptoms being removed,
he thought himself quite well; but some time after, he found that the
testicle which  had been swelled was  become rather smaller than  the 
266
ATROPHY  OF THE  TESTICLE.
other which made him now pay attention to it; this decrease continued
till it'wasted entirely.  For some years past there has been no appear-
ance of a  testicle.  He is not in the least different in inclination or
powers from what he was before.
  Case II.: communicated by Mr. Nanfan. " A gentleman, aged about
eighteen, who never had any venereal complaint, has had two different
attacks of the same  nature, one in each testicle.  February 3, 1776,
after skating a few hours, without having to his knowledge received
any injury from it, he was seized with a violent pain and inflammation
of the  left testicle,  which, in a few days, increased much  in size.  A
surgeon being sent for, followed the usual treatment in such cases of
inflammation.   In  about six weeks, the inflammation and swelling
gradually  subsided,  some  hardness  only remaining.  A  mercurial
plaster was now applied, which, after being worn for some time, was
left  off.   The left testicle  ever  since has continued  gradually to
decrease, and is no larger than a horsebean; indeed, the body of the
testicle is quite decayed, nothing remaining but what  seems part of
the epididymis.  It  appears to have no sense of pain, except when
pressed, and is very  hard and uneven  on  its surface.   The spermatic
cord is not in the least  affected.   October 20,1777, he was seized in
the same  manner  in the right testicle without any apparent cause,
whereupon  I  was applied to.  He  was immediately  bled, took an
opening mixture, after that a saline mixture, with tartar emetic; and
a fomentation and  embrocation of spiritus mindereri and spiritus vini
was used.   On the 27th,  a cataplasm was applied  of linseed meal and
aqua vegeto-mineralis.  This treatment was  persisted in till about the
middle of November.  The inflammation went off,  and the testicle
seemed much in the natural state.  On December 19,1  was applied to
again; it  seemed to  be growing hard and decreasing in size, much in
the  same  manner as the other  had  done, which made  him very
unhappy.   I ordered him some pills, with calomel and tartar emetic,
in hopes  of increasing the secretion of the glands in  general, and
making some change in  the testicle.  At first, this method seemed to
be of service, but  soon  lost its effects, and the testicle began to de-
crease just as the other did."   Mr. Adair and Mr. Pott were consulted
with me, but nothing could be thought of that could give any hopes
of success.  I advised him to employ the parts in their natural uses
as much as inclination led him; but all was to no purpose, the testicle
continued to decrease till not a vestige was left.
   Case III.: communicated by Dr. Cothom, of Worcester. "A young
man, aged sixteen, was suddenly seized with  great coldness and shiver-
ing, attended with  frequent rigors.  During this paroxysm, which con-
tinued three hours, his pulse was small and contracted, and so exceed-
ingly quick that the strokes of the artery were with difficulty counted.
This period was succeeded by an intense heat, and a strong, hard, full
pulse,  on  which account he was copiously bled; a dose of oooling
physic was immediately administered, and a  clyster  thrown up  to
promote  its more speedy effects.  In  the evening, the bleeding was
repeated.   All this  day he complained  of  excruciating pain in his
loins and the side of his belly, descending down into  the  scrotum. 
ATROPHY OF  THE TESTICLE.
267
On examining the part affected, I saw an appearance of inflammation
in the groin of the left side, and a great tension about the ring of the
abdominal muscles, with an enlargement of the testicles.   These parts
were now ordered to be fomented with a discutient fotus, strongly
impregnated with crude sal ammoniac, and to be bathed with spiritus
mindereri  and spiritus volat. aromat., before the application  of each
stupe; and he was directed to take six grains of the pulv. antimoni-
alis, with fifteen grains of nitre, every three hours; his food to be thin
gruel, with fruit  and lemon-juice,  and his drink barley-water, with
sugar and  nitre.  Notwithstanding this antiphlogistic plan of frequent
cooling physic, anodynes, three emetics, and thirteen bloodlettings, the
fever continued, and the  pain, inflammation, and tumor increased till
the eighth day, including the first day of  seizure, when, seeing  no
hope of  discussing the tumor, the testicle being nearly as large as a
child's head, I attempted, by  emollient fotuses  and maturating cata-
plasms, to bring it to suppuration.  On the 10th,  a fluctuation was
perceptible, and on the 12th, much more so, the scrotum having then
put on a livid appearance. I used every possible argument  for per-
mission  to open it, but he, being now quite easy, would not admit it.
On the 15th, the patient was again attacked with rigors, coldness, and
shivering,  succeeded by a great feverish heat, which soon terminated
in  a profuse sweat;  yet no  pain  attended  this paroxysm.  In the
evening, however, the tumor was so  prominent that I was of opinion
it would open spontaneously before morning, when I hoped to obtain
his consent to enlarge the aperture; but this not happening, and  all
entreaties relating to the necessity of an incision proving ineffectual,
I contented myself by giving  the bark with elixir of vitriol.  From
this time, after every paroxysm of fever, the testicle was observed to
decrease.  Not being permitted to make an incision, and his strength
and appetite continuing good, I began  to  entertain hopes of success
without  it, and advised him to persist in the use of the tonic and anti-
septic plan, with the addition of stupes wet with the decoction of bark,
to be constantly applied, by which means, at the end of thirty days
from the first seizure, the  pus was totally absorbed.   The testicle then
appeared to be of the size of a hen's egg, and was as hard as a scir-
rhus.  I directed it to be rubbed, night and morning, with equal parts
of  the unguent, mercur. fort, and  liniment, volat. camphorat., and
ordered,  internally, some mercurial alteratives, with a  decoction of
bark.  By these aids, his night-sweats, and every other disagreeable
symptom, gradually abated; he gathered  strength, flesh, and spirits
very fast,  and  the diseased testicle went on  constantly decreasing,
though very slowly, for near twelve months, at the expiration of which
time there was no other appearance of it than  a confusion  of  loose
fibres, obvious  to the feeling,  in  the upper part of the scrotum.
About a month ago, the  patient consented to my examining it.  Of
the testicle there was  not the  least vestige; neither  could I  perceive
the tunica  vaginalis on that side in the groin; but upon the os pubis,
and  a little under it, I could embrace with my finger and thumb the
cord, and distinguish the vessels, which were without the least degree
of hardness or scirrhosity; and if I pressed one in particular, I gave 
268
GONORRHOEAL OPHTHALMIA.
him exquisite pain for a moment.  He is in perfect health, of a strong,
robust constitution, and has fine,  healthy  children; the  only  change
which he has perceived  in the constitution has been a propensity to
grow fat, which neither temperance  nor violent exercise on horseback
daily,  with little rest, will prevent."1
   [Ricord.—Plastic syphilitic sarcocele, or albuginitis, a symptom of
tertiary  syphilis, which Hunter was not acquainted with, is also a fre-
quent cause of atrophy of the testicles.   It  may even be said that
atrophy is the fatal termination  of this affection when  art  does not
intervene in time.
   Varicocele  must  also be considered as a cause.  This affection was
formerly thought to be incurable,  or rather they did  not dare to treat
it; but,  at the present day, it is successfully treated by my operation
with' a subcutaneous ligature, which is now ranked among those scien-
tific operations, which are  the  most simple, the most inoffensive, and
the most certain in  their results.]
                      CHAPTER   XIV.

                  GONORRHEAL  OPHTHALMIA.

                             BT F. BICOBD.

   We see that Hunter says nothing of gonorrhceal ophthalmia, which,
however, is a very serious and not uncommon complication of urethral
gonorrhoea.

  1 Added: "Case.IV.  A gentleman had a stricture, for which he passed a bougie;
inflammation and  swelling came  upon one of  the testicles ; the inflammation was
removed, and the swelling subsided; the testicle continued to diminish till it was
extremely small.
  " Case V. A gentleman had received a hurt upon one of his testicles in riding; it
inflamed and swelled to a very great degree ;  the symptoms went off, and he con-
sidered himself well; it did not, however, remain of the natural size, but gradually
diminished till it entirely disappeared.
  " Case VI. A gentleman was lifted from the ground by the hands with a considera-
ble jerk; he felt immediately a violent pain in the groin of the left side, and an
inflammation and swelling came  upon the right testicle; when  this  subsided, the
testicle diminished to the size of a pea, and was very hard in its substance.
  " Case VII. A gentleman, eighteen years of age, had a swelling brought upon one of
his testicles by lying upon wet grass ; it afterwards continued to diminish till  it was
only one-fourth of the natural size.
  " Case VIII. A gentleman, twenty years of age, had been attacked at various times
in the preceding eight years with violent pain and swelling in the right testicle and
spermatic cord, which went entirely off, till two years ago  there was a more violent
seizure ; for eight hours  the pain was intolerable, and the swelling very  great;  it con-
fined him six weeks.  Since that time it has been diminishing in size and increasing
in hardness ; at present, it is as small as a horsebean, and the spermatic cord is con-
tracted.  The left testicle has occasionally swelled, but always recovered its usual
size.  During the time he was affected with this pain, he has felt at intervals a pain
about the neck of the bladder, especially when he made water, but not in any violent
degree ; he likewise frequently feels during these attacks a sensation like the circula-
tion of some fluid within the testicles."—Home. 
CAUSES.
269
  Gonorrhceal ophthalmia  appears under two distinct forms;  both of
which, careful observation forces us to admit, though each in turn has
been denied by oculists, who have been willing to admit only one, to
the exclusion of the other.
  I.  Gonorrhoeal ophthalmia .may be the consequence  of direct conta-
gion, that is to say, the result of the application to a sound eye of muco-
pus from a gonorrhoeal urethritis, or from  another eye affected with
gonorrhceal ophthalmia.  The contagious matter may be  conveyed
from  the urethra  of the patient himself to his  own eye, or from one
eye to the other; or, it may be furnished by the urethra  or  the eye
of another person.
  I have never seen this first form of gonorrhoeal ophthalmia—which
comes under the head of severe purulent ophthalmia—accompany or
follow balano-posthitis, vaginitis, or discharges from the uterus.  Lay-
ing aside the very rare cases, where it is  produced  by gonorrhoeal
muco-pus furnished by another person,  it always occurs in  connection
with urethral gonorrhoea.   It is also decidedly  more frequent in men
than  in women, which coincides with the much greater frequency of
urethral gonorrhoea in the former.
  Ophthalmia neonatorum would seem  to be an exception to this rule,
if it were not commonly due to other causes. However, it is  not im-
possible that while traversing the genital passages of the mother,  the
infant's eyes are soiled by irritating matter capable of inflaming them.
An able, but probably absent-minded professor has said that this is
impossible, because children are born  with their eyes shut I  This
might be believed if the eyelids were soldered together, and if, in  the
difficult journey which children have to take in coming into the world,
their' eyelids did not run the chance of being often separated, and their
eyes exposed.
   The origin of the urethritis makes no difference  in the ophthalmia.
I have seen very severe ophthalmias caused by gonorrhoeas which fol-
lowed connection with women during their courses, or  women  affected
simply with purulent  uterine catarrh; and also in cases, which  not
unfrequently occur, where nothing could be  found in the women to
explain the urethral discharge in the men.
  As soon as the urethral discharge becomes purulent, or mucopuru-
lent, and so long-as it continues in this state, it may affect the eyes.
  This form of gonorrhoeal ophthalmia  does not influence the urethral
discharge;  the latter does not stop to give place to the former, and if,
when the  conjunctivitis is most  intense,  the  discharge  sometimes
diminishes in quantity, it is either an effect of revulsion, or more gene-
rally occurs under the influence of other causes.
  Any of the ordinary causes of severe  purulent ophthalmia may com-
bine with the more special cause in producing this urethral ophthalmia,
as we may call  it.  These causes may even  act  alone  in a subject af-
fected with gonorrhceal urethritis, and produce a concomitant purulent
ophthalmia independent of the urethritis.  This will  explain how it
happens that, at certain periods, we  suddenly meet wifh  an increased
number of apparently gonorrhoeal ophthalmias, although the  number
of urethral gonorrhoeas continues the same. 
270             GONORRHEAL OPHTHALMIA.
  Daily observation in a large hospital and in an extended private
practice, does not allow me to admit that gonorrhceal ophthalmia may
ever be produced by exhalations from a urethral gonorrhoea, conveyed
by the air.
  The other morbid secretions, which are called venereal, have been
considered capable of causing gonorrhceal ophthalmia.   There is even
a celebrated case on record of an ophthalmia produced by the pus of a
bubo which was ejected into the eye of a surgeon as he was opening the
abscess.  But if pus from a bubo, a chancre, etc., can give rise to the
affection under consideration, ought we not to see more frequent in-
stances of it ?  Are patients,  who have ulcerated buboes, or freely
suppurating chancres, more careful or more cleanly than those who
have discharges from the urethra ?
  It is not true that gonorrhoeal ophthalmia is connected with gonor-
rhoeal cophosis, coryza, bronchitis, or gonorrhoea of the mouth; these
affections  have never been met with except in books.  Urethral gonor-
rhoea does not prevent a person from having coryza or bronchitis, but
it does not cause them. A person may also have catarrhal ophthalmia
at the same time that he has a gonorrhoea.
  That form of gonorrhceal ophthalmia, which may be considered the
result of contagion, generally affects  only  one eye.  Its  seat is in the
palpebral and  ocular conjunctiva.
  At first, the patient sometimes experiences a slight sensation of heat
and itching, as if he had a speck of dust or other foreign body in the
eye.  The eyelids are often stuck together with a  little  dried mucus,
forming a crust.  The  conjunctiva becomes injected and reddened over
more or less of its palpebral portion, especially on the lower  lid;  but
the redness and swellings which  soon  appear, extend  rapidly to' the
ocular conjunctiva, if the  disease did not commence there also at the
same time.  I have often detected this affection at its very commence-
ment, before the patients themselves  were  aware of its presence.
  In some cases, the inflammation is not  immediately followed by a
morbid secretion; but generally the latter appears with  great rapidity
and is  one of the first symptoms.   I  have seen patients  go to bed at
night, without having noticed anything the matter with their eyes, and
wake up  in the morning with a very decided discharge.  It consists
at first of muco-pus, which appears as strias in the oculo-palpebralfold;
a very abundant suppuration soon follows and frequently with great
rapidity.  The discharge may be clear, serous, white, yellowish or pale,
and rarely colorless.  It trickles down on the cheek, especially when
the eyelids are separated, and often excoriates the  skin with which it
comes in contact.  Generally, an almost pseudo-membranous portion,
more consistent than the rest, remains on  the eye or eyelids, and can-
not be detached except by a jet of water thrown upon the eye from a
small syringe.  The conjunctiva becomes more and more injected and
swollen throughout the whole  of its palpebral and ocular surfaces, and
even seems to be softened.  The sub-conj unctival cellular tissue becomes
infiltrated, and ftie ocular mucous membrane is thus raised in the form
of a ring around the transparent cornea, forming a serous or ©edema-
tous chemosis. On the eyelids, a swelling takes place in the  same 
SYMPTOMS.
271
manner, and often attains a considerable size.  The  superior lid espe-
cially is red, tense, shiny, and immovable;  its free border overlaps the
inferior lid, confines its lashes, and often brings them in contact with
the eye.  Sometimes the eyelids are everted, and acute  ectropion re-
sults, with strangulation of the mucous membrane by the  orbicularis
muscle.  M. Desmarres, in his excellent treatise on diseases of the eyes,
compares this strangulation  to what takes  place  in  prolapsus of the
rectum.  The mucous membrane often bleeds, or the discharge becomes
sanguinolent, sero-sanguinolent, or sanious.  Granulations  are also
developed, particularly on the palpebral conjunctiva;  they spring from
the mucous follicles as in other varieties of purulent  ophthalmia.  The
discharge then assumes greater consistency;  it becomes purulent, and
presents a greenish-yellow color.
   If the disease increase in intensity, true phlegmonous  inflammation
may succeed the  acute oedema of the eyelids.   The chemosis, which
was at first cedematous, may become bloody, and especially phlegmonous,
forming a kind of hard, fleshy ring, which constricts and destroys the
transparent cornea.
   The cornea may remain intact up to this time;  but in certain cases,
at the end of forty-eight hours, and sometimes later—within the course
of seven or eight days from the commencement of the  disease—this
membrane loses its  transparency, and a cloud is spread uniformly over
its surface; it soon swells and softens, and more or less general opacity
supervenes, owing  to purulent infiltration between its lamellas.  This
softening, which gives it a conical shape, is sometimes partial, and then
the  cornea is  not of the same width in  all  its diameters.  Small
abscesses follow sooner or later, which open, allowing pus to escape,
and are succeeded by ulcers which are often very large.  At other
times,  the cornea seems to be destroyed layer by  layer from before
backwards.   In cases of phlegmonous chemosis especially, an opaque,
yellowish circle is often seen, more or less distant from the circumfer-
ence of the cornea, in the midst of which there still exists a transpa-
rent spot, which soon becomes cloudy.   It is this circle which is often
followed by an unguicular ulcer.  But whether the cornea is perforated
by ulceration, or is mortified and detached in one piece, the aqueous
humor escapes with the crystalline lens, and the iris is protruded in the
form of a hernia.
   Finally, gonorrhoeal ophthalmia, after having attained  its maximum
severity, or when it is arrested at a less severe stage, may continue sta-
tionary or begin  to subside.  The discharge diminishes in quantity
and consistency, and  tends to become  serous as at first.  Cases are
sometimes  met with where the cornea, which has escaped the disease
and remained transparent up to this period, suddenly suppurates, when
the discharge has become almost serous  again.  Relapses also take
place in some  instances, and may recur many times and at various
intervals.
   Gonorrhoeal ophthalmia is attended with little pain at first; the pain
does not commence till the swelling of the parts is considerable,  and
phlegmonous chemosis or ulcerations of the cornea take place.  The
pain may extend to the forehead, to the temples, and sometimes to the 
272
GONORRHEAL  OPHTHALMIA.
 teeth;  in some cases it is a throbbing pain.  Photophobia may be
 absent, or appear only for a short time in some patients.  The contact
 of the  tears, which are augmented and rendered irritating, sometimes
 excites a severe burning pain, analogous to that which the urine pro-
 duces in an inflamed urethra.  Generally, there is no  constitutional
 reaction at the outset, nor does it supervene till the deeper tissues are
 involved, or the entire globe of the eye is inflamed.
   The course of gonorrhceal ophthalmia is very rapid; it may destroy
 the eye in a few hours.  It some cases it appears mild at first, contin-
 ues stationary for some days,  and then suddenly assumes a state of
 great severity.
   This severe ophthalmia may, however, terminate in resolution.  If
 the transparent cornea has not been too extensively involved, it may
 recover its normal state.  Opacities, varying in thickness and extent,
 disappear;  ulcerations, even  of large  size, often  cicatrize without
i leaving any trace behind them, or without greatly interfering with
 vision.  But when the cornea has been more deeply affected, it may
 present opacities, indelible cicatrices, staphyloma, adhesions, or hernia
 of the iris.  Finally, granulations—which are in some  instances fun-
 gous—may remain on the conjunctiva.
   There is no pathognomonic  diagnostic  sign of gonorrhceal ophthal-
 mia aside from the cause to which we believe it  should be attributed.
 In  the color of the  inflamed conjunctiva, which some complaisant
 authors have thought coppery;  in the nature and color of the discharge;
 in the intensity of the disease, and its ordinarily acute or sub-acute
 course, there is nothing characteristic which may not be found in other
 purulent ophthalmias.  The same is true  of buboes  behind the ears,
 which, up to the present -time, have been seen by M. Hairion alone.
   The prognosis is generally grave, and the more so, the later a physi-
 cian is called, and the more the cornea is involved.
   Treatment.—The treatment of gonorrhceal ophthalmia should be both
 local and general.
   We should commence with local treatment.  Of all remedies, that
 which  has succeeded best in my hands, is cauterization of the whole
 inflamed conjunctiva with nitrate of silver.   For this purpose, a crayon
 of nitrate of silver is cut perfectly smooth; the  eyelids are everted,
 the superior one first; the nitrate is passed over the mucous membrane
 so as to whiten its  surface, which is afterwards dried or washed with
 fresh water, so as not to leave  any bits of the caustic  to come in con-
 tact with the cornea; the eyelid  is replaced; the inferior lid is everted
 in turn, and is touched in the same way, and with the same precaution,
 as well as all  of the ocular conjunctiva  that can be reached; always
 sparing the cornea, which may be better protected  by being smeared
 with a little oil of sweet almonds.
   If there be any cedematous chemosis, it should first be excised. If
 it be phlegmonous, and curved scissors cannot remove it, it should be
 scarified, as Scarpa directed; this is one of the most important requi-
 sites in the treatment.
   Having done this, the eye should  be covered with fine and light
 compresses, soaked in a decoction of quince seeds and  poppy heads. 
TREATMENT.
273
But it is especially necessary to make injections or irrigations every
hour, or every half hour, and even oftener, when the suppuration is
very abundant, so as  not to let the pus  remain in the eye, which has
become in a measure an abscess, and requires incessant evacuation  to
prevent maceration of the cornea, and all the trouble which may result
from retention of the pus.
  I generally order frictions with extract of belladonna around  the
orbit and in the nostril of the affected side.
  The head should be kept elevated, and the eyes removed from  the
action of the light.
  The above is the most urgent part of the treatment. It is necessary
to cauterize repeatedly  on the same day, or else on following days, so
long as no favorable modification of the  disease is obtained;  but still,
other energetic means should be used at the same time.  Blood should
be  drawn from the arm once or oftener, according to the  strength of
the patient and the development  of the pulse, especially if  there  be
fever.1   Leeches  in large numbers should be applied over the course
of the jugular vein, and to the naso-labial fold.  Purgatives should be
administered, and saline  purgatives in  preference to calomel.   Foot-
baths, with the addition of coarse salt, or  warm applications to the feet,
should also be prescribed.
  When cauterization is no longer necessary, a  collyrium should  be
used, composed of a solution of a  grain  and a half of nitrate of silver
to an ounce of distilled water.  This collyrium  is to be injected  be-
tween the  lids three times a day, alternately  with the  sedative and
mucilaginous collyrium before mentioned, so long as the suppuration
continues, or the resolution is not  complete.
  At a later period, we may have  to repress granulations by cauteriz-
ing again with nitrate of silver, or with acid nitrate of mercury,  as M.
Thiry directs, in those  cases which resist the lapis infernalis.
  It is never necessary, and it may be dangerous to endeavor to excite
or  recall the urethral discharge; this is a purely theoretical and specu-
lative mode of treatment, which should  be rejected in sound practice.
  Copaiba, cubebs,  and  mercury, in  whatever way  employed,  are
always more injurious than useful.
  II. An ophthalmia sometimes occurs during the course  of urethral
gonorrhoea, which is not a consequence of contagion or the  application
of  gonorrhoeal matter to the eye,  as in  the form which I have just
described.

  1  The editor feels compelled to differ from M. Ricord with regard to the abstraction
of blood in gonorrhceal ophthalmia. Bleeding from the arm is rarely, if ever, justifia-
ble. It is of the utmost importance not to allow the strength of the patient to become
depressed, especially when ulceration of the cornea has already commenced ; and in
the great majority of cases, quinine in full doses, porter, and a generous diet, are called
for rather than general depletory measures. Nothing will so conduce to a loss of vision
as a weak and debilitated  condition of the system.
  Locally, leeches or cups  may be applied  at the external canthus at the outset of the
disease, and be repeated if necessary; but our chief reliance is to be placed in radiated
incisions of the chemosed conjunctiva, according  to Tyrrell's method, and, above all,
in frequent lotions, to insure the constant  removal of the pus as fast as it  is secreted,
and in the application, every few hours, of a solution of nitrate of silver, of the strength
of five to ten grains to the ounce of water.—Ed.
       18 
274             GONORRHEAL OPHTHALMIA.
  This is the metastatic ophthalmia pointed out  by Saint-Yves, and
the sympathetic ophthalmia of most oculists, who assert that gonorrhoea
of the eye is never the result of contagion.
  This form also appears in connection with urethral gonorrhoea alone,
during the course of the first week, oftener after the second week, or
later, and sometimes towards the decline of this affection.
  It is also more frequent in men than in women, for the reasons that
I have given.
  Young lymphatic subjects are most disposed to it.  The  ordinary
causes of catarrhal  ophthalmia help to  develop  it.  A rheumatic
diathesis, and the causes of rheumatism, also favor it, as they do
gonorrhceal  arthritis, with which it is often  associated.   I have seen
a large number of patients who, every time they had urethral gonor-
rhoea, had  also  gonorrhceal ophthalmia.  I attended a lawyer, who
had double ophthalmia three times after as many attacks of gonorrhoea,
which he contracted within the  space of two years.  I also had charge
of a rich American, living at Paris, who was very subject to attacks
of the gout, and every time that he caught a gonorrhcea, which he did
four times, he was seized with gonorrhoeal ophthalmia.
  This variety of gonorrhceal ophthalmia has been considered a result
of untimely treatment, and due to the sudden arrest or  repercussion
of a urethral gonorrhcea, by the too early administration of antiblen-
norrhagics.  This  is a serious  mistake; most  patients have received
nc treatment at all when their eyes become affected.  It  is very rare
for the discharge to stop previous to the appearance of the ophthalmia;
it generally  continues without modification; in some cases, however,
revulsion appears to take place, and perhaps a  little more frequently
than in ophthalmia by contagion.
  This form of gonorrhoeal ophthalmia,  which we  may consider  sym-
pathetic in its character, may affect one eye alone, but generally the
two eyes are seized at the same  time, or  successively.  It passes  from
one eye to the other, often returns to the eye first affected, passes again
to the second, and so on several times.
  This disease  generally commences  on the eyeball.  Not only the
conjunctival but also the sclerotic vessels are injected; the eye appears
more tense and more brilliant than natural;  the cornea often  projects
a little more than  usual, and  the  iris  is a little farther  off;  in  some
cases we may satisfy ourselves  that the  aqueous humor  is increased.
At  times there  are symptoms  of iritis, as a change of color in the
iris, contraction of the pupil, which is rarely distorted, and more  or
less photophobia.  The aqueous humor may be cloudy, lactescent, or
flaky, owing to inflammation of the membrane of Descemet;  and false
membranes  sometimes result, which  may give rise to adhesions  or
pseudo-cataracts; but pustules on the iris, or what have been called
condylomata of the  iris,  are never seen as in syphilitic iritis.  A
process takes place in the eye analogous to what we meet with in the
synovial membranes, in cases of gonorrhoeal arthritis, which, as I have
said, sometimes accompanies this ophthalmia, or alternates with it.
  The conjunctivitis is, however, almost always the main feature in 
GONORRHEAL RHEUMATISM.
275
the case; it is sometimes very acute, and often prevents our appreciat-
ing the other symptoms of which I have just spoken; it is perhaps
rather catarrhal than purulent, and has less Tendency to form granula-
tions than the first variety.
  Sympathetic  gonorrhoeal ophthalmia, other things  being equal, is
more  irregular in its course and more  subject to relapses than the
first form.  It often changes its seat, which does not occur in the first
form.
  But laying aside the differences which I have just mentioned, this
variety of gonorrhoeal ophthalmia may  present all the symptoms  of
ocular gonorrhoea from contagion; it may have the same course, occa-
sion the same ravages, produce the same consequences, and have the
same termination. The differential diagnosis  may therefore  present
great difficulty, and it is not surprising  that this form has been con-
founded with the preceding.   It remains to be ascertained from clearly
marked cases, if the discharge is equally contagious in the two forms.
   At any rate, those authors who admit, as I do, these two species of
gonorrhoeal ophthalmia, acknowledge that the latter, which is more
frequent than the former, is, other things  being equal, much less
severe.
  The treatment is the same as for the former species.  When the
catarrhal or purulent state is slightly marked, there is less need of,
and we may oftener omit cauterization than in ophthalmia by conta-
gion.   In this affection, especially when complicated with arthritis, the
administration of tincture of colchicum (from three-fourths of a drachm
to a drachm and a half a day), with nitrate of potassa (from a drachm
and a half to three drachms) in a decoction of borage, has given me
favorable results.  It is taken for granted  that this treatment should
be employed concurrently with the other  means on which  I have
already insisted, and without neglecting  the various indications which
may present themselves.—Ricord.
                    CHAPTER  XV.

                 GONORRHEAL RHEUMATISM.

                          BT P.  RICOBD.

  Hunter has not overlooked the articular rheumatism which may
appear during the course of gonorrhoea; but  he has  not insisted on
this  complication, nor considered it  as  a  frequent  consequence of
gonorrhcea.
  To Swediaur is due the credit of recognizing the connection between
the cause and the effect, between urethral gonorrhcea and the variety
of articular rheumatism which we are about to consider;  it is to this
author, in a word, that we are indebted for establishing the existence 
276             GONORRHEAL RHEUMATISM.
of gonorrhceal arthritis, gonorrhoeal rheumatism,  arthrocele, the go-
norrhceal tumor of the knee, or gonocele, as he called it.
  All authors, who have written on venereal diseases since Swddiaur,
have spoken of gonorrhceal rheumatism, and hence it is necessary for
us to supply Hunter's deficiency in this respect.
  We  are, indeed,  astonished, as Swddiaur was, that authors before
his time said nothing of gonorrhceal rheumatism, which is, nevertheless,
a not unfrequent complication of gonorrhceal  urethritis.  This must
probably be ascribed to the difficulty of distinguishing it  from common
rheumatism;  and to the fact that observers mistook it, when it super-
vened during the course of gonorrhoea, for a simple coincidence, as it
may, in fact, often be.
  However, if we seek for the true  connection between  gonorrhoea
and articular rheumatism,  we find patients, as Hunter did, who have
articular rheumatism  only when they have  urethral gonorrhcea, and
this, too, in many  cases independently of any appreciable cause  of
rheumatism.  As additional proof of the undoubted connection between
these two affections, we often find the sympathetic form of gonorrhoeal
ophthalmia, of which I have spoken,  coexisting or alternating with it.
  There exists,  then, a gonorrhoeal rheumatism, or, if you like  it
better,  gonorrhoea may be considered a special cause of rheumatism,
on which it impresses a certain stamp, a certain physiognomy, although
it  does not always subscribe its name.  Be that as it may, so-called
gonorrhceal rheumatism, like sympathetic ophthalmia, appears only in
connection with  urethral gonorrhoea.   The attempt recently made by
M. Jarjavay, to attribute it also to balano-posthitis, has not been suc-
cessful ; and, in  spite of aid from  the pen of  Dr. Foucard, urethritis
remains the sole master of this complication.
  Gonorrhceal arthritis is incomparably more frequent in men than  in
women, like  gonorrhoeal  ophthalmia, in  consequence  of  the  much
greater frequency of urethral gonorrhcea in the former.
  Gonorrhoeal arthritis has been attributed to the sudden suppression
of the discharge, either occurring accidentally or produced artificially
by the untimely use of the so-called antiblennorrhagics.  In this case,
it has been considered as the result of repercussion or metastasis. This
much abused idea is not only erroneous in  a  nosological point of view,
but is especially false and pernicious  as regards the prophylaxis and
therapeutics of gonorrhoeal rheumatism.
  I am now able to affirm that gonorrhoeal rheumatism, like  gonor-
rhceal  ophthalmia and epididymitis, occur, in  the great  majority of
cases, in individuals who have had no treatment at all, or who have
employed only  emollient  remedies,  and such  antiphlogistics  as are
used, as patients say, to make the discharge  easy.  Doubtless, in some
rarer  cases, rheumatism supervenes during the use of the resins  or
injections ; but then we should reasonably infer that these means have
not prevented the articular affection, instead of concluding that they
have produced it.   This is so true that, in  an  enormous  majority of
cases, I do not hesitate to say in nine-tenths, the discharge continues
unchanged when the arthritis supervenes.   Doubtless, in some cases,
the discharge may have diminished, or be  on the point of stopping, or 
GONORRHEAL RHEUMATISM.
277
even have  already stopped, spontaneously, or under  the influence of
art, when the articulations become affected; but what conclusion shall
we draw from these  rare  instances, if  not that gonorrhoeal arthritis
may occur  at any period of gonorrhoea, or that simple articular rheu-
matism may be mistaken for gonorrhoeal arthritis ?
   Rheumatic complications rarely occur during the course of the first
week of urethral gonorrhoea; the affection of the joints comes on later,
and often not until after weeks or months, and sometimes towards the
decline of  the urethritis,  as if the  assistance of other causes were
requisite for its production.
   Indeed, though urethral gonorrhoea may often be the sole and suffi-
cient cause of arthritis, every one who has investigated this subject
must have recognized the influence of accessory causes. In this respect,
we find that age has an influence as a predisposing cause, and that
young subjects are much more frequently affected, and that not merely
because they have gonorrhcea oftener than at a more advanced age.
   Sex appears to have no other influence than that which results from
the different degrees of facility in the two sexes for contracting urethral
gonorrhoea, which is requisite for  the  appearance  of  the  arthritis.
Hereditary predisposition, which is less marked in rheumatism than in
gout;  cold ; cold combined with moisture; chills during perspiration,
etc.; and, in fine, all the causes of ordinary inflammation of the joints,
may combine with urethral gonorrhoea, which is sometimes to be con-
sidered as  the last  blow of the whip, which sets the rheumatism in
motion.
   Gonorrhceal rheumatism generally appears  suddenly, and without
premonitory symptoms;  sometimes it is preceded by chills and fever,
or by vague, irregular, moving  pains,  which  only become located
afterwards.
   Gonorrhceal rheumatism  has  a predilection for the  femoro-tibial
articulation, as all observers admit.  Professor Cloquet used to think
that, though this was true of men, it was not so  in women;  and  that
the coxo-femoral articulation was found most frequently affected in
females.  I have often convinced myself that M. Cloquet was deceived.
But though the knee is most frequently affected, we must beware of
believing  that it is  rare for the other articulations  to  be  involved.
From the numerous  cases which have  passed under my observation,
both at the hospital and in my private practice, I have  been able to
satisfy myself that not  a  single articulation, great or small, escapes
this disease; and I have come to this conclusion, too, from cases where
I had the strongest reason to  refer the articular affection to urethritis.
To say, then, where articular rheumatism may have its seat, it would
be necessary to enumerate all the articulations, except, however, the
articulation of the heel, of which a certain syphilographer speaks, but
which anatomists have not yet described!  It is true that  Swddiaur
insisted on pain in the heel, but it is much rarer than he stated, and
than the modern author,  to whom I just  alluded, seems to believe.
Generally, the pain and swelling of this region are due to inflammation
of the tibio-tarsal joint.   The disease is sometimes situated in  the 
278
GONORRHEAL  RHEUMATISM.
synovial bursa of the tendo-Achillis, of which I have shown instances
at my clinique.
  I have also met with patients who had very severe  pains in the
plantar region, apparently seated in the fasciae.  There is an instance
of the kind in a young man  that I am  at present  attending in the
Maison de Sante, Rue Lourcine, who is also affected with double gonor-
rhceal ophthalmia of the sympathetic form, and with serous  iritis.
  Gonorrhceal arthritis more commonly affects only one joint, but it
also very frequently  attacks two or more at the same time, or success-
ively.   It may be said with truth, that in many cases several articula-
tions are painful, but that only one is really affected with arthritis, and
that  when  the disease  acquires a certain degree of development in
several joints, it continues a longer time, or  remains permanently in
one of them, when it is to give rise to other complications.
  Gonorrhceal arthritis excites pains, which are sometimes very sharp,
but which are rarely so excruciating as Swe'diaur described them; and,
all other things being equal, they are much less severe than those of
ordinary acute articular rheumatism.  The pain  impedes the motion
of the joint, or even renders it impossible; it is also increased on pres-
sure ; but, in the great  majority of cases, this is not to be compared
with what takes place in  inflammatory  arthritis of true  rheumatic
fever.
  The affected joint  swells sometimes to a large size; but if we seek
to explain this increase of volume, which often supervenes unexpect-
edly, we soon satisfy ourselves, by examining the knee, for example,
where the parts are  most exposed, that there is no swelling of the
articular extremities, nor of the ligaments of the articulation, nor of
the soft parts about the joint, but an effusion into the synovial cavity;
in short, a hydrarthrus.  Fortunately, no one  has  had occasion  to
examine the pathological anatomy of this affection in its first stage;
but the numerous cases which I have observed, and what most authors
say of the  frequency of synovial effusion, convince me that gonor-
rhoeal arthritis is at first a subacute hydrarthrus.   As I was just now
saying, it is in the  knee that we can best  determine the seat and
character of the  disease at its commencement: the  patella is raised
and elevated above the articular surface of the femur; the depressions
at its sides  disappear, and give place to swellings, in which fluctuation
is detected; the fluctuating freedom of motion of the patella, and the
shock impressed upon it when the tumor is percussed, so characteristic
of dropsy of the knee, are well marked. The synovial effusion is
found to exist when  the disease attacks other joints, and is recognized
with more or less facility according to the joint affected.
  Thus far, the articular swelling is generally unaccompanied by any
increase of heat in the part, and the skin  preserves  its normal color.
This state of things is so common, whatever some observers have as-
serted to the contrary, that we must  confess that Sw^diaur  was  right
in considering this affection, which he called a gonocele, as constituting
a white swelling; although  the English apply this term  to  all those
diseases which were formerly included  under  the  vulgar name of
while tumors.   This absence of redness and other external  characters 
GONORRHEAL RHEUMATISM.              279
of inflammation  is so common and so characteristic, that, when the
contrary occurs, we have  reason  to  inquire  if it  is, indeed, nothing
more than gonorrhoeal  arthritis  that we have  in hand.  However,
either in the natural course of the disease, or in consequence of other
predisposing causes, or from the development of complications, we find
the other constituent parts of the joint successively involved,  and
showing symptoms of inflammation, just as we have  inflammation of
the testicle following gonorrhoeal epididymitis.   In this case, swelling
and heat are superadded; and we may find the  small veins more or
less prominent and injected, as in  acute rheumatism.
   If articular  rheumatism progresses, extends,  and acquires a high
degree of intensity—if, in fine, it assumes an  inflammatory type, and,
so to speak, leaves its natural boundaries, the gonorrhoeal  discharge
may diminish  or dry up, by a true  process of revulsion;  but most
generally, as I have said, the morbid secretion from the urethra does
not change  in nature or in  quantity, especially  when the disease
remains within its true limits.
   Gonorrhoeal arthritis is generally apyretic; there is no premonitory
fever, no concomitant sympathetic fever.  Yet we sometimes meet
with  various degrees of febrile movement, rarely comparable, how-
ever, to that which occurs in true  rheumatic fever;  nothing, however,
so far as I know, can prevent the  latter from being developed during
the course of urethritis.
   I have already said that gonorrhoeal arthritis  is a subacute disease,
whose course, from the first, resembles chronic diseases of the joints,
but which may assume the type of the most acute  inflammations.1
   The duration  of simple  cases  of gonorrhceal rheumatism is from
three to six weeks; but it is not uncommon to see it prolonged  for
months, or, at least, to see the  synovial effusion remain a long time.
   In the great majority of cases,  gonorrhceal rheumatism  terminates
in resolution;  sometimes, as in other forms of rheumatism, it changes
from one joint to another, or alternates with ophthalmia. Suppuration,
the existence of  which in common acute rheumatism  has been called
in  question, is perhaps  less doubtful in  this variety; but it must be
confessed, that it does not appear  inherent in the disease; that it is an
exception, which seems to be due to the accessory  inflammation;  it is
as rare, or perhaps rarer, than suppuration of the  tunica vaginalis in
epididymitis, which is so often attended by the simple serous effusion
of hydrocele.  Doubtless gonorrhoeal arthritis may become, in certain
cases (but always owing to certain predispositions or certain complica-
tions), the starting-point of serious articular diseases,  and their conse-
quences ; but in that case, gonorrhoeal arthritis is not the only cause,

  1 In several instances, which were the most clearly marked  cases possible of gonor-
rhoeal rheumatism, I have found symptoms of endocarditis and of effusions into the
pericardium.  I have shown several remarkable examples of this kind at my clinique.
  During the course  of urethral gonorrhoea, and coexisting with arthritis, I have seen
symptoms of compression of the spinal marrow and of the brain, giving rise to paralysis
(paraplegia or hemiplegia), which seemed to follow the course of the articular effusion,
and be produced in the same way, and from their character I could not refer  them to
apoplexy, or ordinary meningitis. 
280
GONORRHEAL  RHEUMATISM.
any more than gonorrhoea  is the cause of cancerous or tubercular
sarcocele when the scrotal organs are involved.
  In  a diagnostic point of view, it has been asked  if gonorrhoeal
arthritis is an effect of the syphilitic virus, proceeding from virulent
gonorrhoea,  and identical with  chancre.  Some authors  have not
hesitated to  reply in the affirmative, and M.Beaumes, of Lyons, is half
inclined to this opinion;  but if there were no other symptoms to dis-
tinguish gonorrhcea from chancre, this  one would suffice to show that
they are perfectly distinct diseases.  Is there any one at the present
day who confounds, for a moment, secondary rheumatic pains, which
are situated in the neighborhood of the joints, which are intermittent,
nocturnal, and exasperated by heat; which  diminish or cease under
the influence of cold and motion, and  do not  increase but  generally
are entirely relieved by pressure; is there any one, I say,  who con-
founds this affection with the disease which I have just described?
Doubtless not, any more than any one could mistake them for tertiary
osteocopic pains, periostosis  and exostosis, unless blind adherence to a
system prevent his seeing the prominent features of the two affections.
Add to this  also the fact that urethral chancres never occasion arthritis,
unless they  are complicated with gonorrhcea.
  But is  gonorrhoeal arthritis due to a peculiar gonorrhoeal virus?
No ; for in  many, and even in most cases, I as well as others  have
seen the joints  become  affected in consequence  of gonorrhoeas con-
tracted under the most simple circumstances, as from uterine catarrh,
from the catamenial flux, and from the use of sounds or bougies; and
such cases are just as severe, or even more  severe, than those which
are most clearly due to a more special  cause.
  But can gonorrhceal arthritis be distinguished from common rheu-
matism ?  Without doubt, you may make the diagnosis of Swe*diaur's
gonocele, when during the course of urethral gonorrhcea, and without
other appreciable cause, an articular affection supervenes of a chronic
or subacute type;  affecting a single articulation, and the knee by pre-
ference ; attended by predominant hydrarthrus, with little or no fever,
heat and redness of the skin, and especially when the patients tell you
that they have such attacks only when they are affected with urethritis.
But in a very large number of cases, in the  absence or less decided
development of undoubted pathognomonic symptoms, it is impossible
to establish the difference, and to know whether you have a case of
gonorrhoeal arthritis, or of articular rheumatism, which is more or less
acute, more or less general, and simply a concomitant of the gonor-
rhoea.  The previous suppression of a gonorrhceal discharge which M.
Bonnet, of Lyons,1 and many other authors, have regarded as the most
certain proof of the nature of the disease, is  inadmissible, as I have
said before,  and would often lead to error.  Let me add, however, that
though the  differential diagnosis is often difficult or even impossible,
it is fortunately not necessary for treatment; for the latter is never
directed against the pretended specific  nature of the disease.
  When the arthritis appears to be solely dependent upon the gonor-
1 Treatise on Diseases of the Joints, Paris, 1845. 
GONORRHEAL  RHEUMATISM.              281
rhcea, and there exists no morbid lymphatic or scrofulous predisposition;
when there is no complication;  when, in fine, the disease is confined
to its natural  limits, the prognosis is not serious: it is an affection
which terminates  rapidly and favorably.  But when the contrary is
the case, the prognosis is drawn from the degree of severity of the
other articular affections which  complicate the gonorrhoeal arthritis,
and their gravity does not depend upon the coexisting gonorrhcea.
  The treatment of gonorrhoeal rheumatism presents  nothing special.
As in gonorrhceal ophthalmia, authors of the present day, who only
write books after long observation, reject entirely the useless and in-
jurious practice of recalling the discharge.
  When the disease is subacute, or assumes at the outset the type  of
chronic affections, I apply immediately a large camphorated blister  to
the affected joint.  This blister is afterwards dressed with opiated
cerate, and is renewed once, twice, or three times, according to the
effect produced. At the  same time that blisters are applied, the patient
should take every day from a drachm and a  half to four drachms of
nitrate of potassa, and three-fourths of a drachm to a drachm and a half
of tincture of colchicum, in a decoction of borage.  The affected joint
is kept perfectly quiet, and the diet is proportioned to  the severity of
the arthritis.  I have found this simple treatment to succeed the  best
and the most  frequently.   When  the  rheumatism assumes a more
decided inflammatory course, we should resort to sedative  and anti-
phlogistic treatment; as leeches to the joint, poultices with the addition
of laudanum, friction with ointments containing camphor or belladonna,
saline purgatives,  diluent drinks, and venesection if the pulse be full
and hard, or especially if there  be rheumatic fever.  But as soon as
the fever subsides, if the effusion remains, we must  place  our chief
reliance on blisters  again.  Mercurial frictions, iodide of potassium,
and all other means which are of use in ordinary diseases of the articu-
lations, may be employed here, though the preceding gonorrhoea is not
the chief indication for their use.  With regard to antiblennorrhagics,
copaiba, cubebs, etc., they have  no influence on  the  arthritis, except
that, by stopping the discharge, they remove a cause  which  might in-
duce a relapse.—Ricord. 
 
PAET   IV.
                      CHAPTER  I.

                         OF CHANCRE.

  I have been hitherto  speaking of the effects of this poison when
applied to a secreting surface, and without a cuticle; of the intention
of nature in producing these effects; and of all the consequences, both
real and supposed.  I now mean to explain its effects when applied to
a surface that is covered  with a common cuticle, as the common skin
of the body, which on such a surface will be found to be very different
from those I have been  describing.  But I  may be allowed  here to
remark that the  penis, the common seat  of a chancre, is, like every
part of the  body, liable to diseases of the ulcerative kind, and, from
some circumstances, rather more so than other parts;  for if attention
is not  paid to cleanliness, we have often excoriations, or  superficial
ulcers, from that cause;  also, like almost every other part that  has
been injured,  these  parts, when once they have suffered from  the
venereal disease, are  very liable to ulcerate anew.  Since, then,  this
part is not exempted from the common diseases of the body, and as
every disease in  this part is suspected to  be venereal, great attention
is to be paid in forming our judgment of ulcers here.
  Venereal ulcers commonly have one character, which, however, is
not entirely peculiar to them, for many sores that have no disposition
to heal (which is  the case with a chancre), have so far  the same char-
acter.  A chancre has commonly a thickened base, and although in
some the common inflammation spreads much farther, yet the specific
is confined  to this base.   The future or consequent ulcers are com-
monly easily distinguished from the original, or  venereal, which  will
be described hereafter.
  It is an invariable effect that, when any part of an animal is  irritated
to a certain degree, it inflames and forms matter, the intention of which
is to remove the irritating cause.  This process is easily effected when
it is on a surface whose  nature is to secrete;  but when on a surface
whose nature is not to secrete,  it then becomes more difficult,  for
another process must be set up, which is ulceration.  This is not only
the case in common irritations, but  also in specific irritations from
morbid poisons,  as the venereal disease and smallpox.   The variolous
matter, as well  as  the venereal, produces ulcers on  the  skin;  but 
284
CHANCRE.
when it affects  secreting surfaces, a diseased secretion is the conse-
quence; and this is different in different parts;  on the tongue, inside
of the mouth, uvula, and tonsils, the coagulable lymph is thrown  out
in form of sloughs, somewhat  similar  to the putrid sore throat;  but
in the fauces, and all down the oesophagus, a thickish fluid, in appear-
ance like matter, is secreted.  When the irritation is applied to a sur-
face whose cuticle is thin, and where there is a secretion naturally, as
the glans penis,  or inside of the prepuce, there it sometimes only irri-
tates, so as to produce a diseased secretion, as was described;  but this
is not always the effect of such irritation on such surfaces.  They are
often irritated to ulceration, and produce a chancre.
   The  poison has  in  general  either no disposition, or  not sufficient
powers to  blister  or  excoriate the common skin;  for if it  did, the
symptoms  most probably would be at  first nearly the  same, if  not
exactly so, with a gonorrhcea; that is, a discharge of matter from a
surface, without a cuticle, newly  inflamed; for it is reasonable to sup-
pose that the poison would produce on that excoriated surface a secre-
tion of matter, which  would be at first a gonorrhoea, and  which very
probably would afterwards fall  into  the second  mode of action, or
ulceration, and then become a chancre.
   There are  three ways in which chancres are produced; first, by the
poison  being inserted  into a wound; secondly, by being  applied to a
non-secreting surface;  and thirdly, by being  applied to a common
sore.   To whichever of these three different surfaces it is applied, the
pus produces its specific inflammation  and ulceration, attended with a
secretion of pus.  The matter produced in consequence of those dif-
ferent  modes of application is  of the  same nature with the matter
applied, because the irritations are the  same in both.
   The  poison much more readily contaminates if it is  applied to a
fresh wound than to an ulcer, in this resembling the inoculation of the
smallpox.  Whether there are any parts of the skin, or any other part
of the  body,  more susceptible of this irritation  than others, in conse-
quence of local  application, is not yet ascertained.
   This form of  the disease, like  the first, or gonorrhoea, is generally
caught on  the parts of generation, in consequence of a connection be-
tween  the sexes;  but  any part  of the body may be  affected by the
application of venereal matter, especially if the cuticle is thin.
   I have seen  a chancre on the prolabium as broad  as a sixpence
caught, the person did not know how.1   The penis, and particularly
the prepuce, being the parts most commonly affected by this form of
the disease,  are so constricted as to  suffer much  from it, especially
when they are very susceptible of such irritation; for the constriction
alone produces  many inconveniences, besides considerable pain, while
under  the  disease, and in general retards the cure.

   1 That this sore was a chancre I made no doubt; for, besides its diseased appearance,
he had a bubo forming in one of the glands under the lower jaw, on the same side.
   It is most probable that his own fingers were the conveyers.
   [These chancres  are very common, and are  generally produced otherwise than by
the contact of dirty fingers.  Their true nature has always been mistaken by Biett,
M. Cazenave, and others, who have confounded them with the secondary symptoms,
which appear on the lips.—Ricobd.] 
CHANCRE.
285
  The chancre is not so frequent an effect of the poison as the gonor-
rhoea, and I think very good reasons may be assigned for it, although
there are more modes than one of catching it, as I just now mentioned;
but the parts in two of them, to wit, the wound and the sore, are sel-
dom in the way of being infected;  therefore, when it is caught, it is
commonly by the same mode of  application with that  of the gonor-
rhoea; but as the cuticle cannot be affected by this poison, this covering
acting as  a guard  to the cutis, it is often prevented from coming in
contact  with  it; and, indeed, it is almost surprising  that  the cutis
should be affected by it where it has such a covering, excepting about
the glans, the inside of the prepuce,  or other parts of the body, where
this covering is thin.  The proportion which the cases of gonorrhcea
bear to  those of chancre is as four or five to one.
  When it is caught in men, it is generally upon the frasnum, glans
penis, prepuce, or upon the common skin of the body of the penis, and
sometimes on the forepart of the scrotum; but I think most frequently
on the frasnum, and in the angle between the penis and glans.   Its
affecting these parts arises from  the manner in which it is  caught,  and
not from any specific tendency  in these parts to catch it more  than
others;  and its affecting the frasnum, &c, more frequently than the
other parts of the penis, arises  from the external  form of  this part,
which is irregular, and allows  the venereal  matter to lie undisturbed
in the chinks, by which means  it  has time to irritate and inflame the
parts, and to produce suppurative and ulcerative inflammation in them.
But as this matter is easily rubbed off from prominent parts  by every-
thing that touches  them, it  is  a reason why such parts in general so
often escape this disease.
   The distance of time between its application and its effects upon the
part is uncertain; but, upon the whole, it is rather longer in appearing
than  the  gonorrhoea; however, this depends in some measure on the
nature of the parts affected.  If it be the frasnum,  or the  termination
of the prepuce into the glans, that is affected, the disease will in gene-
ral appear earlier, these parts being more easily affected than either
the glans, common skin  of the penis, or scrotum; for, in some cases,
where both the glans  and prepuce were contaminated from the same
application of the poison, it has appeared earlier on the prepuce.
   I have known cases where the chancres have appeared twenty-four
hours after the application of the matter, and others where it has been
seven weeks.  A remarkable case of this kind was in a gentleman
who  had not  touched a woman for seven weeks, when a chancre
appeared.  That this was a venereal  chancre was proved by his having
had the lues venerea from it, and being under a necessity of taking
mercury.   An officer in  the army had a chancre which appeared  two
months after he had  had any connection with a woman.  After the
last connection, he marched above a hundred miles, when the chancre
broke out, and only gave way to mercury.
   This, like most other inflammations which terminate in ulcers, begins
first with an  itching in the part; if it  is the glans that  is inflamed,
generally a small pimple appears full of matter, without  much hard-
ness or seeming inflammation,  and with very little tumefaction, the 
286                        CHANCRE.
                                           •
glans not being so readily tumefied from inflammation as many parts
are,  especially the prepuce; nor  are the  chancres attended with so
much pain or inconvenience as those on the prepuce; but if upon the
frasnum, and more especially the prepuce, an inflammation more con-
siderable than the former soon follows, or at least the  effects  of the
inflammation are more extensive and visible.  Those parts being com-
posed of very loose cellular membrane, afford a ready passage for the
extravasated juices, continued sympathy also more readily takes place
in them. The itching is gradually changed to pain; the surface of the
prepuce is in some cases excoriated, and afterwards ulcerates; in others,
a small pimple or abscess  appears, as on  the  glans, which forms an
ulcer.   A thickening of the part comes on, which, at first, and while
of the true venereal  kind, is  very circumscribed, not diffusing  itself
gradually and imperceptibly into the surrounding parts, but terminat-
ing rather abruptly.  Its base is hard, and the edges a  little prominent.
When it begins on the frasnum, or near it, that part is very commonly
wholly destroyed, or a hole is often ulcerated through it, which proves
rather inconvenient in  the  cure, and in general it had better, in such
cases, be divided at first.1
  If the venereal poison should be applied to the skin, where the cuti-
cle is more dense than that of the glans penis or frsenum, such as that
upon the body of the penis, or forepart of the scrotum (parts which
are very much exposed to the application of this matter), then it gene-
rally appears first in a pimple, which is commonly allowed  to  scab,
owing to its  being exposed  to evaporation.   The scab is generally
rubbed off or pushed off, and one larger than the first forms.  I think
there is less inflammation attending these last than those on the fras-
num and prepuce, but more than those upon the glans.
  When the disease is allowed to go on, so as to partake of the inflam-
mation peculiar to the  habit, it becomes, in many instances more dif-
fused, and is often carried so far as to produce disagreeable symptoms,
as phimosis, and sometimes paraphimosis, greatly retarding the cure;
but still there is a hardness peculiar to this poison, surrounding the
sores, especially those upon the prepuce.
  When these ulcers are forming, and after they are formed, or in the
state of inflammation, it is no uncommon thing for the urethra to sym-
pathize with them,  and give a tickling pain, especially in making
water; but  whether or not there is ever a discharge in the urethra from
such a cause I will not determine; but if a discharge never takes place
but when the  disease really attacks the urethra,  it would make us sup-
pose that this sympathy is not really inflammatory; or if it is carried
so far as to produce inflammation, yet that it is not of the specific kind.
However, it is possible, in those cases where there is a gonorrhoea pre-
ceded  by a chancre, that this gonorrhcea may arise  from  sympathy,
and  is  not a disease proceeding from the original contamination, nor

  1 Added: " The original excoriation or wound may heal, although contaminated,
and afterwards become a chancre.  A gentleman, in the act of  copulation, tore the
root of his prepuce all round, but in two days the whole healed ; but one part broke
out afterwards into a chancre, with a hard base, which readily yielded to mercury.
This is similar to what takes place in inoculation for the smallpox."—Home. 
CHANCRE.
287
 from the matter of the chancre.  That the sensation in the urethra, in
 those instances where there is no discharge, is from sympathy, and not
 from the urethra being attacked with the disease at the time that the
 matter laid the groundwork  for the chancre, is  evident from the fol-
 lowing observation: I have seen it happen more than once, when the
 seat of the chancre had broke out a second time, and where no new  or
 fresh infection had been caught, that the patient complained of the
 same tickling or slight pain  in the urethra before any discharge had
 taken place in the beginning  ulcerations.  From the same connection
 of parts, I have seen a chancre coming upon the glans absolutely cure
 both a gleet and  an irritation all along the passage of the urethra.  So
 great was the previous irritation, in this case, that I suspected a stric-
 ture ; but, on passing a bougie, found none.
   In consequence of the urethra sympathizing with the chancre, the
 testicles and scrotum will  farther sympathize  with  the urethra, and
 become affected.  I have seen this  sympathy extend  over the whole
 pubes, and so strong, that touching the hairs gently on the pubes has
 given disagreeable  sensations, and even pain.
   In speaking of the local, or immediate effects of the venereal dis-
 ease, I mentioned that they were seldom wholly specific, and that they
 partook both of the specific and the constitutional inflammation; and
 therefore  it is always very necessary to pay  some attention  to the
 manner in which chancres first appear, and also to their progress, for
 they often explain  the nature of  the constitution at the time.   If the
 inflammation  spreads fast, and considerably, it shows a constitution
 more disposed to inflammation than natural.  If the  pain is great, it
 shows a strong disposition to irritation.   It also sometimes happens
 that they  begin  very  early to form sloughs; when this is the case,
 they have a strong tendency to mortification.
   These additional symptoms mark  the  constitution and direct the
 future mode of treatment.
   When there is a  considerable loss of substance, either from slough-
 ing or ulceration, a profuse bleeding is no uncommon  circumstance,
 more especially if the ulcer is on the glans; for it would appear that
 the adhesive  inflammation  does not sufficiently  take place  there to
 unite the veins of the glans so as to  prevent their cavity from being
 exposed, and the  blood  is allowed to escape from what is called the
 corpus spongiosum  urethrse.   The ulcers  or sloughs often go as deep
 as the corpus cavernosum penis, where the same thing happens.
   [G. G. B.—In this chapter the author has delineated, with his usual
 sagacity and precision, the true characters of a primary venereal sore.
 At least, his description applies to a large majority of such cases.  It
 is  the more valuable as the  points of distinction are not drawn merely
 from obvious appearances,  which, though they  strike  the eye, are
scarcely communicable by language, but  from the laws which govern
 the effects of the  venereal virus, and the  operation of which may be
traced even where the appearances are dissimilar.
  Two consequences  follow the  application  of  the venereal virus,
induration and ulceration.   These two consequences  seem to be dis-
tinct and independent; since, though they generally exist in conjunc- 
288
CHANCRE.
tion, they  are  sometimes  found separate, one  or the other of them
being in some cases wanting.   The  induration,  though not always so
obvious as the  ulceration,  is on  the whole more constant, more cha-
racteristic, more peculiar and  distinct in its appearance.   The author
has therefore rightly  directed the  attention more especially to the
thickening as a distinction of  a primary venereal sore.
   The description given of this peculiar thickening by the author can
scarcely be improved.   It  is " very  circumscribed, not diffusing itself
gradually and imperceptibly into the surrounding parts, but terminat-
ing rather abruptly."  It retains these characters through all its stages,
though they may be sometimes partially obscured by other concomitant
circumstances.
   The thickening in general precedes the ulceration.   The first effect
of venereal contamination is  to  produce this peculiar change in the
texture of the  part; the second  effect is to produce ulceration of the
indurated  portion.  The character  of  primary venereal  infection is
essentially induration  passing afterwards into ulceration.  In the ear-
liest stage of the existence of  a chancre, this sequence is least discern-
ible, there being frequently at that period superficial and incipient
ulceration with very little  apparent  thickening.   But  in the progress
of the disorder the two stages become in general very clearly distin-
guishable.  If the sore be watched, it will be found that the thickening
becomes daily more distinct and extensive, till  the ulcer assumes the
true venereal  appearance  of  a  sore situated on  an  indurated  base.
The induration everywhere encompasses the ulcer, being both beneath
it and around it, forming as it were the bed of the  sore, and at the
same time encircling its margin, so as to connect it everywhere with
the sound parts in the vicinity.   In  fact, it  marks the part most
recently contaminated, which  has not yet  passed into  ulceration.  In
the progress of the case, the induration spreads first, so that no parts
are involved in the ulcer until they have  previously  passed through
this  change of texture.  A primary venereal  sore  is scarcely ever
stationary.  The ulcer itself may be stationary; but careful observa-
tion will detect a gradual increase of the thickened base, which proves,
no less certainly than the enlargement of the ulceration itself, that the
virus is steadily extending.
  These observations will  explain> certain occasional variations in the
aspect of venereal  sores, which, though  sufficiently intelligible when
closely examined, are exceedingly perplexing to those who form their
diagnosis merely from the  obvious appearances.
  It is not very uncommon that a primary venereal sore should assume
the following characters.  A portion of the prepuce, of about the size
of a silver penny, shall become slightly  thickened  so as to lose its
natural flexibility;  and  perhaps the surface shall be  slightly excori-
ated. _ In the course of a few days, if the  part is kept very clean, the
excoriation shall in many cases disappear, but the hardness shall pro-
gressively  increase, assuming  a  more defined  character,  and  at last
forming a large flat mass of the size of half a crown, so inflexible and
rigid that the prepuce cannot  be everted without difficulty.   There
shall be no tenderness, no  inflammation, sometimes no ulceration at 
CHANCRE.
289
 all, at other times only a slight dark-colored excoriation of the surface.
 Yet the  case shall  be venereal.  If the  usual  anti-venereal  remedies
 are not employed, all doubts on this subject shall be removed at  the
 end of eight or  ten weeks by the  appearance of  distinct secondary
 symptoms.
   In this case, the  aspect of the part bears no obvious resemblance to
 that of a common chancre; yet the difference is more apparent than
 real.  The  venereal virus produces the usual induration;  but, from
 the slowness of its progress and  the absence of inflammation, the in-
 durated  portion does not pass into ulceration.   With this single excep-
 tion, the course  of the disease is the same as that of an  ordinary
 chancre. The increase of the hardness is progressive, until mercury
 is employed.  As soon as the constitution is affected by the remedy,
 the thickened mass begins to diminish in size, and it  gradually dis-
 appears  from the circumference to the centre, exactly like the indura-
 tion left by a chancre.   As a still farther proof  of the identity of
 the  diseases, it may be stated that, notwithstanding the absence of
 ulceration, the contiguous surface is often similarly affected.  A similar
 induration will be  produced in the  part of the glans with which  the
 original  tumor  is  in contact, or on the opposite nympha when this
 affection is situated on the nympha in the female.
   Again, the deviation  from the  usual course may be of an opposite
 kind.  The ulceration may be so rapid as to overtake the induration,
 and to destroy it as  quickly as  it  is formed. Sores are frequently
 seen, especially on  the external prepuce, which spread rapidly, some-
 times  by sloughing and  sometimes by  ulceration, with profuse dis-
 charge and some  surrounding inflammation,  but with little or  no
 characteristic hardness.  But the absence of this distinctive character
 of venereal sores  is  only accidental, and is occasioned by the rapid
 progress of the ulcer; for if the extension of the sore be checked by
 local means, which may often be effected, the surrounding induration
 shall appear, and shall  become daily more palpable, until  its farther
 progress is stopped by such remedies as  act directly on the virus, and
 thus remove the  cause from which it arises.
   It is evident that these occasional variations do not affect the truth
 of the general position,  that the natural result of venereal infection is
 induration passing into ulceration.  But in the practical application of
 this principle as  a criterion of the real nature of a sore, some circum-
 stances  must  be taken into the account,  which  often modify the
 appearances and perplex the diagnosis.
   The true venereal induration  is  "circumscribed, and terminates
 abruptly."  But when much inflammation is  present, these characters
 will not  be discernible.  The specific thickening will be confounded
 in the general thickening from inflammation, and will not be distin-
 guishable from that which may attend an  ordinary sore.  Its  existence
 cannot be distinctly and indubitably ascertained till the general  in-
 flammation is removed or palliated;  and then, when the surrounding
 lymph is absorbed, there will still remain at the seat of the sore a
 hardened base  and a hardened circumference,  having a well-defined,
abrupt margin.
       19 
290
CHANCRE.
  Sores that are ill-conditioned may produce surrounding thickening,
although free from all specific virus.  If the surface is sloughy, the
base may be indurated.  In such cases, it is sometimes impossible to
say at once with certainty whether the thickening is to be ascribed to
the presence of the venereal virus, or is the mere consequence of the
ill-conditioned state of the sore.  The opinion should generally be
suspended, and local means should  be used for the removal  of the
slough.   When this is  effected, in common sores, the hardness which
was produced  by the irritation will disappear also; in venereal sores,
notwithstanding a similar change of the surface has been produced,
the induration will nevertheless  remain and continue to spread, and
ultimately the sore will again become foul and perhaps sloughy.
  It is evident, therefore, that the distinction is to be drawn less from
the appearance of the sore at any one moment than from its course
and  progress.   Many circumstances may at one time confuse  the
appearance, and may deceive the surgeon; but it is scarcely possible
that he can err if he watches the progress of the case, and uses means
to obviate the  causes of error.   If the sore be venereal, he will be  able
to detect  the changes which mark the contamination, viz., first, indu-
ration ;  and secondly, ulceration.
  It is not meant that the other characters of venereal sores are to be
disregarded  in forming the diagnosis.  The bright red areola which
encircles them, the mode of extension which is equally in all direc-
tions, the disposition of the discharge from them to produce similar
sores on the surfaces with which it is  allowed to come in contact—
these all  form important distinctions, and  should by  no means be
overlooked.   But  it often happens that these tests cannot be applied.
The red areola is  often obscured by surrounding inflammation, and
altogether undistinguishable.  Sores which are  not  venereal often
spread regularly and evenly from a centre.  Where attention is paid
to cleanliness,  and the discharge is  not allowed to collect, no other
sores will be  produced, and the original chancre will  remain single.
The  character  and course of the induration form  on the whole  that
criterion which is most certain and most generally observable.
  But it must not be forgotten that there  is a class of  venereal sores
to which the above description does not apply.  In the sores usually
called phagedenic, the progress of the  ulcer is not preceded  by the
venereal induration, nor is  such induration  left  after it  is cicatrized.
The other points of discrimination fail also.  The  extension is irregu-
lar, one edge generally spreading while another is healing; and  the
discharge does not infect the parts on which it is suffered to rest. Yet,
undoubtedly, these sores are the consequence of impure connection,
and are followed by secondary symptoms; and it is therefore difficult
to deny their venereal origin, though the laws which they observe are
very  different from those  which regulate the course  of a  common
chancre.   They are comparatively rare.  The description of the author
is applicable to forty-nine cases out of fifty; and its practical value is
scarcely diminished by the occasional occurrence of phagedenic sores,
which may be readily  known by  the characters which peculiarly 
CHANCRE.
291
belong to them, and  of  which a more particular description will be
given hereafter.—G. G. B.]
  [Ricord.—A chancre is to syphilis what the bite of a mad dog is to
hydrophobia.  There can be  no constitutional syphilis without this
primary ulcer, except through hereditary transmission.
  This proposition, it is seen, is contrary to Hunter's doctrine, and to
the opinions of those  who have followed the  same track.   I will not
repeat the incontestable proof, which  I have given elsewhere, that
gonorrhcea and chancre are two distinct diseases, both in their cause
and their effects.   What  I am  to establish here is, that it is not true
that chancres are limited  to non-secreting surfaces, nor that the moment
the syphilitic virus acts on a mucous membrane, its  power of produc-
ing this ulcer is lost.  Careful  observation shows that certain accessory
conditions are requisite for the deposited virus to produce its specific
effect, and that these conditions are most readily met with on the skin
and those mucous membranes, whose texture  resembles  the cutis.
But though they are more rarely found on true  mucous membranes,
they nevertheless exist there in some cases; so that a syphilitic ulcer
may be developed on any part of the  body, which can be directly
subjected  to  contagious  influences.  Hence,  we meet with chancres,
not only on all parts of the skin, without any exception, but also on
the mucous  membrane of the lower part of the rectum, throughout
the whole extent  of the vagina, on the  neck of the uterus, even in
the cavity of this organ,  in the male and female urethra at different
depths, in the cavity of the mouth, on the free margin of the lips, on
their internal surface, on the internal surface of the cheeks, on the
tongue, on the posterior and superior walls of  the pharynx, and finally
on the palpebral and  ocular mucous  membranes.  In all the parts I
have just  mentioned, I have found regular chancres either in the living
or  dead subject; and authentic observations of such cases, collected
at my clinique, have been published in my Traite Pratique des Mala-
dies Veneriennes, and plates of  them are given in my Iconographie de
VHdpital des  Vineriens.
  For the syphilitic virus to act, it must be introduced under the epi-
dermis or epithelium; it must find its  way into  an  open follicle;  be
applied to a denuded  or  excoriated surface;  enter  some solution of
continuity; and in this way reach the cellular tissue, the  lymphatic
vessels, or ganglia. But to  infect any of these parts, the contagious
pus must be left a certain time in contact with them, without undergoing
alteration. The virus has generally no effect on tissues  protected by
a sound epidermis, or sound epithelium; but  Hunter, perhaps, carried
his confidence on this point too far; for though  contagious pus may
remain a long time on sound  skin without affecting it, yet it often
happens that it finally irritates it and excoriates it, as all acrid morbid
secretions do, when spread over the cutis; and these excoriations, at
first simple, may give place to true inoculations and  successive chan-
cres, such as  are observed every day in patients who at first had  only
one.  Contagious matter may also be  deposited without effect upon
any surface, whether of skin or mucous  membrane, which is constantly
bathed by a normal or morbid secretion, because it  cannot reach the 
292
CHANCRE.
surface through the secretion which covers and protects it, or because
it is changed in its character, or washed away by this secretion.   Place
any part of the skin, or of the accessible mucous membranes, in such
a physical condition that the virulent pus may penetrate within  it,
and remain there without undergoing alteration, and you will find no
more privileged idiosyncrasies, such as some persons believe to exist,
nor any invulnerable regions or tissues.  The frasnum, the free portion
of the prepuce, and that part of its internal layer which extends upon
the base  of the  glans, are more frequently affected with chancres,
because these  regions  are most readily scratched  or  torn in  sexual
intercourse.  The same is true of the fourchette  and the neighbor-
hood of the carunculas  myrtiformes in women; and in both sexes, it is
true of those parts of the anus which are cut by the median line, and
more  particularly of the anterior portion of this  orifice  behind the
raphe".
  If Hunter had more carefully traced effects to their causes  in the
production of  chancres, he would  have found, as I have, that in most
women who communicate gonorrhoeas to men, nothing can be found,
except a discharge, or that even this is wanting;  and that when such
women have chancres  alone, the  gonorrhceal discharges in the men
either proceed from urethral chancres, or are the product of simple
catarrhal inflammation, such as we know may be excited by pus from
a chancre.  If gonorrhoea were  a specific effect of the virus which
produces chancres, it would be as rare  as it is common; for, without
disrespect to  Hunter's memory, gonorrhceal  discharges constitute a
larger  proportion of venereal diseases  than he stated.  The large
number of gonorrhoeas is easily explained when we consider that all
the causes of catarrhal inflammation may produce them, and that there
is no reason why they may not be developed spontaneously!   Moreover,
in men of the world, who examine and take care of themselves, gonor-
rhoea is considerably more common than chancres; and the latter are
found only in  slightly increased numbers in the inferior classes, who
are less careful and less cleanly.   Who can tell the number of gonor-
rhoeas contracted in unsuspected connections, or in connections which
ought not to be suspected; gonorrhoeas which are then  said to be mild,
and a mere over-excitement or irritation ?  But, with regard to chan-
cres, is there any one who would  consider them simple ulcers  merely
from the fact that he has no reason  to suspect the good  faith of her
from whom he caught  them ?
   I have proved, beyond a doubt, that virulent pus always acts in the
same manner,  wherever the primary ulcer is situated from which it was
derived; that sexual intercourse is not necessary for it to  produce  its
specific effect; and that there is no necessity for it to  be recently
secreted and still warm.   In fact, chancres, wherever situated,  furnish
specific and contagious pus; the results of artificial inoculation are
more certain than the effects of ordinary contagion; and virulent pus,
which has been preserved a long  time in tubes, may be inoculated like
vaccine virus.
   I have demonstrated, experimentally, that the formation of a chancre
is not preceded by a period of incubation;  and that  the moment the 
CHANCRE.
293
specific virus is placed in contact with the tissues in such a manner
that infection is possible, a process is set up, which goes on incessantly,
though with various degrees of regularity and  rapidity in different
cases, until it produces a perfect ulcer.
  But since careful experiment does not allow us to admit a period of
incubation, understood literally, for primary ulcers,  we must  also, of
necessity, deny any relative periods of incubation inherent in  the dif-
ferent tissues.  Only there are parts of the  body, which, from their
organization, or from accessory causes, take on a morbid state  more
readily than others; and in which, for example, inflammation, ulcera-
tion, and suppuration progress more rapidly than elsewhere,  though
this difference in the rapidity with which the disease runs through its
phases cannot be referred, as Hunter asserts, to different periods of in-
cubation.
   The apparently late appearance of some chancres  is explained not
only by the fact that their  evolution is slower in some individuals and
on some tissues, but also by various circumstances which  come under
our observation every day.   Thus, many patients do not perceive the
existence of a chancre until it has  already  acquired  a considerable
size, or has become painful;  the  chancres which others discover are
successive chancres, which appear at various intervals after the primary
infection and the development of the  first ulcer, as  results of subse-
quent inoculations by pus, which was furnished by  the latter, and
which waited for that condition of the neighboring parts, of which I
have spoken above, before acting.
   In the same way chancres may be produced by a  secretion  resem-
bling a gonorrhoea, but furnished by a neighboring mucous membrane
affected with deep-seated chancres, which sometimes excite a discharge
subsequent to their development.  If we  recollect that virulent pus
may be separated for  a long time from the ulcer  which  produced it,
without losing its contagious property, and that it may remain on the
tissues  without  effect until  they  open a  door to it, we  shall easily
account  for those chancres which Hunter saw, and which  appeared'
seven weeks after connection, and for the gonorrhoeas which preceded
or followed them.
  At any  rate, it is  allowable to say, contrary to what  Hunter ad-
vances, that a chancre appears sooner after the application of the virus
than true gonorrhoea does after the various causes to  which it may be
due.
  But, for a proper appreciation of chancres, there are some important
distinctions, which I think  it desirable to mention in this place.
  A chancre has no premonitory symptoms;  the  sensation of  itching
is not constant; it belongs  rather to other diseases, and especially to
herpetic and eczematous  eruptions, which  are so  common  on the
genital organs, and which so often lead to mistakes.  When  itching
occurs, it accompanies rather than precedes the first appearance of the
chancre.
  A chancre  does not always commence  in the same way.  If the
virulent pus is introduced beneath the epidermis or epithelium, it pro- 
294
CHANCRE.
duces a pustule j1 if it penetrates into the cellular tissue, into a lym-
phatic vessel, or ganglion, it causes inflammation and an abscess;  but
if, as most commonly occurs, the virus is applied to a denuded surface,
a chancre is produced at the outset.  Yet, whatever the first form  and
seat of a chancre may be, its  subsequent course presents variations
which it is very necessary to know, if you would avoid mistakes.  In
this respect, chancres should be divided into regular and irregular;
the former are those whose course is not  influenced  by any  local or
constitutional complications;  whilst the latter undergo important
modifications, under the influence of different causes independent of
the virus.
  Chancres of all varieties have two periods, one  of which  may be
called the specific  or  progressive  period,  the  other the reparative
period. The first commences the moment the virus acts, and continues
so long as the ulceration, which may extend or remain stationary, fur-
nishes inoculable pus;  whilst the second  is set  up when the specific
ulcer passes into the state of a simple ulcer, ceases to furnish conta-
gious pus, and advances towards cicatrization.
  A regular chancre,  situated on the skin or mucous  membranes, con-
sists  of an  ulceration  of small  size,  generally  involving the whole
thickness of the integument, and stopping at the subcutaneous or sub-
mucous cellular tissue, which  serves as its base.  The form of  a
chancre is generally circular, but  it  may  undergo  many variations.
When all points of the ulcer do not rest on homogeneous  tissues, as
happens when one part is situated  on the internal surface of the base
of  the prepuce,  and the rest on the corona glandis, it  is no longer  per-
fectly round.  The same is true in cases  where  the chancre is formed
in a previous solution of continuity of determined form, as in fissures
of  the prepuce,  of the fourchette, anus, etc., and where it is developed
in folds and depressions of the surface, which allow  the neighboring
parts  to  come  in contact.  Several  chancres,  by overlapping  each
other, may apparently lose  their circular form.  The base of a chancre
is not always the seat of a decided and clearly marked thickening and
engorgement, as Hunter's statement, and especially Mr. Babington's,
would lead one to believe.   There  are many  regular chancres whose
base does not differ at all from the neighboring parts.  The floor  of a
chancre is generally buffy, grayish, furrowed, and  uneven;  its edges,
cut perpendicularly, more  or  less serrated, and presenting  the same
aspect as the base, are generally  undermined and  slightly everted,
which gives the ulcer rather an  infundibuliform  shape; finally, the
circumference of a chancre may be surrounded with a reddish areola
of a more or less dusky and dark  color, in proportion to the  intensity
of the inflammation of the surrounding parts, and especially in  pro-

  1 It is ourious to see M. Gibert, who denies the pustular development of chancres,
thus  express himself in his Manual of Diseases  of the  Skin: " Inoculation of the
venereal virus, with a lancet, is followed by a pustule, which is succeeded by an ulcer
having all the characters of a chancre."
  It seems to me that, having once admitted this point, my learned confrere might
have allowed that, in sexual or other intercourse, an analogous state of things might
exist to that produced by the lancet; that is to say, that the pus might be insinuated
 under the epidermis or epithelium. 
                            CHANCRE.                        295

portion to the extent that the edges are affected and undermined.
The pus secreted by chancres at this  period  is inconsistent, ichorous,
and loaded with detritus of the tissues or of  the blood; and, unless it
is mixed with other normal or morbid secretions, it is alkaline and
often contains animalcules.  It continues fluid in those parts which
are removed from the action of the air, as on most mucous membranes,
but dries and forms crusts on almost all parts of the skin.  It is quite
abundant in some regions, as on the  glans, prepuce, vulva, anus, etc.,
and if it remain on the part, it soon  acquires  odor;  whilst  in other
places, it is less abundant and  thicker, especially in the cavity of the
mouth, where the saliva constantly washes  away that portion of it
which does not adhere to the ulceration.
   The duration of the specific period of a chancre cannot be limited;
but in the case of a regular chancre it may terminate in from two to
four  weeks, rarely sooner, and  often later.  Then,  the  reparative
period  is announced by the disappearance of the areola, if such  ex-
isted ;  by the  subsidence of its edges, whose margin  assumes a pale
grayish color, as they become  adherent again and  incline towards the
floor of the ulcer, upon which they soon throw out concentric circles
of cicatrization ;  the floor of the chancre  becomes clean and covered
with healthy granulations, whilst the  base is  absorbed  and disappears.
   A regular chancre is generally a mere local affection, and may pass
through these different phases and terminate  in a perfect cure, without
any assistance from art.
   But a chancre may deviate from its typical course, both in its pro-
gressive and  reparative period,  and present  varieties, which, from
being  imperfectly studied or understood, have appeared to some  ob-
servers to be entirely different affections.
   Thus, a chancre is sometimes entirely superficial, and is masked by
surrounding catarrhal inflammation, as  in  some cases of  ulcerous
balanitis and  balano-posthitis, urethral and  vaginal  gonorrhcea,  etc.
But the three most important varieties of chancre are:   1. Indurated
chancres; 2. Diphtheritic or pultaceous phagedenic chancres, and 3.
Gangrenous phagedenic chancres from excess of inflammation.
   First Variety;  Indurated Chancres.—In this variety,  the base of the
chancre becomes thickened and indurated, as  was first observed by
Jean de Vigo, and as Hunter has well described it.   This induration
is  generally clearly circumscribed, and, as Bell says, is not unlike half
of a pea placed beneath the ulceration.  When the induration is situ-
ated in lax cellular tissue, which yields equally in every direction, it
is  perfectly circular; but if it meets with tissues which are at all dense,
or if it is compressed by the surrounding parts, it changes its form and
may become elliptical or shaped like a crest,  of which we see frequent
instances  in the furrow at the base of the glans.  In all cases, the
induration covers a larger  surface than the  ulceration above  it, and
when it raises the latter  above the  level of the surrounding parts, it
gives rise to a variety of chancre called ulcus elevalum.  The specific
induration of a chancre gives to the touch a peculiar and characteristic •
elastic feel, which is easily recognized when  once felt,  and  which can
rarely be  mistaken for hard oedematous or inodular tissue; the two 
296
CHANCRE.
states which resemble it the most.  This induration never, in any case,
precedes the chancre, as Mr. Babington says it does;  nay,  more, it
rarely supervenes till the fifth day after infection, or later.  Observers
have  been deceived on this  point  in several ways; thus, infection
sometimes takes place in a follicle, whose orifice closes or bears merely
a minute ulceration, so  that nothing is discovered  till the induration
supervenes;  again,  the virus may act in the cellular  tissue, in a
lymphatic vessel, or ganglion, after the ulcer or solution of continuity,
which served as its door of entrance, has cicatrized;  and in this case, as
I have elsewhere said, an indurated shell or callous cyst forms around
the infected point;  finally, new ulcerations sometimes  supervene on
indurations remaining after the cicatrization of previous chancres.
  In  many cases, the induration of the  base and  edges  of the ulcer
seems to limit its extent; but it sometimes happens that the  chancre
extends in consequence of excessive induration, and especially in con-
sequence  of  the  rapidity with which the latter takes place.  The
tissues, which are in this case involved in a kind of plastic apoplexy,
are rapidly destroyed; the circulation  is impeded  or completely sus-
pended, by  obliteration of  the vessels, and  gangrene  supervenes.
Mortification commences here in  the centre of the indurated parts;
it is, so to speak, molecular mortification, and never occasions extended
eschars, except in another variety, which we shall  consider hereafter.
  The induration almost always occupies  the  base of  the ulcer, and
involves its edges, which are no longer undermined;  and these, from
their outline, may give the chancre various forms, of which it has been
attempted to  make varieties, such as the fluted chancre, &c.  In some
rarer cases, the edges are the only seat of  the induration, and conse-
quently a ring is formed, which Wallace designated as primary  aunular
syphilis.  But in all these varieties, an indurated chancre is generally
indolent, has little tendency to become complicated by inflammation,
and suppurates very little.
  Common inflammation often masks the specific induration,  so as to
deceive you,  and make you think that inflammatory and phagedenic
chancres may be followed  by constitutional infection, like indurated
chancres.   I  have myself committed this error, which  is easily made
when the  patients are not observed at the  outset of the disease; and
I have detailed several instances of it in my Iconographie de VHopital
des Veneriens.  But, in these cases, induration precedes the inflamma-
tion and phagedena; for, when there has  been no induration,  there is
no constitutional infection.   Moreover, when a chancre  becomes indu-
rated, or is to be followed by infection of the system, whether the in-
duration be strongly or feebly marked, it is inevitably  attended with
engorgement of the neighboring lymphatic ganglia in anatomical con-
nection with  it.  The ganglia in this case, do not acquire a large size;
they generally remain indolent, and never suppurate, or at least never
specifically.
  Acetate of lead, chromate of potash, corrosive sublimate, nitric acid,
nitrate  of silver, &c, may, for a time, produce artificial  indurations,
which sometimes counterfeit specific indurations to perfection; but the
symptomatic swelling of the glands is in that case wanting, as also 
CHANCRE.
297
constitutional symptoms at a later period.  These artificial indurations
are also of much shorter duration than specific induration, unless they
are kept up by a continuance of the causes which produced them.
  The specific induration of a chancre is formed of fibro-plastic tissue,
as has been shown in England by my friend  and pupil, Mr. William
Acton, and in France by M. Marchal (de Calvi), and by my learned
friend, the skilful microscopist, M. Lebert.
  Second Variety; Pultaceous or Diphtheritic  Phagedenic Chancres.—
In  this second variety, the characteristic induration which we have
just discussed is entirely wanting, or is  rapidly  destroyed  where it
once existed; and if a thickening of  the  base and edges of  the ulcer
be  sometimes observed,  it  consists  only  of unhealthy cedema, or
phlegmonous engorgement.
  The ulcers which belong to this variety, and which constitute phage-
denic ulcers par excellence (corroding ulcers), are inclined to extend in
surface rather than  in depth; the skin, mucous  membranes, and  the
submucous and subcutaneous cellular tissues, opposing their progress
much less than the fascial and muscular tissues.  These chancres may
retain  their circular form, but generally  they plough up the tissues
irregularly, become serpiginous, and constitute a  very remarkable
variety, which is quite distinct from all others.  In this case, they may
at the  same time enlarge at all points of their circumference, but they
are more inclined to extend towards  those  parts which are the most
depending, and which thus favor infiltration of the  pus into the sub-
cutaneous or submucous cellular tissue.
  In many cases, also, these chancres present a striking analogy to  the
different varieties of hospital gangrene. Their floor is generally uneven
and covered with a grayish coating,  a  kind of false membrane, that
might be  mistaken for a gangrenous eschar, but which, in reality, is
only the result  of a peculiar diphtheritic secretion.  In some cases,
we find only pultaceous matter irregularly distributed over the surface,
and granulations escaping here and there, which are many times
destroyed by ecchymosis, hemorrhage, and gangrene, before they lead
to cicatrization.
  In serpiginous  chancres, cicatrization does  not take place as in  the
other varieties.  This is one of the characteristics of this form, which
would almost lead one to believe that  it recognizes a special cause, dif-
ferent from that  of  the other varieties.  In fact, cicatrization in this
form commences at a few points near the centre of the ulcer, whilst
ulceration goes on at the circumference.  In some cases, the edges heal
on one side, and fresh ulcerations appear on the other, leaving behind
them cicatrices which they respect more than they do the  sound  tis-
sues.
  The edges  of these ulcers are generally very thin, irregularly  cut
and perforated, especially in those parts where they are the most under-
mined.   They lose their lining cellular tissue, and turn back on the
skin, or else are depressed on that portion of the ulcer which they over-
lap ; but sometimes they are thickened by oedema or  inflammation.
Their color is generally a dusky violet, like that of the areola which
surrounds them. 
298
CHANCRE.
   The chancres of which we are now speaking are almost always very
irritable, and are generally attended with very severe pain and inflam-
mation.  They suppurate freely, their duration is indefinite, and they
may last for months or years. I have seen one which had lasted seven
years, and which still furnished inoculable pus.  Yet surely the patient
had had time enough to become syphilized.
   These chancres are kept up and extended, not only by the progress
of the specific ulceration, but also by successive inoculations from one
place to another; and, up  to the present day, their number has  been
found illimitable.
   Phagedenic chancres  may be considered as ulcerations of an acute
type, with reference to the successive parts which they involve, but as
a  chronic  affection when we regard their total duration, especially in
the serpiginous  variety.
   Third Variety; Inflammatory or Gangrenous Phagedenic Chancres.—
In some cases,  chancres excite, or  are  complicated with, very acute
inflammation, which may terminate in  gangrene.  Here the  specific
ulcer is  generally destroyed by the rapid progress of the ulceration,
and on the fall of the eschar or sphacelus, only a simple ulcer remains.
The tissues on which it is situated may continue engorged from oedema
or phlegmonous inflammation, but they  present none of the characters
of induration which belong to the first variety.
   The  three varieties of chancre which I have  described often  exist
alone, or are variously combined.  The  reparative period of a chancre
has also its irregularities, in the same way that the specific period has
varieties and numerous intervening shades of difference.  The repara-
tive  process may be only partial:  that is to say, confined either to  a
part of the circumference or to a part of  the floor of the chancre.  One-
third or one-half of the chancre may cicatrize, while  the rest is  still
in the  progressive  stage;  and  in  this case, it is not uncommon for a
relapse to  take place, and the ulceration  to regain those portions which
were beginning to  heal, as takes place  in serpiginous chancres.   But
there are  other varieties  in this stage, which  some observers  have
endeavored to make distinct species of  ulceration.  Thus, the floor of
the ulcer is  sometimes  elevated above the level of its edges, and pre-
sents a  granular convex surface, such as is  often seen on the neck of
the uterus, and which is still, in some countries, referred to a variety
of the ulcus elevalum.  At other times,  true vegetations, more or less
perfectly organized, succeed the granulations, when not repressed at
the proper time, giving rise to what has  been called a fungous or vege-
tating chancre.  Finally, a chancre may cicatrize and  the induration
remain, or else  the ulcer may undergo  a transformation  in situ, pass
into  the state of a secondary symptom, and assume the characters of
secondary ulcers, and more particularly the  characters of  mucous
papules or tubercles.
   Without entering into other considerations, which would  prolong
this  note  to too  great  an  extent, it is  easily seen from the preceding
remarks, that those symptoms which have hitherto been relied on to
establish the diagnosis of chancre, have  only a relative value, and that
we should often be deceived, if we always tried  to distinguish a chan- 
                         SIMPLE  CHANCRE.                     299

ere by the presence of an indurated base, as Hunter directs, and as Mr.
Babington seems to assert even more decidedly.—Ricord.]
  [Editor.—Some chancres are of a purely local nature.   Their action and
influence are confined  to their immediate neighborhood.   They respect the
general constitution, never give  rise  to syphilitic symptoms in distant parts
of the body, and when once healed, no after-consequences are to  be feared,
the system remaining in the  same condition as before their appearance.
  Other chancres,  on  the contrary, have a far different  prognosis.   In the
course of a few weeks or months, they are invariably followed by constitu-
tional symptoms,  which may invade  all the  tissues of  the body.  The
constitution has become infected, and syphilitic phenomena may manifest
themselves years after the primary sore has healed.
   All other distinctions  between different varieties  of chancre are of com-
paratively minor importance to  this.  -Constitutional infection or constitu-
tional immunity are characteristics which overshadow all others.   Founded
on  this basis, we have the  classification of  chancres  into non-infecting and
infecting chancres; the former being also called simple or soft chancres, and
the latter hard or indurated  chancres.

                   SIMPLE OR NON-INFECTING CHANCRES.
   Frequency.—This is by far the most frequent variety of  chancre met with
in practice.   M. Puche,  the  associate  of  Ricord at the Hdpital  du Midi,
found the following proportion in ten thousand chancres, observed during a
period of twelve years :—
        Indurated chancres........1,955
        Simple chancres........8,045
                                                    Total,  10,000
   Thus we have nearly four simple chancres to one indurated chancre.  The
records of other observers vary somewhat from  this, but they all concur in
showing the much greater frequency of the simple ulcer.   This  fact  is due
to two causes—
   1.  A simple chancre is the most fruitful source of the syphilitic virus.  It
not only secretes such virus  in larger quantity and for a longer time than the
indurated chancre, but its secretion is also more contagious.
   2.  A simple chancre is no protection against subsequent  contagion, whilst
an indurated chancre, as  a general rule,  is never met with  but once  in the
same subject.
   Seat.—It has been stated on a previous  page of this work that chancres
may be met with on any part of the  integument or accessible portions of the
mucous membranes of the body.   This is  absolutely  true of indurated
chancres, but Ricord has recently called attention to a most remarkable and
singular exception to  this law in the  case  of simple chancres.   He states
that, in the whole course of  his long  and  extensive practice, he has never met 
300
SIMPLE  CHANCRE.
with a soft chancre on the face or head.   Hundreds of chancres in this situa-
tion have come under  his observation, but they have  all been  indurated.
MM. Puche and Cullerier also testify to the immunity of the cephalic region
from soft chancres, judging from their own experience.'  Moreover, a careful
search of all  the writings on syphilis has produced  but two instances of a
simple chancre situated  above the neck, and these of such a doubtful character
as to lead to a suspicion of  the accuracy of their observation.
   Ricord states that he does not deny the possibility of the existence of a
soft chancre upon  the  head.  On the contrary, he  believes that such ought
to  be met  with.   All  that he  asserts  is,  that, as  yet, no well established
instance of a soft cephalic chancre has ever been observed.  The explanation
of this exemption of the head from soft chancres  is, at the  present time,
difficult, if not impossible.   The fact, if established by farther observation,
is one of the greatest obstacles  to the admission of two  kinds of syphilitic
virus as the origin of the two kinds of  chancre.
   Characteristics.—The most important point to be observed in  the exami-
nation of a chancre is the condition of its base.   The base of simple chancres
is characterized by a softness and suppleness which is almost equal to that of
the  sound tissues.   In  many  cases,  however,  the  tissues surrounding the
chancre become the seat of inflammatory engorgement,  and present  a hard-
ness  to the touch, which, however, is sufficiently distinct from the  specific
induration of infecting  chancres  to be considered hereafter.  This point has
also already been noticed by M. Ricord on page 296.
   A  practised eye will  often recognize  a simple chancre at a glance by its'
edges, which are perpendicular and sharply cut, and  its  floor,  which  is irre-
gular as  if worm-eaten.  These characteristics will be  better understood
after describing the opposite features of an indurated chancre.
   The power of contagion of a simple chancre is much superior  to  that of
an indurated one.   Neighboring parts are inoculated by its virus with great
facility.   Hence it is  that  we  much more frequently meet with several soft
chancres grouped together than  a single one alone; and  the number of the
ulcers is therefore of some assistance  in forming our diagnosis.
   The secretion of virulent pus is much more abundant from  a simple than
from an indurated chancre, and also preserves its contagious properties for a
greater length of time.   Of the two periods of all chancres, already described
on page  294, the first  or  specific period, in the  case  of simple chancres,
absorbs nearly the whole duration of the ulcer.  The sore may even, to all
appearance, be nearly healed, the reparative process having already been set
up around its circumference, and yet a few  points  at  the centre may still
furnish pus which is capable of inoculation.  In the strength of its powers
of contagion, the simple chancre forms a striking contrast with the indurated
chancre.
   Simple chancres are  unlimited in their duration.   In many cases, indeed,
cicatrization takes place in the course of a  few  weeks; but it  is not unusual
to find the ulcer persist for a  much longer period.   This variety of  chancre 
SIMPLE  CHANCRE.
301
is also especially destructive in its tendency, often involving the tissues over
a considerable extent of surface.   It constitutes  that form  of primary ulcer
which is especially liable to take on phagedenic ulceration, resulting in hor-
rible mutilations,  such as loss  of the penis  or labia, deep and  extensive
cavernous ulcers in the groins, etc.  The occurrence of phagedena, however,
is not exclusively confined to simple chancres; it is also met with, though
much more rarely, in connection with indurated chancres, but in this case  it
is less violent, and more amenable to treatment.
  The condition of the lymphatic ganglia in the groins affords valuable aid
in assisting our diagnosis between simple and  indurated chancres,  the effect
of each of these varieties upon these ganglia being  peculiar to  itself.   This
point will be fully considered  hereafter in connection with buboes.   At pre-
sent, it is sufficient to state that, in the case of a simple  chancre, the inguinal
ganglia are either entirely unaffected, or, if  involved, acute inflammation
attacks a single  ganglion, which exhibits a  strong tendency to suppurate,
and, in most cases, gives exit to pus which is capable of inoculation.
   Origin.—It  was formerly supposed that the syphilitic virus  was a unit,
and that the fact  that one person has a simple chancre while another has an
indurated one was due to individual idiosyncrasy, the  exciting cause  being
the same in both cases.  Carmichael, in 1815, was one of  the  first to call
this idea in question, and he maintained that there were four kinds of  syphi-
litic virus, each of which was productive of a train of constitutional  symp-
toms  peculiar  to  itself.   Carmichael's views, however,  were soon shown to
be  erroneous,  and they  have long  since been  abandoned and  well nigh
forgotten.   But the marked difference in the  form  and constitutional effect
of the simple and infecting chancres has again of late years excited suspicion
that the cause upon which they depend is not identical.
  To determine this point, observers have directed their attention to  the
origin of chancres,  and endeavored, in every  possible case, to compare  a
chancre with the ulcer from which it was derived, in order to ascertain if a
simple chancre always produces  a simple chancre and an indurated chancre
an indurated one.   If this be so, we can no longer hesitate to admit that the
virus in the two cases is different.   Let us see  what  has been ascertained on
this point with regard to simple chancres.
  Late experiments in syphilization  upon persons previously unaffected  by
syphilis, though deserving of the highest reprobation  in a  moral point of
view, might have  done much to elucidate this question, if the character  of the
ulcer from which  the pus was taken  and the character  of the sore  produced
had always been accurately determined.   But the absence of these data in
the majority of cases renders these experiments comparatively unavailable to
science.   In the few instances, however, in which this oversight has not been
committed, pus from a simple chancre inoculated upon a sound person has
always produced a simple chancre.
  But a more fruitful field for this investigation is to be found in the com-
parison of the chancres of individuals who infect  each other  in ordinary 
302
INFECTING  CHANCRE.
sexual intercourse, avoiding, of course, with great care, all the sources of
error to which such a comparison is liable.
  A sufficient time has not yet elapsed  to collect  a  large number of cases.
Ricord states that, judging from recollection, in all cases, when  he  has  been
able to trace a chancre  to  its source,  he has always found the two of the
same variety.   M. Clerc reports five cases  of simple chancre  derived  from
simple chancres.   In thirty-nine cases of simple chancre, MM.  Fournier and
Caby have been able  to  examine the ulcers  from which they were derived,
and in every instance found that they also were simple chancres.
  These facts would appear  to be  sufficient to authorize the following pro-
position : A simple chancre is  derived from  a simple chancre, and can only
give rise to a simple chancre.


                    INFECTING OR INDURATED CHANCRE.
   This variety of  chancre is confined exclusively to man.   The experiments
of  Auzias-Turenne, Diday,  and others, would  seem to show that simple
chancres may be communicated to the  lower  animals, but all attempts to
inoculate animals  from indurated chancres have been unsuccessful, and no
evidence of constitutional syphilis has ever been found upon them.
   Evolution.—The development of an indurated chancre is always slow and
insidious.   The ulcer is formed, and may even acquire a considerable size,
without exciting sufficient pain or tenderness  to attract the attention of the
patient.  Even if noticed, it often passes for a mere excoriation,  unworthy
of  being presented to a surgeon.   But, in very many  cases, the patient is
entirely ignorant  of its existence.   The appearance of  secondary  symptoms
may be the first thing which leads him  to seek advice, and the existence of
his primary sore be first made known  to him after the examination of his
 surgeon.  I might cite many facts to prove the truth of this assertion, and to
 show how careful we should be in admitting  that any case of constitutional
 syphilis has not been preceded by a primary sore.
    Symptoms.—The  appearance of an  indurated  chancre  is  peculiar.   Its
 surface  is  smoother, less  irregular and worm-eaten than  the surface of a
 simple chancre.  In  its period of progress,  the  floor  of the ulcer has a
 grayish and  lardaceous  look, but  is  still quite regular, and is  sometimes
 smooth  enough to form a reflecting surface to the light.   Its edges are  gene-
 rally smooth and shiny as if coated with varnish, whilst its centre  presents a
 more sombre and uniform grayish tint.  There is another important distinc-
 tion between simple and  indurated chancres to be found in the edges of the
 ulcers.  The edges of a simple chancre are  abrupt and perpendicular, as if
 punched out; the edges of an  indurated chancre are sloping  as if the sore
 had been scooped out.   In the former, they are usually undermined, in the
 latter adherent.
    The  characteristic induration of an infecting  chancre  has already been
 described by Ricord on page  295, but a few points require farther notice. 
INFECTING  CHANCRE.
303
This induration is clearly and abruptly defined, the tissues around it preserv-
ing their normal softness,  unless  in the  exceptional cases where simple in-
flammation of the part supervenes.   To the touch it has an elastic, cartila-
ginous feel,  which is quite distinct from  the  hardness of  inflammatory
engorgement.  It may be difficult to describe in words the difference in the
sensations produced by the two, but they are none the less distinct, and not
easily mistaken for each other, when once felt.
  In some cases  the induration,  instead of penetrating into the tissues be-
neath the chancre, is superficial, and merely lines its under surface ; so that
if you grasp the  ulcer between two fingers,  you  do not feel a mass like a
split pea—to which Bell compares it—but, as  it were, a layer of parchment
underlying the chancre.  Ricord has given to this form of induration the
name of parchment induration.   It is often so superficial and slightly marked
as to escape  notice, unless the surgeon looks for it and his fingers have  been
educated to detect it.
   Specific induration  of  a  chancre usually first appears  during the latter
part of the first week following the infecting coitus.   It is fully formed in
the course of the second  week.  Such  is  the general  rule.   Ricord states
that he has never met with it before the third day after coitus, and he believes
that it is never manifest before this time.   It sometimes appears late, but it
is very rare indeed for it to  be formed as late as during the third week.  If,
therefore, induration is to take place at all, it does  so during a very early
period of the existence of a chancre.
   This valuable symptom of an infecting chancre is not equally well marked
in all parts of the body.  It appears to be best developed in  those regions
which are the most richly supplied with lymphatic vessels, as in the  corona
glandis, upon the lips, etc.; and in such situations it is also the most per-
sistent.  On the contrary, there  are certain regions where it is very slightly
developed, very difficult to detect, and where it disappears very soon.   Thus,
on the mucous membrane of the  vagina, upon the carunculas myrtiformes, at
the anus, etc., an infecting chancre never takes on  that  thick induration
which so markedly  characterizes  it in the corona glandis.  When thus situ-
ated, the induration is usually of the parchment form, occupying the surface
alone, and is often so slightly marked as to  be with difficulty detected by a
novice, although readily appreciated by a practised hand.   It is to be recol-
lected also that in those regions in which it assumes but a slight development
it is  also very transient.  A few days are sometimes sufficient for its disap-
pearance, which may even take place before the complete cicatrization of  the
ulcer.  These difficulties in detecting the induration of an infecting chancre
are confessedly great, but they are not insurmountable, especially when  aided
by other symptoms, of which we shall speak hereafter.
   It has been asserted by some authors that an infecting  chancre does not
become  indurated  in women.  This is  an  error.   At the  vulva, upon  the
nymphas, the clitoris  and the urethra, specific induration  is well  marked.
Upon the labia majora, an infecting chancre is as  strongly indurated as any 
304
INFECTING  CHANCRE.
infecting chancre in man.  It is  true  that within the opening of the vulva,
upon the vaginal walls, induration is but slight, rapidly disappears, and is with
difficulty appreciated, but  its existence, in most cases, cannot be called in
question.
  Another difference between simple and indurated chancres is in the amount
of their suppuration.  The former suppurate freely, and are the  most fruitful
source of virulent pus.   Indurated chancres, on the contrary, suppurate very
little, and furnish only a small amount of watery secretion, which is generally
thin and sanious.
  Simple chancres are  generally found in groups at the outset, or subse-
quently become multiplied by successive inoculations at various points in the
neighborhood.   In the great  majority of cases, there is  only one  indurated
chancre ; or if more than one exist at the outset, it is very rare to find others
springing up  around  it by a series of successive  inoculations.   It is only
during the earliest  days  of its existence that an indurated chancre can re-
produce  itself upon the same individual.   At a later period it gives rise to a
different kind of  ulcer, if to  any; but of this, more hereafter.
  Whilst the simple chancre has  a decided tendency to spread and encroach
on the surrounding tissues, an indurated chancre soon attains its  maximum
development, and appears to be limited by the deposition of plastic lymph
which takes place beneath and around it.   It is very rare  to  find it taking
on  phagedenic ulceration; so rare, indeed, that it is a commonly received
opinion that phagedena is a protection against constitutional infection.  This,
however, is a mistake.    The  local consequences of phagedena are not a pro-
tection against infection  when the original chancre is an infecting one; and,
indeed, under these circumstances, the gravity of the constitutional symptoms
is proportionately great.    Phagedena is only a complication of chancres, and
as such may attack both varieties, though, for some  unknown cause, it usu-
ally affects only the simple form.    When it involves an indurated chancre, it
is generally much more limited in extent, and more amenable to treatment.
   Course and Termination.—An indurated chancre runs through its different
phases with comparative rapidity,  and, as a  general  rule, is  sooner healed
than a simple  chancre.  Throughout  its whole course, it  excites  but little
pain and uneasiness, so that  it is often unnoticed by the patient.  Cicatriza-
tion finally takes place  as in the simple  chancre, from the circumference
towards the centre.  The infecting chancre is alone capable of being trans-
formed into a mucous tubercle, although a simple chancre,  in  the process of
cicatrization, may become covered with luxuriant granulations which closely
resemble this secondary symptom.  The true transformation of  an infecting
chancre into a mucous tubercle will be described hereafter.
  As a general rule, the induration remains for some time after  an infecting
chancre has healed.  Its elasticity gradually decreases ; it becomes soft and
finally disappears entirely, sometimes leaving behind it  a slightly depressed
cicatrix of a deep violet color.   The length of time after the  chancre has
healed, during which the induration may be detected, is  extremely variable, 
INFECTING  CHANCRE.
805
depending apparently upon its situation.  It has already been remarked that
it lasts the longest in those regions where it is  best  developed.  This rule,
however, is  not invariable, even in the parchment-form of induration.   In
ordinary cases, we  can often  perceive it for  six or  eight months after the
healing of the primary sore.   Ricord states that in one case he observed it
as late as the thirtieth year.   In a few exceptional cases, after having nearly
or quite disappeared, it is  suddenly re-developed.
   The  condition of the neighboring lymphatic vessels and ganglia should
always be examined in forming our diagnosis between an infecting  and sim-
ple chancre.  The effect of an indurated chancre upon these is peculiar  and
constant, and will be described in connection with buboes.
   Prognosis.—An indurated chancre is an infecting chancre.   It is no longer
a mere  local affection;  but the first manifestation of a constitutional disease,
the prelude  of constitutional syphilis.   Hence it is more proper to consider
the induration as the consequence, than the origin of  constitutional infection.
The induration underlying the base of a chancre is the effect of the reaction
of the poison  on the  general  system;  it is, indeed, the  first of a train of
secondary symptoms.
   Does not  occur twice in the same person.—An  indurated chancre gives
rise to a diathesis, or, to a peculiar state of the  system as  a consequence  of
infection, and comes under the general law of virulent affections, in accord-
ance with which they are not repeated twice  in  the same individual.  It  is
in accordance with  the same  law, that one vaccination prevents the vaccine
virus from taking again, at least for a  length of time.  Thus one attack  of
smallpox is  a preventive against another, and measles and  scarlatina rarely
occur twice.  The same is true of  indurated  chancres.  A person who has
had one never has another.  The syphilitic diathesis  is  never doubled  any
more than any other morbid diathesis ;  at least  there is no unquestionable
instance of  such repetition on record.   Ricord has never met with  such a
case, and though several have been reported by other writers on syphilis, yet
they all  admit of doubt as to the correctness of their observation.   Owing
to the liability to error in forming the  diagnosis of an indurated chancre, it
is important that any case, intended to prove  the occurrence a second time
of an indurated chancre in the same person, should show that it was followed
in each instance by the usual train of constitutional phenomena.
  Although clinical facts such as these are at present wanting, yet  we are
perhaps not justified in denying  the possibility of their occurrence.   It is well
established that the modification which the system receives from typhoid  and
the eruptive fevers  may die  out in time, and  a person undergo  a  second
attack.   Revaccinations are  also  successful  in  some instances.   Analogy
would therefore lead us to  believe that the syphilitic diathesis may also disap-
pear, at least, in some fortunate  cases, and then  a second indurated chancre
and its  consecutive symptoms would  be possible ; but,  as yet, we have  no
proof that this ever occurs.  It is to be  hoped,  however, that farther obser-
       20 
306
INFECTING  CHANCRE.
vations will establish the contrary, for, if syphilis can occur twice in the same
person, it follows that a first infection may be exhausted; but it is generally
believed, at the  present day, that, though this fearful disease may be cured
in its manifestations, its tendency can never be eradicated.   What a consola-
tion, then, would  it be to  humanity to be able to say that  constitutional
syphilis may be perfectly  cured!  The  question may be asked, however,
whether, if the syphilitic diathesis never becomes entirely extinct, it may not
be so far subdued as to exercise only a preservative influence against a second
infection,  but of this  we have no proof.   Constitutional symptoms  often
appear after the diathesis has been latent for many years.
  Before leaving this subject,  it is desirable to point out some of the sources
of error, to which investigations as to the possibility of a  second attack  of
constitutional syphilis are liable.   In the first place, the testimony of patients,
or even of most physicians, as to  an anterior infection, cannot  be accepted;
owing to  the imperfect ideas which generally prevail on this  subject.   One
practitioner regards every venereal symptom, including gonorrhcea, vegeta-
tions, and simple chancres, as constitutional effects of the virus.   Another is
unable to distinguish between a true syphilitic eruption and one produced by
the use of cubebs or copaiba.
   But suppose that we ourselves are twice called to attend the same  patient,
at a considerable interval of time, and in each instance think that we recog-
nize an indurated chancre.  There are still certain  ways  in  which  we may
deceive ourselves.  Are  we sure that the constitution became  infected from
the first chancre ?  If constitutional symptoms followed it, there can be no
doubt.  If nothing was  observed except the chancre, and a mercurial course
was administered, the case is less certain.   It is not always easy to determine
whether a chancre is indurated or not, and we may have been mistaken in
our diagnosis.
   Again, there is another source  of error.   An indurated chancre may heal,
leaving behind  it its induration, and some months or  years after, a second
chancre appear on the cicatrix of the first.   The indurated base of  the first
 chancre appears to belong to the second  chancre, which, after  all, may be
 only a simple  ulcer.  Nay, more, even if  the induration of a first chancre
 has entirely  disappeared, a second chancre, occurring in the same spot, may
 be sufficient to cause its reappearance.
   Finally, suppose that constitutional symptoms follow two chancres, occur-
 ring at a considerable interval of time, those which succeed the second chan-
 cre may  be entirely independent of it, and due to the infection produced by
 the first.  Fortunately  the  manifestations of  constitutional  syphilis affect
  different tissues, and assume  different forms, according to the  time which has
  elapsed  since  infection, so that  the  character  of the  symptom will  always
  determine whether it is due to a recent or  remote chancre.
    Origin.—We have already seen that there is  ground for believing  that a
  simple chancre is  always derived  from, and can only give rise to, a  simple 
INFECTTNG  CHANCRE.                   307
chancre.   It remains  to examine the laws of transmission of the indurated
or infecting chancre.   For reasons which will  be evident hereafter, it  is
desirable, in the first place, to  pursue  this investigation  upon persons who
are exempt from any  previous syphilitic  infection;  and in such cases, we
arrive at a law similar to the one which prevails  in the case of simple chan-
cres.   In  fifty-nine cases, collected by  Ricord's Interne, M. Fournier, an
indurated chancre was, in every instance, derived from an indurated chancre.
MM. Clerc, Bassereau, Diday, and others, arrive at the same conclusion from
their own observation, and the fact appears now to be well established  that
between persons, exempt from previous infection, an indurated chancre gives
rise to a chancre of the same nature.
   But another class of cases yet remains.  We have endeavored to show that
an indurated chancre  never occurs twice in the  same  subject.   What then
will be the consequence if a person, already infected with syphilis, be exposed
to the virus of an infecting ulcer ?   When pus from an indurated chancre is
inoculated artificially upon the person bearing the  chancre, the inoculation is
either unsuccessful, and produces no result, or the chancre which  is developed
has a soft base, and is analogous in its form and  aspect to a simple chancre.
   It is an  observed fact, that in the great majority of cases in which a person,
bearing an indurated chancre, is inoculated with  his own virus, no chancre is
produced.   Fifty-five  such inoculations,  performed by M. Fournier with pus
taken from the chancres after they had  attained  their full  development, but
before their period of decline, were entirely without result.  In a few instances,
however, especially when  the  pus  is taken  from the chancre at an earlier
period, an ulcer is produced, which, as  already stated, is entirely analogous
to a simple chancre.   In those cases also in which the contagion takes place
in sexual intercourse,  the result is the same ;  though the person  transmitting
the  disease has an indurated chancre, the person  receiving it, if previously
infected with  syphilis, contracts only what is apparently a simple chancre.
If you follow a  chancre,  produced under such circumstances,  through the
different phases of its development, you will  find no trace of specific indura-
tion about it; and if you  examine  the neighboring lymphatic ganglia, they
will exhibit no change analogous to that produced upon them by an infecting
nicer.
   The pus, then, of an infecting chancre produces, upon a person previously
infected, a chancre with a  soft base, and analogous in appearance to a simple
chancre.
   But though thus resembling each other in  their  external aspect, are these
two chancres  identical  in their nature; or does  the apparently soft chancre
of an infected individual still preserve the attributes of an infecting chancre,
and especially the  power of causing an  infecting  chancre, if communicated
to a person free from previous taint ?  Ricord is inclined to believe the latter
solntion of this question to be the  correct  one; since four  instances have
come under his observation in which an apparently soft chancre in a syphilitic 
308
PHIMOSIS.
 subject has given rise to  an indurated chancre followed by  constitutional
 symptoms in a person free from previous taint.
   The following propositions comprise the conclusions at present attainable
 with regard to the transmission of the two kinds of chancre :—
   I. A simple chancre in subjects previously free from syphilis, is transmitted
 as a simple  chancre.
   II. An indurated  chancre is transmitted as an  indurated chancre in like
persons.
   III. An indurated chancre produces, in persons before infected, a chancre
 with a soft base, and analogous to a simple chancre.
   IV. A chancre with a soft base in an infected subject, will give  rise to a
 simple, or to an indurated chancre, according to the nature of the ulcer from
 which IT was derived.
   Is there a double syphilitic virus ?—Thus far in our investigation as to the
 nature of chancres, wo have been  guided by observation.   The mind natu-
rally wishes  to proceed one step farther,  and ascertain whether there exists a
special cause for each of these two varieties of ulcers; in short, to  solve the
question of the unity or the duality of the syphilitic virus.  But, as yet, we
should be too  hasty in attempting to decide this question.   Many points yet
remain  doubtful, and require farther investigation; the veil is not  wholly
lifted; perhaps we are not yet prepared to  look at the question in all its
bearings; we have only a glimpse of the whole subject;  we must wait.
   And yet it would appear that, however this question may be solved, there
can be  only one virus  which deserves  the  name  of syphilitic.  Even if it
should be demonstrated that the two varieties of chancre belong to two
species which  are pathologically  distinct, it would  only prove  that by the
side of syphilis there exists another affection, manifesting itself like it at the
outset by an ulcer, which secretes virulent and contagious pus, but, unlike it,
never infecting the economy.  We could not  conclude that  the syphilitic
virus is double, but that there exists a second  venereal or chancrous virus,
independent of syphilis.  In other words, we would then admit two poisons,
one belonging to syphilis, and producing the  infecting chancre, the other
distinct from syphilis, and giving rise to  the simple chancre.—Editor.]

                § 1. Of the Phimosis and Paraphimosis.
   These diseases arise from a thickening of  the cellular membrane of
the prepuce,  in cousequence of an irritation  capable of producing con-
siderable and diffused inflammation, which, when  it does happen, is
generally in  consequence of a  chancre in this part.   This irritation,
however, and inflammation, sometimes attacks the prepuce, even when
the disease  is in the form of what I suspect  to be a gonorrhcea of the
glans  and  prepuce, sometimes  even   in the  common gonorrhcea, but
most frequently of all from a chancre in the prepuce.   When  this dis-
ease or tumefaction takes place in consequence of a chancre, I suspect 
PHIMOSIS.
309
that there is an irritable disposition in the habit;  for it is plain there
is more than the specific action, the inflammation extending  beyond
the specific distance.1
   It may be observed, here, that the prepuce is no more than a dou-
bling of the skin of the penis when not  erected, for then it becomes
too large for the penis, by which provision the glans is covered and
preserved when not necessary to be used, whereby its feelings are pro-
bably more acute.  When the penis becomes erect, it in general fills
the whole skin, by which the doubling forming the prepuce  in the
non-erect state is unfolded, and is  employed in covering the body of
the penis.
   The diseases called phimosis  and paraphimosis,  being a thickening
of the cellular membrane of this  part, they will commonly be in pro-
portion to the inflammation and distensibility of the cellular membrane
of the part.   The inflammation often  runs high, and is frequently of
the erysipelatous kind; besides, in such parts, where the cellular mem-
brane is so very loose, the tumefaction is considerable, and the  end  of
the prepuce  being a depending part, the serum is accumulated in  it,
which, in many inflammations, is allowed to pass from the inflamed  to
some more depending part, as in an inflammation  of the leg or thigh,
where the foot commonly swells  or becomes cedematous in consequence
of the descent of the serum extravasated above.
   A natural contraction  of the aperture of the prepuce is very com-
mon, and so strong in some that those under such construction of parts
have a natural and constant phimosis.  Such a  state of  parts is often
attended with chancres, producing very great  inconveniences in the
time of the cure; and in those cases of considerable diffused inflamma-
tion, a  diseased phimosis, similar to the other, unavoidably follows;
and, whether diseased or natural, it may  produce the  paraphimosis
simply  by the prepuce being brought back upon  the penis;  for this
tight part acting as a ligature round the body of the penis behind the
glans, retards the circulation beyond the ligature, producing an cede-
matous inflammation on the inverted part of the prepuce.  When the
paraphimosis  takes place  in consequence of a natural tightness only,
although attended with chancres, yet it  has nothing to do with the
constitution, this being only accidental; however, in  either case, a
paraphimosis is to be considered as in some degree a local violence.
   This  natural phimosis is so considerable in some children as not  to
allow the urine to pass "with ease; but, in general, becomes larger and
larger, as boys grow up, by frequent endeavors to bring it over the
glans, by which the bad consequences that  would otherwise ensue  in
it when affected with disease are often prevented.

  1 Any ulcer on the internal prepuce may produce phimosis, because it may  he
attended  by so much thickening as to destroy the natural flexibility of the  prepuce.
A chancre is more likely to produce it than any other sore, because  it is necessarily
accompanied by induration, and that of a kind which is much more obstinate than
the thickening of a common inflammation.—G. G.  B.
  [I cannot allow Mr. Babington's erroneous assertion, that " every chancre  is neces-
sarily accompanied by induration," to  pass without contradiction, now that we know
that the majority of chancres are not indurated.—Ricohd.] 
310
PHIMOSIS.
  This part  of the prepuce, although in most men it is loose enough
to produce no inconvenience in a natural state, yet sometimes contracts
without any visible cause whatever, and becomes so narrow as to hinder
the water from getting out, even after it has got free from the urethra,
so that the whole cavity of the prepuce shall be filled with the urine,
and give great  pain.   The cases that I have seen  of this kind have
been principally in old men.
  When the prepuce is in its natural position, it then covers entirely
the glans, and is commonly a little loose before it; when it begins to
swell and thicken, more and  more of the  skin of the penis is drawn
forwards over the glans, and the glans at the same time is pushed back-
wards by the swelling against its end.  I have seen the prepuce pro-
jecting, from such a cause, more than three inches beyond the glans,
and its aperture much diminished.
  The prepuce often becomes in some degree inverted by the inner
skin yielding more than the outer, having  a kind of neck where the
outer skin naturally terminates.  From the  tightness and distension
of the parts  in a state of tumefaction it becomes  impossible to bring
it back over the penis,  so as to invert it and expose the sores on the
inside.
  Such a state of the prepuce is very often  productive of bad conse-
quences, especially when the chancres are  behind the glans; for the
glans being between the orifice of the prepuce and the sores, it there
fills up  the whole cavity of the prepuce,  between the  chancres and
opening, and often so tightly,  that the matter from the  sores behind
cannot get a  passage forwards between the glans and prepuce, by which
means there  is an accumulation of matter behind the corona glandis,
forming an abscess which produces ulceration upon the  inside of the
prepuce.  This abscess  opens  externally, and the glans often protrud-
ing through  the opening, throws the whole prepuce  to  the  opposite
side, the penis appearing to have two terminations.
  On the other hand, if the prepuce is loose, wide, and is either ac-
customed to be kept back in its sound state or is  pulled back to dress
the chancres, and is allowed to remain in this situation till the above
tumefaction  takes place, then it is  called a  paraphimosis;  or if the
prepuce is pulled forcibly back after it is swelled, it  is then brought
from the state of a phimosis, as  before described,  to that  of a paraphi-
mosis.
   The last-described situation  of the prepuce  is often much  more
troublesome, and often attended  with worse symptoms, than the former,
especially if it should have been changed from a phimosis to a  para-
phimosis. The reason  of which is,  that the  aperture of the prepuce
is naturally less elastic  than either the internal inverted part or the
external skin; therefore, when the prepuce is pulled back upon the
body of the penis, that part grasps it tighter than any other part  of
the skin of the penis, and more so in proportion  to the inflammation;
the consequence of which is, the swelling of the prepuce is divided
into two, one swelling close to the glans, the other behind the stricture
or  neck.  This stricture is often so great as to interrupt  the free cir-
culation of  the blood beyond it, which also assists in increasing the 
PHIMOSIS.                        311
swelling, adds to the stricture, and often produces  a mortification of
the prepuce itself, by which means the whole diseased part, together
with the stricture, is sometimes removed, forming what may be called
a natural cure.1
  In  many cases, the inflammation not only affects the skin of the
penis, in which is included the prepuce, but it attacks the body of the
penis itself, often producing adhesions and even mortification in the
cells of  the corpora  cavernosa, either of which will destroy the dis-
tensibility  of those parts ever after, giving the penis a curve to one
side in its  erections.  This sometimes takes place through the whole
cellular substance of the penis, producing a short and almost inflexible
stump.
   The adhesions of those cells do not proceed from  venereal inflam-
mation  only;  they  are  often the consequences  of other diseases, and
sometimes they take  place without any visible cause whatever.
   A gentleman, sixty years of age, who has been lame with the gout
these twenty years  past, has for these eighteen months had the penis
contracted on the left and upper side, so as to bend that way very con-
siderably in erections, which erections are more frequent than common.
   Quere: Is the gout the cause  of this, by producing adhesions of the
cells of one corpus cavernosum, so as not to yield  or to  allow of the
influx of blood on  that side ?   And is the irritation of the  gout the
cause of the frequency of the erections ?
   [Ricord.—Congenital phimosis, in any of its various degrees, may
undergo no modification from the presence of gonorrhoea, balanitis, or
even chancres;  for the prepuce often escapes  the inflammation and
ulceration, in spite of its intimate connection with the  diseased parts.
However,  in many cases, whether there was previous congenital phi-
mosis or not, accidental phimosis supervenes under circumstances and
with peculiarities which it is  important to  understand, and  on which
Hunter has not perhaps sufficiently dwelt.
   If we examine the morbid affections which may give rise to phimosis,
we find that it is seldom a consequence of urethral gonorrhoea.   Yet
it does  occur in some cases of urethritis, more especially when the
latter is complicated with inflammation of some of the lymphatic ves-
sels of  the penis, or with phlegmon and abscess in the neighborhood
of the urethra.  External gonorrhoea  is the most common cause of
accidental  phimosis, especially when the inflammation  involves the
internal layer of the prepuce.   Chancres, when free from complication
with balanitis and  posthitis, produce it much  more rarely.   But be-
sides these causes,  which may be considered the most important, there
are still others which it is desirable to understand.  Thus, in constitu-
tional syphilis,  various eruptions may take place on  the glans and
prepuce, and phimosis supervene, either in consequence of the inflam-

   1 A young man came into St. George's Hospital with a paraphimosis in consequence
 of chancres on the inside of the prepuce. All the parts before the stricture, formed
by the prepuce, mortified and dropped off. I ordered nothing but common dressings, and
it healed very readily, and he left the hospital cured of the local complaint. Whether
or not absorption had taken place previous to the mortification I  do not know, as  I
never heard more of him. 
312                        PHIMOSIS.
mation which  sometimes precedes  or attends  them, or  from hyper-
trophy of the tissues, as occurs  in  tubercular  eruptions, or again, it
may be owing to the development of vegetations.  And this  is not
all;  simple irritation, excessive use and  fatigue  of the parts, and
herpes and eczema, which are so frequent in .this region, may also oc-
casion it.   I once saw a very acute phimosis which followed rupture
of a vein and infiltration of blood, as also happens in infiltration of
urine.
  After these considerations, if we  study the intimate nature of phi-
mosis, we find that it depends either on development of  the parts in-
closed within the prepuce, while this  envelop  remains  sound, or on
different morbid states affecting  the latter.  To the first class belong
vegetations, tubercles, and hypertrophy of  the glans, which make this
organ relatively too large to pass through the opening in the prepuce;
whilst to the second class belong those changes which may take place
in the prepuce itself.  The latter may consist merely of simple oedema,
which sometimes complicates  erysipelas, as is observed after the ap-
plication of leeches to the skin of the  penis; at other times, there is
true phlegmonous inflammation  occasioned by a bastard gonorrhoea,
or following inflammatory chancres.  In such cases, abscesses form in
the substance of the prepuce, and may open  externally or internally,
sparing one or the other of the two preputial folds, or the whole thick-
ness of this envelop is destroyed  by an eschar or ulcer proceeding from
within outwards.  Then, as Hunter so well observes, in proportion as
the orifice of the prepuce contracts, the pus accumulates between it
and the glans, forming an abscess which is discharged by the accidental
opening, through which the glans itself often protrudes.  It is remark-
able that it is always the superior portion of the prepuce which is
destroyed,  the inferior portion generally resisting, and the preputial
orifice being also spared in a large number of cases.  But whatever
may be the cause of these acute  inflammatory phimoses of gangrenous
tendency, if we wait for the efforts of nature, it often happens that the
glans and  corpora cavernosa are destroyed by the  retention  of the
virulent or ichorous pus, although  at first they took no part  in the
affection.  We have said that chancres may be the cause of phimosis,
and in such cases the prepuce may present variations in  respect to the
extent and situation of the ulcers, which  it is interesting  to  notice.
When the  ulcers are situated at the orifice of the prepuce, there is
commonly only a part of it which is incapable of sufficient dilatation
for the passage of the glans, and in this case the stricture takes place
without  there necessarily  being any other  complications.   Another
notable state of things exists, when the  prepuce is the seat of indura-
tion pertaining more particularly to a callous chancre; and it is not
uncommon in this case to find the prepuce of its ordinary dimensions,
but having lost its natural suppleness and  power of being everted, in
consequence of the induration which renders it almost  cartilaginous.
Finally,  as I said above, phimosis is sometimes the consequence of the
development of modular tissue  in the substance of the prepuce, or of
cicatrices most frequently observed on its  free  border, and caused by
the various losses of substance  to which it is liable.   Again, in some 
CHANCRES  IN WOMEN.
313
cases, there are congenital or accidental adhesions between the glans
and prepuce.
  From the preceding  considerations, a distinction should always be
made between permanent and temporary phimosis.  To the first belong
congenital phimosis, and phimosis consequent on vicious cicatrices;  to
the second, all those morbid alterations which are susceptible of cure,
and which leave the prepuce in  its normal state.   This distinction is
not without value in  practice; since, though an  operation is  almost
always indicated in the first case, we  may, and  frequently should,
abstain from one in the second.
  With regard to  paraphimosis, allow  me to recall a  few practical
points, which should be remembered in  the treatment.   Paraphimosis
most frequently follows congenital or accidental phimosis; but it may
also  be primary; that  is to say, occur in individuals whose glans is
habitually uncovered.   Paraphimosis succeeding phimosis soon attains
its highest degree of intensity; whilst, on the contrary, its progress is
more or less slow and  gradual when it  is primary.  Sometimes it is
simply cedematous, or  cedematous and complicated with various kinds
of induration; at other times it is decidedly inflammatory.
  Paraphimosis may occur in the course of urethritis or balanitis, or
in connection with various ulcers.  When it is very intense, the stran-
gulated parts become engorged, as Hunter remarks;  and thus I have
seen gangrene of the glans produced.  But, generally, it is the prepu-
tial  ring which ulcerates and is destroyed; but the ulceration, which
tends at first to separate the mucous from the cutaneous layer of the
prepuce, does not always promptly relieve the stricture; and hence
adhesions, vices of conformation, and hard persistent oedema are often
produced.
  In a practical point  of view, reducible paraphimosis must also be
distinguished from irreducible, and regard be  paid to  the attending
circumstances.  But I  shall have occasion to return to this subject in
speaking of the treatment.—Ricord.]
                     CHAPTER  II.

                   OF  CHANCRES IN  WOMEN.

  Women are subject  to chancres; but  from the simplicity of the
parts, the complaint is  often less complicated than in men.  For in
this sex we have only the disease and constitutional affection, and no
inconvenience arising from the formation of the parts.
  When the matter is introduced into the vagina or urethra, it there
irritates a secreting surface, as I described  when treating of the disease
in general and of women in  particular; but when it is lodged in the
inside of the skin of the labia or nymphas, those parts are often  only
affected with gonorrhcea; but, like the  glans penis in men, they are 
314
CHANCRES IN  WOMEN.
also capable of ulceration.  Ulcerations are generally more numerous
in women, because the surface upon  which they can form is much
larger;  we find  them on the edge of the labia, sometimes on the out-
side, and even on the perineum.
  Ulcers that are formed on the inside of the  labia or  nymphas are
never allowed to dry or scab;  but on the outside they are subject to
have  the matter dry upon them, which  forms a scab similar to those
on the body of the penis or scrotum.
  The venereal  matter from such  sores is  very apt to run  down the
perineum to the anus, as in gonorrhcea,  and excoriate the parts,  espe-
cially about the anus, where  the skin is thin,  and  often produces
chancres in those parts.
  Chancres have been observed in the vagina; which I suspect not to
have  been original ones, but to have arisen from the spreading of the
ulcers on the inside of the labia.1
  This form of the disease, like the gonorrhcea, both in women and in
men,  is entirely local,  the  constitution having no connection  with it
but sympathetically, and I believe much more seldom in  this than in
the former.
  [Ricord.—I will not add to what I have said in speaking of chan-
cres in  general, nor repeat my views  on chancres of the vagina and
uterus, which coincide with  Mr. Babington's  remarks.  I  will  only
observe that chancres  in women are far from always  being as simple
an  affection  as Hunter supposed;  and that, on the contrary, it is not
uncommon to see them take on all the complications which may  exist
in  men, whether they  be  situated  on the vulva, urethra, vagina, or
uterus.
  However, this chapter deserves still farther to fix our attention; for
a1 misunderstanding of some passages of it, has caused ideas to be  attri-
buted to Hunter which this great master never had.   Indeed, Hunter
acknowledges here, and in all the  rest  of his work, that both gonor-
rhoea and chancre in the two sexes are at first entirely local  affections,
the consecutive effects of which are of two distinct kinds,  according
as they are  the  result of absorption of the virus, producing constitu-
tional syphilis,  or of simple sympathetic  reaction, determining fever,
disturbance of the system, &c.  Some syphilographers, supporters of
the so-called  physiological school, have, therefore, been wrong in think-
ing they found  in the writings of Hunter an  avowal of the doctrine
of sympathies, such as they  teach it;  for Hunter was  too good an
observer to fall  into such an error.
  But admitting, as I  do, Hunter's true  and practical distinctions, and
recognizing, as  he did, that gonorrhcea  excites sympathetic reactions
more frequently than a chancre does, I still grant to chancre alone the
prerogative of determining constitutional infection by absorption.]

  1  Original chancres do occasionally occur within the vagina, being  situated  on the
membrane lining the vagina, or on  the os uteri itself.  These chancres can only be
detected by the use of a speculum.  However, sores on these internal parts are ex-
tremely rare, notwithstanding the degree in which they are  exposed to the contact of
the venereal virus during coition.—G. G. B. 
TREATMENT OF CHANCRE.
315
                     CHAPTER  III.

GENERAL OBSERVATIONS ON THE TREATMENT OF CHANCRES.

  The inflammation from the venereal poison, when it produces ulcera-
tion, generally, if not always, continues till cured  by art, which I
observed was not the case with the gonorrhcea.  It will, perhaps, not
be an easy task to account for the material difference  in the two kinds
of disease; but I am inclined to  think that, as the  inflammation in
the chancre spreads, it is  always attacking new ground, which is a
succession of irritations, and is the cause that it does not cure itself.
  Chancres, as well as the gonorrhcea, are  perhaps  seldom or never
wholly venereal, but are varied by certain peculiarities of the constitu-
tion at  the time.   The treatment, therefore, of them, both local  and
constitutional, will  admit of great variety;  and it is upon the know-
ledge of this variety that the skill  of the surgeon principally depends.
On°this account, the concomitant symptoms  are what require particu-
lar attention.  Mercury is the cure of the venereal symptoms abstract-
edly considered; but there is no specific for the others, the treatment
of which must vary according to  the constitution.  From hence, we
must see that no one kind of medicine joined with mercury will be
likely to  succeed in all cases, although the  different pretended secret^
are of this kind, some cases not requiring anything excepting mercury,
others requiring a  something besides, according to their nature, which,
in many cases, it will not be an easy matter to find out from the appear-
ances of the chancre itself, but which must  be discovered by repeated
11*19,1 S
   Probably, from  the before  mentioned circumstances it is  that a
chancre is, i'n  common, longer  in healing than most of the local effects
from the constitutional  disease, or lues venerea, at  least longer than
those in the first order of parts; and this is found to be the case, not-
 withstanding  that  the cure of a chancre may be attempted both con-
 stitutionally and locally, while the lues venerea can,  in  common, only
be cured constitutionally.  It is commonly some time before a chancre
 appears to be  affected by the medicine.  The circulation shall be loaded
 with mercury for three, four, or more  weeks, before a chancre shall
 begin to separate  its discharge from its surface, so as to look red  and
 show the living surface; but when once it does change, its progress
 towards healing is more rapid.   A lues venerea shall, in many cases,
 be perfectly cured before chancres have made the least change.
   Upon the same  principle, some attention should be paid to internal
 medicines ; and  it  should be considered whether weakening, strength-
 ening, or quieting medicines should be  given; for sometimes one kind,
 sometimes another, will be proper. 
316               TREATMENT  OF CHANCRE.
  Chancres admit of two modes of treatment; the object of one is to
destroy or  remove them by  means of escharotics or by extirpation;
that of the  other is to overcome the venereal irritation by means of the
specific remedy for that poison.
  I have endeavored to show that chancres are local complaints; this
opinion is farther confirmed by their being destroyed or cured by
merely a local treatment.  But in chancre, as well as in a gonorrhoea,
it has been disputed whether mercury should ever be  applied  locally
to them or not;  some have objected to it, while others have practised
it, and probably the dispute is not yet generally settled.
  Upon the general idea which I have endeavored to give of the vene-
real disease, it can be no difficult task to determine this question.
  It is to be observed that, in the cure of the chancres, we  have two
points in view: the cure of the chancre itself, and the prevention of a
contamination of the habit.
  The first, or the cure  of the  chancre, is to be effected by mercury
applied either in external dressings, or internally through the circula-
tion, or in both ways.  The second object, or preservation of the con-
stitution from contamination, is to be obtained, first, by shortening the
duration of the chancre, which shortens  the time of  absorption, and
also by internal medicine, which must be in proportion to the time
that the absorption may  have been going on.
  If the power of a chancre to contaminate the constitution, or, which
is the same thing, if the quantity absorbed is  as the size of the chancre
and the time of absorption, which most  probably it is, then whatever
shortens the time must diminish that power or quantity absorbed; and
if the quantity of mercury necessary to preserve the constitution is as
the quantity of poison absorbed, then whatever lessens the quantity
absorbed must proportionally preserve the constitution.  For instance,
if the power of a chancre to contaminate the constitution in four weeks
is equal to four, and the quantity of mercury necessary to be given
internally,  both for the cure of the chancre and the preservation of the
constitution, is also equal to four, then whatever shortens the duration
of the chancre must lessen in the same proportion the quantity of the
mercury; therefore, if local  applications, along with the internal  use
of mercury will cure the chancre in three weeks, then only three-fourths
of the mercury is necessarily wanted internally.  Local applications,
therefore, so far as they tend to shorten the duration of a chancre,
shorten the duration of absorption, which also shortens the  necessity
of the continuance of an  internal course of mercuiy, all in the same
proportion.  For example, if four ounces of mercurial ointment will
cure  a chancre and  preserve  the constitution  in four weeks, three
ounces will be sufficient  to preserve the constitution if the cure of the
chancre can  be by any  other means forwarded so as to be effected in
three weeks.  This  is not speculation, but  the result of experience,
and the destruction of chancres confirms it.
  [G. G. B.—The author's experience on this  point  seems to be at
variance with that of others.  It does not appear that in practice it is
safe to make the period of the  healing  of the sore a  measure of the
length of the mercurial  course.  General experience would  seem to 
TREATMENT OF CHANCRE.
317
 show that a mercurial course for primary symptoms, even though  it
 be commenced before the chancre has existed a week, cannot be con-
 tinued for a less period than a month, without exposing the patient to
 imminent danger of a subsequent relapse.—G. G. B.]
  [Ricord.—All of Hunter's general observations on the treatment
 of chancres are far from having been confirmed by experience.
  Doubtless, most chancres are cured only by art; but it can be shown
 that many heal of themselves, and heal the  faster the  less they are
 irritated by improper  treatment.   For instance, an uncomplicated
 chancre which would get well in three or four weeks, if kept clean
 and dressed simply, is often kept up and even extended, by the appli-
 cation of unsuitable mercurial dressings.
  If we compare gonorrhoea with chancre in respect to  the facility of
 their cure, daily observation will compel us to admit that  Hunter's
 views on this subject were rather theoretical than practical; for it may
 be shown that, on the whole, a chancre is cured sooner than a  gonor-
 rhcea, at least in the great majority of  cases, and without the aid of
 mercurials.   If we abandon the two diseases to themselves, or to the
 resources of nature alone, we find many more interminable gleets than
 chronic venereal ulcers.   If Hunter had not been influenced by adhe-
 rence to a system which continually hampered him in his explanations,
 he would have observed cases in which the analogy between a chancre
 and certain forms of gonorrhoid discharges was perfect, viz., those cases
 in which the discharge depends upon a chancre situated in the urethra,
 in the deep portion of the vagina or in the cavities of the uterus.  Hun-
 ter makes a very true remark, and one which explains many facts, viz.,
 that chancres do not always exist alone; that is to say, the syphilitic
 ulcer is frequently complicated with other pathological conditions, which
 alter its  character or  mask it, and which, at the  same time that they
 cause it to deviate from its regular course, present indications so com-
 plex or so opposed to each other, that no single method of treatment
 can  be rationally employed in all cases.  We must coincide with Hun-
 ter, especially when he says that gonorrhcea is perhaps seldom or never
 wholly venereal;  as I have shown, it is venereal only when it coexists
 with a chancre.
  It is not true, as Hunter asserts, that specific inflammation prevents
 the spontaneous cure of a chancre, by spreading and always attacking
 new ground; for it is very certain, all other things being equal, that
 a syphilitic ulcer is sooner circumscribed and limited than gonorrhceal
 inflammation, which constantly tends to  involve more and more of the
 mucous surface of which it at first affected only a single  point.
  Laying aside the complications of a chancre, and regarding the pri-
 mary ulcer alone, we must beware of believing mercury its only spe-
cific. This  powerful therapeutic agent has no true specific property,
except in case the chancre be indurated.
  Hunter is right in saying that induration is a frequent property of a
chancre,  but he does not dwell  sufficiently on the  importance of this
symptom with regard to the prognosis of the primary ulcer, the possi-
bility of the appearance of constitutional symptoms, and especially
the therapeutic indications, which it always furnishes. 
318
TREATMENT OF CHANCRE.
  An extended  and careful  experience, added to exact experiment,
authorizes me to lay down the following propositions, which any one
may verify:—
  1. A chancre is at first essentially a local affection, and it continues
to be so unless induration and symptomatic engorgement of the neigh-
boring ganglia supervene.  The duration of the disease, and the extent
and  number  of the affected  surfaces add  nothing to the  chances of
constitutional infection.
  2. If a chancre become indurated (and this rarely happens before
the  fifth or sixth day),  the disease ceases to be simply a local affec-
tion ; induration being a certain proof that the system is contaminated.
  I do not know if there be  any  exceptions to this law.
  3. There are two things to be considered in the cure of  a chancre;
first, the cicatrization  or  disappearance of the ulcer;  secondly, the
state of the tissues beneath it.  A  cure is really effected,  only when
the  induration disappears.   An  indurated chancre  which cicatrizes
very rapidly, will be followed by constitutional symptoms, as well as
one which continues a  longer time; whilst a  non-indurated chancre,
which is as long or even  longer in getting well than the former, will
cause nothing of the kind ; induration being requisite for the produc-
tion of the constitutional phenomena of syphilis, no matter how long
the  primary ulcer lasts.
  4. We are  to regard the  use  of mercury  as the most  efficacious
special treatment for indurated chancres that we  possess; induration,
being an indication that constitutional syphilis  already exists, over
which,  as Hunter judiciously remarks, mercury has frequently more
power than over the primary ulcer, especially when  the latter is not
attended with induration.
  5. The early administration of mercury,  in cases of indurated chan-
cre, may anticipate the development of constitutional symptoms.
  6. In the case of an uncomplicated indurated chancre, mercurial
treatment may be local or general.
  7. The duration of mercurial treatment  is  not to  be measured by
the  cicatrizatiou of the chancre, but by the entire disappearance of the
induration; and even this is not always sufficient.
  Let any one reflect on the  preceding propositions, and he will find
that in them the apparently contradictory opinions of authors har-
monize.—Ricord.]


                § 1. Of the Destruction of a Chancre.

  The  simplest method of treating a chancre  is by  destroying or ex-
tirpating it, whereby it is reduced  to the  state of a common sore or
wound, and heals up as such.  This only can be done on the first
appearance of the chancre, when  the surrounding parts are not as yet
contaminated, because  it is  absolutely necessary that  the  whole dis-
eased part should  be removed, which is done with difficulty when it
has spread considerably.  It may be done either by incision or by
caustic.  If the chancre appears upon the glans, touching it with the 
TREATMENT OF CHANCRE.
319
lunar caustic is preferable to incision, because the hemorrhage by such
a mode would be considerable from the cells of the glans.
  The common sensation of the glans  is not very acute, therefore the
caustic will give but little pain.  The  caustic to be used should  be
pointed at the end like a pencil, that it may only touch those parts
that are really diseased.  This treatment should be  continued till the
surface of the sore looks red and healthy, after having thrown off the
last sloughs; after it has arrived at this state, it will be found to heal
like any other sore produced by a  caustic.
  If the sore is upon the prepuce, or upon the common skin of the
penis, and in  its incipient state, the same practice may be followed
with success;  but if it has spread  considerably, it is then out of the
power of  the caustic when only applied in this slow manner to  go so
deep as to keep pace with the increasing sore, but it is very probable
that the lapis  septicus  may answer very well in such cases.  When
this cannot be conveniently used, incision will answer  the purpose
effectually.
  I  have taken out a chancre by dissection, and the sore has healed
up with common dressings.  However,  as our knowledge of the extent
of the disease is not always certain, and as this uncertainty increases
as the size of the chancre, it  becomes necessary in some degree to
assist the cure by proper dressings, and therefore it may be prudent
to dress the sore with  mercurial ointment.  From such treatment
there is but little danger of the constitution being infected, especially
if the chancre has been destroyed almost immediately upon its appear-
ance, as we may then reasonably suppose there has not been time for
absorption.   But, as it must be in most cases uncertain whether there
has been absorption or not, this practice is not always to be trusted
to, and from that circumstance perhaps never should;  and, therefore,
even in those cases where the chancre has been removed almost imme-
diately, it would be prudent  to give some  medicine internally, the
quantity of which should be proportioned to  the time and progress of
the sore;  but if it has spread to a considerable size before extirpation,
then mercury is absolutely necessary, and perhaps not a  great deal is
gained by the extirpation.
  [G. G. B.—The treatment of chancres by caustic or extirpation is
more beautiful in theory than commendable in practice.  It  is impos-
sible to know with certainty to what distance the virus has extended,
and the whole of the  contaminated parts may not therefore be de-
stroyed by the caustic.  This defect is  not always evident at the time.
The sore may cicatrize under the caustic, yet the  virus may not  be
extirpated, and the general system may be subsequently  affected.
Again, caustic seems to  increase the disposition to absorption, so that
if the object  is not attained  by the first application  it will not in
general be  achieved by its repetition.   Hence it  happens, in  very
many instances, that the use of caustic is followed immediately by a
bubo, and, at a more remote period, by secondary symptoms; and the
patient, who might have been cured in the first instance by a moderate
course of mercury, is subsequently exposed to the necessity of passing
through  a protracted course, which is not only attended with much 
320
TREATMENT  OF CHANCRE.
trouble and  annoyance, but which cannot be employed without con-
siderable risk to the general health.   The treatment by caustic should
therefore  be  reserved  for  those cases where, from peculiar circum-
stances, an immediate course of treatment must be avoided at all risks.
   When caustic is supposed to be successful, the sores are, for the
most part, not chancres, but simple pustules  or herpetic vesicles.—
G. G. B.]
   [Ricord.—The destruction of chancres as soon as they appear, or,
in other words, their abortive treatment, is one of the most interesting
points connected with syphilis, and also one which has given rise to
the most erroneous theories and most dangerous modes of practice.
   If a chancre be  at first a local affection, as Hunter asserts, and as
observation and experiment prove it to be, we must be consistent, and
treat it as everybody treats the bite of a serpent or a mad  dog; that is
to say, destroy the  local disease  as  soon as possible, so as to get the
start of absorption and its consecutive phenomena.   Reflect well on
this subject;  on it  depends the future of syphilis; on the one hand is
the possibility of destroying this terrible scourge, and on the  other its
eternal propagation.  Preach the truth to men of the world; tell them
that secondary symptoms have rarely, if ever, followed chancres which
were destroyed before the fifth or sixth day after the infecting coition;
and if  you can drive  them to  examine themselves carefully, and to
destroy early and  thoroughly every suspicious point, you will  save
them from constitutional infection.
   It has been said that chancres which are cauterized are oftener fol-
lowed by secondary syphilis than others; but not a single one of those
persons who  have made this assertion has taken the trouble to point
out the exact condition of the chancres at the time of cauterization; as
if chancres had only one form, and were always the same in all indivi-
duals, in all stages, and in spite of all  possible complications.
   Well, then, taking into account this consideration, without which it
is impossible to reason, we may lay down the following propositions :—
   1. When a chancre  is  destroyed by cauterization  before the sixth
day after infection,  the  cure is very rapid, and the patient is generally
protected from contamination of the system.
  2. When a chancre has already lasted a certain time, and is attended
with induration, cauterization does not  prevent or favor constitutional
infection.   In this case  it is no longer an abortive treatment,  and can
only serve to  modify the ulcer and to hasten its cicatrization, which is
always desirable, since secondary symptoms do not occur in proportion
to the rapidity of the cicatrization.
  3. It is a mistake to say that, by cauterizing a chancre  and healing
it too soon, you lose a guide for the treatment.  The only true guide
furnished by  the primary ulcer is its induration ; and when induration
exists,  cauterization, as  it is commonly practised, does not destroy it.
  4. Even those who censure cauterization, tell you  that secondary
symptoms are proportioned to the extent, number, and duration of the
primary ulcers; and yet they think  themselves logical  when  they
reject a means, which, according to their own doctrine, diminishes the
extent and limits the number of the diseased surfaces, and also abridges 
TREATMENT OF CHANCRE.
321
the duration of the local disease, which is a permanent focus for con-
stitutional infection.
   5. It has  been said that cauterization favors  the development of
buboes.   This is a mistake, which has been accredited on the authority
of Bell's slender statistics.  Daily statistics, collected on an immense
scale at the  Hopital des VeneViens at Paris, give a formal contradiction
to this assertion.  Like any other cause of irritation, cauterization may
excite sympathetic engorgement of the neighboring lymphatic ganglia;
but virulent buboes do not spring up under its influence;  these obey
laws which we shall consider hereafter.
   6. It is very curious to see cauterization applied every day to  all
kinds of poisoned wounds, to malignant pustule, and to the bite of a
dog; to see it employed, also, against  smallpox, in experiments  on
vaccination, &c, without its ever entering anybody's head to ascribe to
its use the constitutional symptoms which generally follow; whilst, in
case of syphilis, an exception is made which nobody can explain, which
'logical  reasoning  repudiates, and  which  experiment  proves not to
exist.
   7. The three methods proposed by Hunter, for destroying the local
disease, may be thus summed up:—
   a. A sharpened crayon of nitrate of silver is the mode which is most
generally applicable, and which is sufficient when the disease has just
commenced, whatever may be its situation.
   b. Caustic potassa should be employed only when we wish to pene-
trate to some depth into the  deeply affected tissues; but in that case
I prefer Vienna paste, which is more easily managed,  and especially
more readily limited in its action.   I now employ monohydrated nitric
acid.
   Formula  for Vienna paste:—
                       R:.—Calcis gv;
                          Potassa? 3yj.—M.
   c. With regard to excision, when performed too near the boundary
of a chancre, the wound soon resumes the character of a virulent ulcer.
When an indurated chancre, or an induration remaining after a chancre
which has cicatrized is completely excised, the wound may still become
a specific ulcer, and a new induration follow; but in  all cases, even
when no ulcer ensues and the wound heals like a simple wound, the
excision of  the induration does not prevent other phenomena of con-
stitutional infection following.
   Old and  fresh wounds  in the neighborhood  of chancres, and  the
excision of  different varieties of chancres, at various distances and in
their various  stages, form the  subject of a work which I shall soon
publish.
  A surgeon,  who a short  time ago thought that he had invented a
suture to be used in circumcision, by which he claimed that he always
obtained union by first  intention in this operation, whatever the pre-
vious state of the parts might have been, maintains at the present day
that, at whatever distance you excise a chancre, the operation is always
followed by a  chanprous ulcer.   On which  occasion was this  surgeon
right ?—Ricord.]
      21 
322
TREATMENT OF CHANCRE.
  [Editor.__In his recent work on chancre, M. Ricord states that he is now
using, in the abortive treatment of chancres, a paste composed of sulphuric
acid and vegetable charcoal, combined in sufficient quantities to form a  semi-
solid.  This caustic applied to the surface of a chancre forms a dark-colored
crust, which adheres to the tissues, and does not, as a  general rule, become
detached till the second week, by which time the surface beneath is nearly or
quite healed.
  The application of  this caustic excites severe pain, much less, however,
than that produced by nitric acid or the actual  cautery, and less persistent
than the pain produced by Vienna paste.  Its action extends to a considerable
depth, and, like the  chancre  itself, appears  to  modify  the tissues in the
neighborhood; hence  it is the best agent we can employ for the purpose of
destroying a specific ulcer.]

            § 2.  Of the Cure of Chancres.—Local Application.

   The cure of a chancre is a different thing from  its destruction, and
consists in destroying its  venereal  disposition, which  being effected,
the parts heal of course as far as they are venereal.
   Chancres may be cured  in two  different ways, either by external
applications, or  internal through the circulation.   The same medicine
is necessary for both these purposes, that is, mercury.
   I have shown that a gonorrhoea and a chancre have so far the same
disposition as to form the same kind of matter, yet I have also observed
that mercury has no more power in curing the gonorrhoea than any
other medicine, and  therefore it might be supposed  that mercury would
 have  no effect in the present complaint; but we find that in a chancre
 it is a specific, and will  cure every  one  that  is truly venereal; but as
 other dispositions take place, so other assistance is often necessary, as
 will be taken notice of in the history of the cure.  The action of this
 medicine  must be the same in whatever way it is given, for its action
 must be upon the vessels of the part, in one way acting only externally,
 in the other internally.1
    For external  local applications mercurial ointments are the common
 dressings; but  if the mercury were joined with watery substances in-
 stead of oily, by mixing with the matter, the application would be con-
 tinued longer to the sore, and would prove  more effectual.   This is an
 advantage that  poultices have over common  dressings.  I have often
 used  mercury rubbed down  with  some conserve in the room of an
 ointment, and  it has answered  extremely well.  Calomel used in the
 same way, and   also the other  preparations of mercury mixed with

   1 This is well illustrated by the application of some medicines locally to parts whose
 actions are immediate and visible ; and by throwing the same medicine into the con-
 stitution the same immediate and visible effect is produced ;  for instance, if ten grains
 of ipecacuanha is thrown into the stomach of a dog it will in a short time make him
 vomit, from its local applications to that  viscus; and if a  solution of five grains is
 thrown into a vein it will produce vomiting before we can conceive it to have got to
 the vessels of the  stomach.  The same effects are produced from an infusion of jalap
 thrown into the veins that are commonly produced when taken into the stomach and
 bowels. 
TREATMENT OF CHANCRE.               323
mucilage or with honey, answer the same purpose.   Such dressings
will  effect a cure  in  cases that are truly venereal; but perhaps we
seldom have a constitution quite free from some morbid tendency.
  Some will have  an  indolent disposition, to counteract which it will
be right to join with the mercury some warm balsam in a small pro-
portion, or  as much  red precipitate  as will only stimulate, without
acting as an escharotic; and sometimes both may be necessary.
  Calomel mixed with some salve, or any other substance which will
suspend it, is more active than common mercurial ointment, and in
such cases as require  stimulating applications it will answer better.
  Many other applications are recommended, such as solutions of blue
vitriol, verdigris, calomel, with the spiritus nitri dulcis, and many others.
  But as all of these  are  only of service  in  remedying any peculiar
disposition  of the  parts, having no specific power  on the venereal
poison, and as such dispositions are innumerable, it becomes almost
impossible  to say what will be effectual in  every disposition; some
will answer in  one state of the  sores, some in another.   It may be
found oftentimes that the parts affected are extremely irritable; in such
cases it will be necessary to mix the mercury with opium, or perhaps
preparations of lead,  as white or red  lead, to diminish the  action of
the parts.
  The oftener the  dressings are shifted the better, as the matter from
the sore separates  the application  from the diseased parts, by which
means the  effects  are lost or diminished.  Three times every day in
many cases is not oftener than necessary, especially if the dressings are
of the unctuous kind; for they do not mix, like watery dressings, with
the matter, so as to impart some of their virtues to it, which would, in
a proportional degree, affect the sore.
   Chancres, after having their venereal taint corrected, often become
stationary, and having acquired new dispositions, increase the quantity
of disease in the part, as will be taken notice of hereafter.  When they
become  stationary only, they may often be cured by touching them
slightly with the lunar caustic.  They seem to require that the surface
which has been  contaminated, or the new flesh which grows upon that
surface, should be either destroyed or altered before it can cicatrize;
and it is often surprising how quickly they will heal after being touched,
and probably once or twice may be sufficient.
   [Ricord.—1.  Although, as a general rule, we should not dress an
ulcer or a wound so frequently as to interfere with the process of cica-
trization, yet we must take care not to follow the same precept with
regard to chancres in the progressive stage; here, we must recollect,
that the secreted pus is  a permanent cause of disease, and that it is
important not to let it remain on the tissues.  The dressings should be
repeated, therefore, three or four times a day, according to the abund-
ance of the suppuration.
   2.  It is a rule,  with the exception of certain cases which will be
mentioned hereafter,  to keep the affected parts exposed; and we must
be very careful  not to let cutaneous chancres be covered with scabs,
under which the pus  may stagnate and burrow.
   3.  So long as a  chancre remains in a state of ulceration, it  may be 
324
TREATMENT  OF  CHANCRE.
cauterized with nitrate of silver or nitric acid, whenever its floor or
edges—after the fall of eschars produced by previous cauterizations—
present the characters belonging to this period; but  as  soon as the
reparative stage  commences, we should  spare those parts which are
healing, but redouble our care in cauterizing those which are still in
the course of specific ulceration.
  4. Fatty substances, in general, are commonly injurious in the treat-
ment of chancres;  and we may assert that, except  in certain  cases,
mercurial ointments are more injurious than any others.   Nothing is
more common than to see non-indurated chancres multiply, extend, or
become inflamed, when they are dressed with mercurial ointments.
  5. As we have already said, it  is well  not  to leave the pus of a
chancre in contact with the secreting surface;  and it is  also very de-
sirable to diminish its secretion.  Dry charpie, which forms a kind of
sponge, and carded  cotton fulfil  one of these indications.  But the
treatment which yields the  most rapid  cures, is with the aromatic
wine of the French codex.   The following is the manner in which I
employ it:—
  I direct patients to wash the ulcer carefully with this liquid, without,
however, fatiguing the parts, or making them bleed;  and then to apply
a little fine charpie, soaked in it just enough to be moist; for, when it
is too wet, it macerates the parts and impairs the effect.  At each dress-
ing, the charpie should be moistened with the same fluid before being
detached, so as not to tear the ulcer, to which  it may have adhered in
drying.
  All persons who will follow my clinique at the Hopital du Midi, can
convince themselves of the good effects of this treatment; after which,
unless it be badly applied, successive chancres never occur, as takes place
so frequently after other  dressings.  The aromatic wine diminishes the
purulent secretion, tends to  modify and  cicatrize the surface of the
virulent ulcer; and, by acting on the neighboring  parts as a powerful
astringent, renders them incapable of inoculation.
  But I have met with some patients in whom the secretion continued
to be very abundant even under this treatment; and, in that case, dress-
ings with the vinous  decoction of oak bark were perfectly successful.
I, however, now prefer the following solution:1—
                      R.—Ferri et potassse tart, gv;
                          Aquae §vj.—M.
  When there is pain, and the aromatic wine increases it, we may, by
adding six or seven grains of extract of  opium to every ounce, again
make it a very excellent application.  It is well to  remark, however,
that among those patients who continue  to  suffer pain, some will be
found in whom  it is  made to disappear by increasing the quantity of
opium; while, in others, the latter must be diminished.
  Yet in some cases  it is necessary to suspend the medicated wine or

  1 In his Lecons sur le Chancre, M. Ricord speaks in the highest terms of this solu-
tion as a dressing for chanores, especially when the sore shows a tendency to extend.
Indeed, he regards it as almost a specific against phagedenic ulceration, when given
internally as well as applied locally. He uses the same formula for internal adminis-
tration, ordering the patient to take a tablespoonful three times a day.—Ed. 
TREATMENT  OF CHANCRE.
325
the ferruginous solution for a while, or even to give them up entirely.
Thus, in some patients, the suppuration ceases, but the ulcer remains
stationary, and, in that case, we should substitute, for several days, a
dressing of some emollient decoction or opiated cerate,1 and afterwards
resume the wine or  the solution.  Also, in some other patients, when
the ulcers are accompanied by induration, these dressings increase the
latter,  and  prevent  cicatrization.   But with  the exception of these
cases, those means which I have  mentioned constitute  the general
mode of dressing which I prefer.
   6. When the reparative  stage commences, so long as it  proceeds
regularly, we must continue the dressings, resuming cauterization only
when  it is necessary to  repress  exuberant granulations.  Finally, it
often happens that nothing  is wanting but the  epidermis to complete
the cure; the surface of the ulcer, raised to a level with the surround-
ing parts, is red, and covered with scarcely any secretion, and yet the
ulcer does not heal.   Then, the superficial application of nitrate of sil-
ver, so as  to whiten the surface without cauterizing it deeply, will be
sufficient to complete the  cure.
   7. In regular uncomplicated chancres, local treatment  is sufficient,
provided that no induration be left after the treatment in the part which
was affected.  During this treatment, we should content ourselves with
keeping the patient  as quiet as possible, and subjecting him to regimen
proportioned to his constitution.  Indeed, in this respect, we want no
invariable rule.   Debilitating regimen, strict diet, diluent drinks, and
general and local antiphlogistics, which are indicated in stout  indivi-
duals  inclined to inflammation, would be most injurious  in  feeble
lymphatic  subjects,  already suffering  from  imperfect  nourishment.
For such we should prescribe with caution  a moderately tonic regi-
men, and,  in general, all  such means as will correct  any abnormal
deviation of the system and remedy any concomitant unhealthy state;
for we must recollect that a poor constitution or coexisting diseases
are  the cause of the complications which may accompany chancres,
and of the vicious course which they may follow.
   When a regular  chancre has cicatrized, and  the tissues beneath it
have completely recovered their normal state, the patient, after  a few
days, may indulge without fear in sexual intercourse.  But the case is
different when an induration is  left beneath the cicatrix, which may
again  open, giving rise to ulcerations, and we must recommend abso-
lute continence until the  cure is perfect.
   But now let us examine, in respect to their treatment, the principal
varieties of chancre which we have admitted.
   1.  Concealed Chancres.—When a  chancre  is situated in the urethra,
and is accompanied  with  symptoms of acute gonorrhcea, antiphlogistic
treatment should be resorted to at first; as leeches to the perineum and
over the symphysis pubis, emollient or opiated local baths, general
bathing, and copious drinks.  The  patient  should endeavor to avoid
erections, which stretch the diseased parts, tear  them, and increase the

   1 The opiated cerate of the Formulaire des Hdpitaux de Paris contains a drachm of
laudanum to an ounce of cerate.—Ed. 
326               TREATMENT OF CHANCRE.
ulceration.  For this purpose, I prescribe two of the following pills to
be taken every evening:—
                      R;.—Pulv. camphorse,
                          Ext. lactucse, aa Qij.
                          M. ft. pil. xx.
  If small abscesses form  in the part of the canal occupied  by the
chancre, care must be taken to open them early; finally, when the
inflammatory complications are quieted,  injections should be made in
the urethra of aromatic wine, at first diluted with an equal quantity of
a decoction of  poppy-heads, and afterwards  pure, if it do not excite
irritation.  A solution of tartarized iron is also very good.
  When the chancre is situated at the opening of  the canal, so as to
be seen, the treatment directed for other chancres is applicable to it;
only it  is very useful, in case the patient can bear  it, to keep a little
cylinder of charpie, soaked in the lotion that is used for the dressing,
between the lips of the meatus, so as to prevent their coming in contact.
  With regard to the gonorrhcea which accompanies the chancre in
such cases, when dependent solely upon the latter, it disappears with
it;  or, when it is a concomitant affection, it subsides under the use of
antiblennorrhagics, which should be employed at  the same time with
the other treatment.
  In cases where chancres are situated in the deep  parts of the vagina,
on  the  os tineas, or within  the uterine cavity, the parts should be ex-
posed at each dressing, by means of a speculum, so as  to enable us to
cauterize the ulcers and make the necessary topical applications.  With
regard  to chancres of the inferior part of the rectum and of the anus,
they demand the greatest cleanliness and repeated dressings, especially
after the stools, which should  be made easy in every possible way.
The stools should also be  preceded, if  possible, by a  small, strongly
mucilaginous enema, so that the hard feces may not fret the diseased
parts.   This precaution is almost indispensable, and should be omitted
only in case the passage of the clyster-pipe—which, by the way, should
be of India rubber—excites  more pain  than the passage of the feces.
Dressings are maintained in  this part by means of a small mesh; or
when the presence of a foreign body excites too much spasm and pain,
they may be simply inserted flatwise against the  affected membrane,
or the  fluid  may be injected.  We must be careful not to repeat the
 error which has been made of mistaking ulcers of this nature for
 simple fissures, and excising them, which does  not fail to extend the
 disease.
   2. Superficial Chancres.—In most cases these chancres present no
 peculiar indication.  When they are situated on the glans or prepuce,
 and complicated with balanitis, they may be mistaken, in case they are
 not indurated, for simple erosions accompanying this catarrhal inflam-
 mation, but then superficial cauterization and the  interposition of fine
 linen between the glans and  prepuce, suffice to make them  disappear
 in a few days; if they resist, they are to  receive  the  complete  treat-
 ment for chancres above directed.
   3. Indurated  Chancres.—Induration,  an  essential property of the
 classic Hunterian chancre, should never be lost  sight of in treating 
TREATMENT OF CHANCRE.
327
venereal ulcers; for though it is undoubtedly true that the chancre in
this case may be cured by various means, and that it sometimes cures
itself without the assistance of art, it is none the less true that, in most
cases, the induration remains after cicatrization of the  ulcer, and it is
well known what will  then happen.   It is rare for much inflamma-
tion or pain to complicate  this variety of chancre, and the treatment
should be directed chiefly with reference  to  the induration.   In the
most simple cases, indurated chancres should be dressed two or three
times a day with fine charpie smeared with a thin coating of the fol-
lowing ointment:—
          R.—Hydrarg. chloridi mitis gr. xv ;
              Unguenti opii, vel ung. cucumis sativi, §j.—M.
   If there be much suppuration, this dressing should  be preceded  by
a lotion  of  the aromatic wine;  and if it still  continue too abundant,
the wine should be used alone.
   But if nervous  irritability and  inflammation be present, and the
molecular gangrene extend, we should use in preference a concentrated
solution of  opium, and employ emollients and antiphlogistics at the
same time,  until the ulcer is restored to a more simple state.
   In small  indurated chancres, cauterization  is much less efficacious
than in other varieties,  for it cannot reach the whole disease ; still, the
application of nitrate of silver  is not without  benefit;  it favorably
modifies the surface, often stops the progress of the gangrene, and in
the reparative stage suitably represses the granulations, which, in this
form,  have  sometimes a tendency to become fungous and vegetate.  It
is proper to say that nitrate of silver  is injurious  to this variety of
chancre, only so far as it is misapplied.
   With regard to mercurial ointments directed against the induration
 remaining  after cicatrization of the chancre, though  they are often suc-
 cessful,  it should be understood that, in some cases, more  particularly
 when applied to  mucous surfaces, they soon excite irritation, and
 bring back the stage  of  ulceration, especially when  the  ointment is
 rancid.
   But though skilful local treatment  is frequently sufficient for  the
 complete cure of indurated chancres, yet, in the majority of cases, a
 cure by these means is very slow, and even when once obtained is only im-
perfect.   The difficulty of radically curing indurated chancres by ordi-
 nary  remedies, and the good  effects  of  mercurial  treatment, are  the
 principal arguments which have led this chancre to be considered as
 the only type of primary syphilis, and mercury as  its only specific.
   4. Diphtheritic, or Pultaceous Phagedenic Chancres.—The causes which
 give rise to this  variety of chancre should be carefully studied.  The
 patient's residence is often unhealthy, cold, and moist, and if he changes
 it for the better, his disease improves.  In this way, chancres contracted
 in warm countries and brought to a northern climate, are often aggra-
 vated in a  frightful manner; but when transported from north to south,
 they frequently heal rapidly and favorably.
   In  this variety of chancres, we frequently find some coexisting affec-
 tion of  the viscera, under the influence of which it seems to be devel-
 oped.  As we have already said, it is most commonly some derange- 
328               TREATMENT OF CHANCRE.
ment of the digestive organs, and then we should direct our treatment
principally against this cause ; if it be allowed to go on, or be aggra-
vated by bad treatment, we must not hope to cure the syphilitic ulcer
which depends upon it.
  While we fulfil all the therapeutical indications which may be pre-
sented by other pathological  affections, such as  scrofula, scurvy, dar-
trous diseases, &c., which often complicate the variety of chancre which
we are now considering, we must beware of attributing  the rapid and
untoward progress of the ulcer to the  greater intensity of the virus;
this is a common  error, which  does much harm, by inducing  those
practitioners who follow exclusively the old ideas on this subject, to
resort promptly and energetically to the asserted  specific, and to ad-
minister mercury in doses proportioned to the  strength of the virus
which they wish to neutralize.
  I  feel authorized to  assert that, with a very few exceptions, the
common use of mercurial dressings externally, and mercurial prepara-
tions internally, are injurious to the extreme in  a sloughing  or  diph-
theritic  chancre;  and the more so, since this chancre, not being  indu-
rated, is oftener complicated with inflammatory symptoms and nervous
irritability.  Indeed, it is not uncommon to see these ulcers,  when on
the  point  of passing into the  reparative stage,  become very  much
worse under the influence of this treatment, and from  being limited
and  regular, become phagedenic and serpiginous, simply from  the
effect of mercurial treatment.
  Whatever the origin of a chancre of this form  may be, whether it
succeed a chancre of the skin or of the mucous membrane, or a viru-
lent bubo, the most favorable  treatment, and the one which is most
frequently and promptly followed by success, consists in the combined
use  of cauterization and the local application  of aromatic  wine, or
especially  the solution of tartarized iron.   Cauterizations with mono-
hydrated nitric acid should be made to penetrate deeply, and should
be repeated in  some cases twice a day, so as to follow the disease in its
progress.  The dressings should be repeated in the same way, for the
secretion is very abundant, and should be  often  removed.  In some
patients, the ulcer is made to heal. only by irrigating it  almost con-
stantly.
   Care must also be taken not to tear or scratch the skin in  changing
the dressings ;  each new rent is inoculated, and every abrasion  of the
skin favors the absorption of the virus and the extent of the disease.
   When the local inflammation is very acute, it has been advised to
apply leeches within the ulcer; I myself disapprove of this treatment,
as its results are far from having the advantages that some practitioners
attribute to it; and besides the difficulty of making these animals take
hold on an ulcerated surface, their bites extend the ulcers to the depth
of the divided tissues.   With still stronger reason, we  should abstain
from applying them in  the  neighborhood of chancres; for  each bite
with which the pus comes in contact forms a fresh ulcer.  When the
local inflammation requires depletion, leeches should be applied at some
distance and in non-depending parts, and their bites should afterwards
be protected  by compresses  soaked in lead water, to  preserve them 
                   TREATMENT OF CHANCRE.                329

from contact with the pus, until  they are completely healed.  Again,  «
in cases of inflammatory complications, starch or milk poultices, warm
mucilaginous baths, with diet suited to the general and local symptoms,
absolute rest and diluent drinks, soon produce favorable results.
   These chancres  may be attended with  great irritability  and pain,
both with  and without inflammation; in both cases, so long as these
symptoms last, preparations of opium should be used externally and
internally.  The following local application should be made:—
                       R:.—Extracti opii gj;
                           Aquae lactucae §vj.—M.
   But here, again, cauterization with nitrate of silver is a powerful
auxiliary.   We must beware of allowing ourselves to be deceived by
erroneous  ideas, and  must continue  the application of the caustic  in
spite of the pain and inflammation.   In most cases, nitrate of silver is
the most powerful  sedative and  the  most certain antiphlogistic,  when
well applied.  Every day the students following my clinique convince
themselves of this  truth, and  hear patients request to be cauterized.
The severe pain that it excites for a moment on the application of the
caustic soon lulls,  and  gives place to a sensation of ease, such as  is
sought for in vain by other treatment.
   Whatever may be  said on the subject, there are but few exceptions
to this rule, and only a few cases are met with in which it is  necessary
for a time to omit the combined application of these means, substituting
fatty dressings, and more particularly opiated cerate.
   However, a phagedenic chancre may continue to extend, or remain
in statu quo and show no tendency to  heal.   When we cannot discover
the cause of the obstinacy of such cases, we may still sometimes succeed
with carrot poultices, warm melted wax, or digestive ointments.   The
most powerful caustics  are sometimes used with benefit in such  cases,
as butter of antimony,  caustic potash, the arsenical paste of  Rousselot
or frere Come,' and the actual cautery applied directly or objectively.2
I have  employed Vienna paste, and especially monohydrated  nitric
acid, with success.
  But frequently in  the phagedenic variety of chancre,  the edges  of
the ulcer are so undermined and thinned, that it is an impossibility and
a mere loss of time to attempt to cure it so  long as this state of things
continues.   The affected tissues should be destroyed; but to  act effica-
ciously and promptly,  it is important to  establish some distinctions.
When the ulceration  follows an abscess, the edges may be extensively
undermined, and the  skin very thin from the confinement of the pus,
without having assumed the phagedenic form in the sense that we at-
tach to the expression;  whilst in other cases it may follow this abnor-

  1 Formula  for Rousselot's arsenical powder (French Codex):—
                   R.—Acidi arseniosi 3J !
                       Sanguinis draconis,
                       Hydrarg. sulph. rubri, aa 3ij<—M.
  This powder is made  into  a paste at the time of using it by mixture with  a little
saliva or mucilage.—Ed.
  8 Objective cauterization consists in holding the cautery at a short distance from the
part to be cauterized.—Ed. 
330
TREATMENT  OF  CHANCRE.
0 mal course.  In case there is no  true phagedena, no matter what the
  extent of the tissues  to  be sacrificed  may be, a knife, or better still,
  curved scissors, may be used to remove them freely, so as to give the
  wound the most favorable form  for cicatrization; but we should, as
  much as possible, avoid producing any deformity, which, in certain
  regions, remains an indelible witness of a disease, even the old attacka
  of which it is important  to conceal.  But  the use of the knife is pre-
  judicial in the extreme when we have in hand a progressing phagedenic
  ulcer; far from limiting  the disease, it  aggravates and increases it, un-
  less the bleeding wound  be immediately cauterized; but it is better in
  these cases to use caustics alone, and Vienna paste in preference to all
  others.  With this caustic we may not  only clearly limit the parts to
  be removed, but  possibly destroy completely the virulent surface, or
  at least protect  the new edges of the ulcer from immediate inoculation,
  by the interposition of an eschar and by a kind of vital reaction, the
  absence of which, in some cases,  is one of the principal causes of the
  progress of the ulceration.
     But, following the rule which I have previously laid down, must we
  invariably abstain from the use of mercurials and the various remedies
  recommended as anti-syphilitics ?  Though it is undoubtedly true that
  in the great majority of  the cases before  us, mercury, sudorifics, &c,
  are more prejudicial than useful, still, there are instances in which they
  are the only means that produce a good effect.  This fact is often proved
  even in the practice of those who have born the bitterest hate to mer-
  curials.   But is it possible, in the present state of science, to point out
  precisely the instances in which mercury is  useful or indispensable ? So
  far as I know, such cases have no characteristic mark.  But when the
  disease goes on in spite of the means indicated  above, as a last resort,
  I employ the treatment which has so long been regarded as specific.  I
  first  apply it in local applications, and then as a general  agent given
  internally or by frictions through the skin;  afterwards, according to
  the effect obtained, I continue the local  application, or the general treat-
  ment alone, or both together, if amelioration takes place, or suspend
  them if the disease become worse under their influence.  Wnenever a
  person, following the practice of the old school, thinks that he should
  commence with mercurials, a course which  I do not recommend, he
  should at least  beware of proceeding blindly, and should  suspend his
  treatment as soon  as he finds the results unfavorable.
     With regard to other so-called anti-syphilitic agents, they may be
  used when there is need  of general tonics or stimulants to act on the
  digestive tube,  the skin,  the urinary passages, &c.  In the same way,
  emollients and local or general antiphlogistics are very often called for,
  and are also efficacious when understandingly and suitably employed.
   The internal treatment which has lately given me the most favorable
  results is the administration of the tartrate of iron and potash, in doses
  of from two scruples to  three drachms a day, in the form of solution
   or in syrup.1

     1 The curative influence of an attack of erysipelas, supervening upon a phagedenic
  ulceration, is often remarkable. Ricord states that he has seen two enormous pha-
   gedenic chancres, which had resisted all treatment, get well after being thus modified.—
   Ed. 
TREATMENT OF PHIMOSIS.
331
   5.  Gangrenous Phagedenic Chancres from Excessive Inflammation.—
The inflammation which gives these chancres their peculiar form should
be the principal object of treatment.  It cannot be too often reiterated,
that in these cases the original cause of the disease should for a time
be forgotten.  How many accidents do we  see result from mercurial
treatment, used unseasonably and empirically, and directed against the
specific cause, in spite of the complication  which contraindicates it!
I repeat again, the element to contend against, the symptom which for
a time constitutes the principal disease, is the inflammation.  All our
remedies  should  be directed against this,  and should be proportioned
to its intensity.   If, in spite of our rational and sound practice, gan-
grene supervene, it  requires no other treatment than  ordinary cases
entirely foreign to syphilis.  Other indications present themselves only
after  these symptoms have disappeared, leaving the chancre under one
of the forms previously mentioned; but generally the  chancre is then
replaced by a simple wound, which ordinary local means lead to rapid
cicatrization.
   Whenever any variety of phagedenic chancre perforates the frasnum,
and produces a fistulous passage, isolating portions of the tissues,  the
parts  thus separated and ulcerated should be divided or excised; their
mutual contact keeps up the morbid state, and the position of the parts
prevents  adhesion.   For  example, when the frasnum is perforated, a
cure is obtained in  half the  time by excising it with small  curved scis-
sors;  one blade of  the scissors is passed through the opening and  the
bridle severed close to the glans; then the remaining portion adherent
to the prepuce is cut off, and the ulcerated  surface and the bleeding
tissues are exposed and carefully cauterized.
   In  order to avoid the annoying hemorrhage after  section  of  the
frasnum, which  cauterization does  not  always promptly  stop, I pre-
viously pass two threads  through the perforation, tying one next to
the glans, and the other next the prepuce, and then cut between  the
two ligatures.—Ricord.]

§  3.  Of the Treatment of Phimosis in consequence of or attended with
                             Chancre.

   From the history which I have given of the disease, we must  see
that a phimosis  may be of two  kinds;  one natural, with the disease
superadded, the other brought on by disease.  The  first  may  be  in-
creased by the disease; but if otherwise,-it is not so troublesome as
the other.  Such as arise  from the  disease, I  have observed, depend
upon  the peculiarity of the constitution.  In either  case it is often
not practicable to apply dressings to the chancres or the inside  of the
prepuce.
  A phimosis should be  prevented, if possible; therefore, upon the
least signs of a thickening of the  prepuce, which is known  by  its
being retracted with difficulty and  pain, the patient should  be kept
quiet;  if in bed, so much  the  better, as in an horizontal position the
end of the penis will not  be so depending, but may be kept up.  If
confinement in bed cannot be complied with, then the end of the penis 
332
TREATMENT  OF PHIMOSIS.
should be kept up to the belly, if possible; but  this can  hardly be
done when the person is obliged to walk about, for the extravasated
fluids, descending and remaining in the prepuce, contribute often more
to render the prepuce incapable of being drawn back than the inflam-
mation itself.
   When the diseased phimosis completely takes place, the same pre-
cautions may  be  followed; but as  the sores cannot be dressed in the
common way, we must  have recourse either to dressings  in form of
injections, or to the operation for the phimosis.  If we use  injections
only, they should be often repeated, as they are only temporary appli-
cations.
   The dressings, in  form of injections, should be mercurial, either
crude mercury rubbed down  with a thick solution of gum Arabic,
which will assist  in retaining some of the injection between the glans
and prepuce;  or  calomel with the same, and a proportion of opium.
In the proportion of these no nicety is required;  but if a solution of
corrosive sublimate is made use of as an injection, some attention is to
be paid to its  strength.   About one grain of this to an ounce of water
will be as much as the sensation of the  part will allow the  patient to
bear, and if this  gives too much pain it may be  lowered by adding
more water.
   After the parts are as well cleaned as possible with this injection, it
will be necessary to  introduce  other mercurial applications of some
kind, to remain there till the parts want cleaning again, which will be
very soon.  Such as are mentioned before will answer this purpose
very well;  but I have  my doubts about the propriety of  using any
irritating medicines or injections in such cases.
   As often as he voids his urine the patient may wash the parts, by
pressing the orifice of the prepuce together, so  as to  oblige  the water
to run back between the prepuce and glans;  and immediately after
this the patient should  use the  mercurial applications, otherwise  this
operation of washing may do harm, as it will wash away the former
application of mercury; but in many cases the parts are so sore as not
to allow of  this practice.
   A poultice of linseed meal alone, or of equal parts of this and bread,
should be applied.  This poultice should be made with water, to which
one-eighth of laudanum has been added.   But previous to  this, and
immediately after  the  cleaning, it would be very  proper to let the
penis hang over the steam of hot water, with a little  vinegar  and
spirits of wine in it, which is the neatest way of applying fomentations.
   The oftener this is practised the better, for thus, a mercurial applica-
tion is kept in contact with the diseased parts a greater number of the
hours out of the twenty-four than otherwise could be were the matter
allowed to lie on the parts.
   When to the above mentioned symptoms a bleeding of the chancre
is added, I do not know a more troublesome complaint, because here
the cells or. veins  have no great  disposition for contraction.1  Oil of

   1 I suspect that, where chancres bleed profusely, the blood comes either from the
glans, when there are chancres there, or from the spongy substance  of the urethra, 
TREATMENT  OF PHIMOSIS.
333
turpentine gives the best stimulus for the contraction of vessels of all
kinds; but where bleeding arises from an irritable action of the ves-
sels, which is sometimes the case, then sedatives are the best applica-
tions.  Whatever is used  in such a state  of the prepuce must be
injected into the part.
  When, in consequence of the treatment, the inflammation begins to
go off, and the chancres to heal, it will  be necessary to move the pre-
puce  upon the glans as much as they  will allow of, to prevent adhe-
sions, which sometimes happen when there have been chancres on both
surfaces  opposite to  each other.  Indeed, the practice  here recom-
mended is such as will in general prevent such consequences.
  If this has not been properly attended to, and the parts have grown
together, the consequences may not be  bad; but it must be very dis-
agreeable to the patient, and a reflection upon the surgeon.
  I have seen the opening into the prepuce so much contracted from
all  these internal ulcers healing and uniting, that there was hardly any
passage for the water.   If the passage in the prepuce so contracted be
in a direct  line with the orifice of the urethra, then a bougie may be
readily passed; but this is not always the case; it often  happens that
they are not in a direct line; therefore an operation becomes necessary.
The operation consists in either slitting up part, of the prepuce, or
removing part of it; but as these parts have become very indistinct
from  the adhesions, either the slitting  it up, or removing  part of it,
becomes a difficult operation.  Whenever the urethra is discovered, or
can be found out by a bougie, that is to  be introduced, and its applica-
tion repeated till the passage becomes free, and has got into the habit
of keeping so.
  I observed formerly that this tumefaction sometimes produced a con-
finement of the matter formed by the chancre, and that while this effect
lasted, no subsiding  of the inflammation or tumefaction could take
place; that, therefore, those diseases continued to exist,  and that the
part thus circumstanced came under our definition of an abscess;  that
is, the formation of matter in a state  of confinement.  Although it
never has been  considered in this  light, yet the necessary treatment
shows it to be such.   This consists in laying it open from the external
orifice to the  bottom where the matter  lies, as in a sinus, so as to dis-
charge it.  However, the intention annexed to this practice was not to
allow of the discharge of the matter of the sore, but to admit of the
applications of  dressings  to  it, for it has been recommended and
practised where there was no particular confinement of matter, which
I have not found to be necessary merely for that purpose, as we are in
possession  of  an  internal remedy; and if  the opening  produces no
other good but the allowing of the application of dressings, it is not
so material, because the sores may be washed with an injection through       %
a syringe.

where the chancre has begun about the fraenum, for we seldom see profuse bleedings
from the prepuce when its inside is the seat of the chancre, and can be exposed; but,
indeed, in such cases, the inflammation is not violent. 
334
TREATMENT OF PHIMOSIS.
  § 4.  Of the common Operation for the Phimosis produced by Chancres.

   The common operation for the phimosis is slitting the prepuce nearly
its whole length, in the direction of the penis; but even this is some-
times thought not  sufficient, and  it is directed to cut the  prepuce in
two different places, nearly opposite to  one  another.  When it was
thought  proper to be done in  this way, it was imagined that it was
seldom necessary to cut the whole length of the prepuce.  It will in
some degree depend on circumstances which practice is to be followed.
If it is a natural phimosis, without tumefaction,  and the chancre is
near the orifice of the prepuce, which in some cases it most probably
will be, as the glans  is not denuded in coition so as to have chancres
deeper seated, then it may  be necessary only to go as far as the chan-
cres extend.
   From the common  situation  of the chancre, this disease  of the phi-
mosis  arises more commonly from the tumefaction of the  parts;  and
from the idea I have endeavored  to give of the inconveniences aris-
ing from this phimosis, where  the  chancres  are  placed behind the
corona, producing a  confinement of the matter behind the glans, slit-
ting open the prepuce a little way cannot be sufficient, for in such cases
it must be exposed to the bottom, or no good can arise from the opera-
tion.
   Although this operation  will not take off the tumefaction of the pre-
puce so  as to allow it to be brought back, yet it  will allow of a free
discharge of the matter; and also, in some cases, it will allow of dress-
ings being applied to the sores, but not in all, for the tumefaction will
not allow more of an inversion of the prepuce than before, and in such
the sores cannot have dressings applied  to them.
   In many cases, it will be found that so violent an operation is im-
proper, for it often happens that,  while  the inflammation  is  so very
considerable, there is danger of increasing it by this additional violence,
of which mortification may be the consequence;  while, on the other
hand, there  are cases where a freedom given to the parts  would pre-
vent mortification, so that the surgeon must be guided by the  appear-
ances and other circumstances.   Besides these reasons for and against
the operation arising from the disease itself, it will not always be con-
sented to by the  patients  themselves, for sosie have such a dread of
operations that they will not submit to cutting instruments; however,
in those cases where the matter is confined, it will be absolutely neces-
sary to have an opening somewhere for the discharge of it.   This is
often produced by the ulcerative process going on on the inside, which
makes an opening directly  through the skin, laterally, which affords a
direction for the surgeon; therefore, the opening may be made directly
into the  cavity of the prepuce, through the skin,  on the side of the
penis, by a lancet; or a small caustic may be applied there, for which
the lapis septicus  is the most convenient.
   The opening will allow of the discharge of the matter, and also
admit any proper wash to be thrown in.  But this  opening should not
be a large one, as in many  cases the consequence of this lateral open-
ing proves very troublesome; for, from the tumefaction of the prepuce, 
TREATMENT OF PHIMOSIS.
335
the glans is squeezed on all sides, and rather more  backwards  upon
the body of  the penis than in any other direction, by which means it
is often forced through this opening, whereby the glans is directed  to
one side, and the prepuce to the opposite, having a forked appearance.
Besides, this state of the parts tightens the skin of the penis round
the root of the glans, acting there somewhat like a paraphimosis, and
sometimes makes the whole prepuce mortify and drop off, which is
often a lucky circumstance; but if this is  not  the consequence, then
amputation of the prepuce becomes necessary;  however, this should
not be done till all inflammation is gone off, and the chancres are cured,
when probably the tumefaction of the prepuce will have considerably
subsided.
  A mortification of the prepuce is sometimes a consequence of chan-
cres when attended with violent inflammation, even without any pre-
vious operation; and 1 have seen cases where the glans and  part of
the penis  have mortified, while the prepuce has kept its ground.  But
I should suspect in all such cases that there is some fault  in the con-
stitution, and that  the inflammation is of the erysipelatous, not of the
true suppurative kind.
  I have seen the mortification go so far as to remove the whole of
the diseased prepuce, and the parts have put on so favorable an  ap-
pearance that I have treated it as a common sore, and no bad conse-
quences  have happened.  In this case the disease performed what is
often recommended in other diseases of this part, that is, circumcision;
but this is not always to  be trusted to, for if absorption of the vene-
real matter has taken place previous to the mortification, a lues venerea
will be the consequence, although the parts heal very readily.

          § 5. Of the Constitutional Treatment of Phimosis.

   In those cases where violent inflammation has attacked the seat of a
chancre, producing phimosis as before  described, and often so  as to
threaten mortification, a question naturally occurs, what is to be  done?
Is mercury to be given  freely to get rid of the first cause? or does that
medicine increase the effect while it destroys the cause ?  Nothing but
experience can determine this.
   I should incline to believe that it is  necessary that mercury should
be given, for I am afraid our powers to correct such a constitution,
while the first cause subsists, are weak.  However, on the other hand,
I believe  the mercury should be given sparingly; for if it assists in
disposing the constitution to such symptoms we are gaining nothing,
but may lose by its use.   I therefore do suppose that  such  medicines
as may be thought necessary for the constitution should be given liber-
ally, as well as the specific.  Bark is the medicine that probably will
be of most general use; opium in most cases of this kind will also be
of singular  service.   The bark should be given in large quantities,
and along with it mercury, while the virus is still supposed to  exist.
Or if the inflammation  has  arisen  early in the disease, they may be
then given together, so as to counteract both diseases, and  not  allow
the inflammation to come to so great a height as it would otherwise do 
336
TREATMENT OF PHIMOSIS.
if mercury was  given at first  alone.  This inflammation  may be so
great in many cases, or be so predominant, that mercury may increase
the disposition, and  therefore become hurtful.  Where this  may be
supposed to be the case,  bark must be given alone.
   [G. G. B.—In many cases of phimosis mercury is not necessary, be-
cause in many cases  the affection arises not from a venereal chancre,
but from a common  sore; as, for instance, from that sort of ulceration
which the author has denominated gonorrhoea of the glans and prepuce.
When the sore is a chancre mercury must be used, and  the sore will
seldom be overcome without it, because washes and other topical appli-
cations, as well as  diaphoretics and purgatives internally, though they
exercise a certain degree of power over the inflammation,  do not re-
duce the genuine venereal thickening.  If  the surgeon is in doubt as
to the real nature of the sore within, he may suspend the use of mer-
cury till the inflammation has  been partly subdued by other means,
and he has acquired  evidence of its true character, from the obstinacy
of the contraction, or the distinct perception of the chancrous indura-
tion.   But the presence of active inflammation forms no objection to
the employment of mercury.   On the contrary, under such circum-
stances, mercury will in all cases be beneficial.  Even when  the pre-
puce  is sloughing, it is not in general contra-indicated, provided the
bright arterial color  of the part, and the state  of the pulse  and of the
skin, show that the arterial action is above  the natural standard.  The
sloughing in such cases arises either from  the confinement of matter
within the prepuce, or from the excessive violence of the inflammation.
In the first case  it will be stopped by making an opening with a lancet
at the part where the abscess is pointing; in the second case it will be
most effectually limited by quickly subduing  the  inflammation;  and
this may be best accomplished by absolute  rest, by the internal use of
antimony  and mercury, and by the  frequent injection of saturnine
washes under the prepuce.]
   [Ricord.—It  is  not always easy to treat phimosis; and it seems to
me that Hunter, in spite of his good precepts,  has not pointed  out
precisely enough the course to be followed.
  No matter what form of venereal disease complicates phimosis,  if it
be attended with much inflammation, we should first resort to antiphlo-
gistic treatment.  Venesection is  frequently indicated when there is
general reaction; but in most cases leeches are sufficient.  They should
be applied over  the symphysis pubis, to the perineum or the inguino-
crural regions, and never on the penis.  Local and general baths are
very useful; poultices favor oedema  and  are  generally injurious;  the
most that we can do  is to apply emollient and sedative fomentations.
Injections of emollient decoctions, and, better still, of a solution of
thirty grains of  nitrate of silver to three ounces of distilled water, in
cases  of  balano-posthitis, should  be  frequently  made  between  the
glans and prepuce; a crayon  of nitrate of  silver may also be passed
between the glans  and prepuce, and the parts superficially  cauterized.
Rest, strict diet,  diluent drinks, and an elevated  position of the penis
are to be joined  to tftese means.  I should also add to this treatment
the administration of laxatives, among which mercurials  should be 
TREATMENT  OF PHIMOSIS.
337
preferred;  Belloste's pills,1  calomel, and  particularly the sedatives
of the genital organs; camphor  combined  with opium is of great
service.
  If the inflammation continue to progress, if there be symptoms of
strangulation of the part inclosed within the prepuce, accumulations of
pus, danger of perforation, and especially danger of  gangrene, or if
mortification has already taken place, we must resort to an operation.
But an operation, which some  persons regard as the first thing to  be
done, should be performed, as Hunter directs, only with great reserve.
If there was no congenital or permanent phimosis before the disease,
we must not operate too hastily; and the same rule should be observed
if there be chancres.   In the latter case, especially, it should be re-
membered that the benefit derived from evacuation  of the pus and
removal of the stricture, does not always compensate for the inevitable
inconvenience arising from inoculation  of the wound and extension of
the  chancre.   But in case of congenital  phimosis,  which of itself
requires an operation, or when there is  merely balanitis, or  finally,
when  the symptoms become severe, we must operate, whatever the
concomitant circumstances may be.
  With the above exceptions, we  should be more and more careful in
resorting to  the knife.   Rest, diuretics, injections,  and  astringent
fomentations readily  subdue cedematous phimosis, which, in the most
obstinate cases, rarely resists gentle and methodical pressure by means
of small strips of emplastrum de Vigo cum mercurio.  With regard to
phimosis dependent on specific indurations, it yields only to the special
treatment for indurated chancres.   This is the only case in which the
local or general use of mercurials is justifiable and can be made with
success.
  . When an operation becomes necessary, the method of performing it
is not unimportant.  In congenital  or permanent phimosis, circumcision
gives the best results, and should always be preferred.  If circumcision
cannot be performed on account  of the state of the parts, we should
never resort to partial operations,  as Hunter recommends, especially if
they are to include only a small portion of the prepuce, and permanent
phimosis previously existed.  Such operations are afterwards followed
by cicatrices, which tend still farther to diminish the preputial orifice.
In the great majority of cases,  the prepuce should be incised its whole
length.  In any case, where there are chancres, indurations, or  bad
cicatrices, they should be included in the parts removed.—Ricord.]
                   i
  1  Formula for Belloste's pills : (Formulaire Magistral.)
                     R.—Hydrarg.  chloridi mitis,
                         Pulveris aloes, aa gr. xij;
                         Pulveris rhei gr. vj ;
                         Pulveris scammonii gr. iv ;
                         Piperis nigri gr. ij.—M.
                          Ft. pil.  xxxvj.
  Twelve of these pills are given as a cathartic; two as an alterative.—Ed.
22 
338
TREATMENT OF  PARAPHIMOSIS.
   [Editor.—The following  are  the  most approved methods of circumci-
 sion :—
                          M. Ricord's Method.
   1. The penis being relaxed, and no traction exercised upon the prepuce,
 the course of the intended incision is traced with iuk upon the skin, follow-
 ing the oblique direction of the base of the glans and a little in front of it.
   2. The prepuce is drawn forwards and  grasped from above downwards
 between the blades of a pair of dressing-forceps just back of the ink line, and
 the portion of the prepuce in front is excised with a bistoury.
   3. The external retracts more than the internal  layer of the prepuce, and
 the latter requires to be  cut  shorter.  For this purpose, it is slit up on ita
 superior surface completely behind the corona, and the  flap thus  formed on
 each side  excised, together with the fraenum if it be too  long.   The edges of
 the wound are united by  sutures,  or better  still, with M. Vidal's serres fines.
   M. Ricord has also invented  a pair of fenestrated  forceps, to be  used
 instead of the common forceps, and has modified the operation by passing
 three or four threads through the fold of the prepuce grasped by the  forceps
 and  between the fenestras of the latter, previous to  the incision.   After
 making the incision and withdrawing  the forceps, each  thread is  cut in the
 centre  and the divided halves tied, so as to  unite the edges of the wound and
 form twice as many ligatures  as there were  threads.

             The Method of MM. Maisonneuve and Montanier.
   1. The  prepuce is drawn  forwards  and seized  in front of  the glans by
 dressing-forceps, which are confided to an assistant.
   2. The  part in front of the forceps is cut off with straight scissors.
   The  forceps being withdrawn, the skin retracts, leaving the  glans covered
 with the mucous layer of the prepuce.
   The  mucous layer is now divided longitudinally with the scissors introduced
between it and the dorsum of the  glans.
   4. The  two flaps are turned back and kept  in contact with the skin by
 means  of serres fines, or several points of suture.
   The  application of the serres fines in this and other operations  about the
 genital organs requires  some care and nicety; but when  the edges  of the
wound are thus accurately adjusted, without the cellular  tissue being allowed
to protrude between, the results are more satisfactory than  by  any other
mode of union.]

        §  6. Of the Treatment of the Paraphimosis from Chancre.
   A prepuce in the state of inflammation and tumefaction, and  which
has been  either kept back upon the body of the penis while inflaming,
or pulled back  when inflamed,  seldom can  be again brought forwards
while  in this state, and  therefore becomes also the subject of an  opera-
tion which consists in dividing the same part, as in  the phimosis, only 
TREATMENT OF PARAPHIMOSIS.
339
in a different way, arising from its difference of situation, the intention
of which operation is to bring the prepuce, when brought forwards, to
the state of a phimosis that has been operated upon.   This operation
becomes more necessary in many cases under this disease than under
the phimosis, because its consequences are generally worse; since,  be-
sides the real disease, viz., inflammation, tumefaction, ulceration, &c,
there is a mechanical cause producing its effects, by grasping the penis,
which can of itself produce inflammation where the prepuce is naturally
tight, as has been observed.   From whatever cause it arises, it often
produces mortification in the  parts between the stricture and the glans
if it is not removed.  This removal sometimes happens naturally by
the ulceration of the strictured part, but an operation is generally ne-
cessary, and it is more troublesome than  in  the former case,  because
the swelling on each side of the stricture covers  or closes in upon the
tight part, and makes it difficult to be got at.
  The best way appears  to be to separate the two swellings as much as
possible where you mean to cut, so as to  expose  the neck;  then take
a crooked bistoury which is pointed, and  passing it under  the skin at
the neck, divide it; no part of the two swellings on the sides  need be
divided, for it is the looseness of the skin in these parts which admits
of their swelling. When this is done the  prepuce may be brought for-
wards  over the glans; but as this  disease arose from  chancres which
may require being  dressed, and as the state of  a  phimosis is a very
bad one for  such treatment, it may be better, now that the stricture is
removed, to let it remain in the same situation till the whole is well.
  . If the paraphimosis has arisen from a natural tightness  of  the pre-
puce, and its being  forced back by accident, then no  particular treat-
ment after the operation is  necessary but to go on with  the cure as
recommended in chancres.  It is indeed probable that in consequence
of the  violence produced by the position of the prepuce as  also by the
operation, a considerable inflammation may ensue; but as  this will be
an inflammation in  consequence of violence only, local treatment for
the inflammation will be sufficient.
  But if it is a paraphimosis in  consequence of a  diseased phimosis,
then the same mode of treatment becomes equally necessary as  was
recommended in the phimosis attended with considerable inflammation;
and probably rather more attention is necessary here, as violence has
been added to the former disease.
  [Ricord.—No attempt should be made to reduce  a paraphimosis,
when it is consequent upon a previous permanent phimosis; for if we
succeeded we should only relieve  the symptoms by restoring  the con-
genital malformation, and in most cases at a cost of suffering, which
is sometimes ineffectual, and is a  hundred times more severe  than in-
cision  of the stricture would produce.  Superficial scarifications, when
the parts are cedematous, cold and methodical compression either ap-
plied suddenly or continued several hours by means of circular band-
ages, are almost always sufficient.   Besides other well-known methods
of forcing the glans through the constricting ring, my learned friend,
M. Seutin, of Brussels, has proposed a pair of forceps, the extremities
of which resemble two spoons, which grasp the glans, and compress it 
340
CHANCRES.
more readily, he says, than the fingers of the operator can  do.1  In
those cases of paraphimosis which I have elsewhere spoken of as irre-
ducible, we should operate immediately, and, as Hunter says, perform
an operation back of the glans similar to that for phimosis.   But to
make this operation complete and of actual service, it is necessary not
only to cut through the whole thickness of the swelling in front of the
stricture,  but also to divide the skin behind to an extent equal to the
length of the glans; in this way, there  is no farther necessity of re-
duction, and there is no danger of a phimosis occurring, and requiring
a second operation.—Ricord.]


       § 7. Of the Cure of Chancres by Mercury given internally.

   While  chancres are under local treatment, as before described, it is
necessary to give mercurials internally, both for the cure of a chancre
and the prevention of a lues venerea; and we may reasonably venture
to affirm, that the venereal disposition of chancre will hardly ever with-
stand both local and internal mercurials.
   In cases of chancres where local applications cannot easily be made,
as in cases of phimosis, internal mercurials become absolutely necessary,
and more so than if they could be conveniently and freely applied ex-
ternally.   However, even in such cases, internal mercurials will in the
end effect a cure, so that we need seldom if ever be under any appre-
hension of not curing such a disease.
   In every case of a chancre, let it be ever so slight, mercury should
be given internally, even in those cases where they were destroyed on
their first appearance.   It should in all cases be given the whole time
of the cure, and continue for some time after the chancres are healed;
for as there are perhaps few chancres without absorption of the matter,
it  becomes absolutely necessary to give mercury to act internally, in
order to hinder the venereal disposition from forming.2
   How much mercury should  be thrown into the constitution in the
cure of a  chancre, for the prevention of that constitutional affection, is
not easily ascertained; as  there is in such  cases  no disease  actually
formed so as to be a guide, it must be uncertain what quantity should
be given internally. It must in general be according to the size, num-
ber, and duration of the chancres.  If large, we may suppose that the
absorption will be proportioned to the surface, and, if long continued,
the absorption will be  according to the time; and if they have  been
many, large, and continued long, then the greatest quantity is necessary.
   The circumstances,  therefore, attending the chancre,  must be the
guide for  the safety of the constitution, especially in those cases where
some stress in the cure is laid upon the external remedy.

  1 The chief advantage of M. Seutin's foreeps is, that they allow the prepuce to be
drawn over them, while the compression is still continued.—Ed.
  2 Added: " When chancres are attended with a great degree of inflammation and
swelling of  the neighboring lymphatic glands, there are peculiarities in the constitu-
tion which are unfavorable to the use of mercury;  it should, therefore, in such cases
be used with caution, and joined with such remedies as will make it less irritating to
the constitution."—Home. 
CONSTITUTIONAL  TREATMENT.
341
  The mercury given to act  internally must be thrown in either by
the skin or stomach, according to circumstances.
  The quantity in either way should be such as may in common affect
the mouth slightly, which method of giving mercury will be considered
hereafter.
  When the sore has put on a healthy look, when the hard basis has
become soft, and it has skinned over kindly, it may be looked upon as
cured.
  But in very large chancres, it may not always be necessary to con-
tinue the application of mercury, either for external or internal action,
till the sore is healed; for the venereal action is just as soon destroyed
in a  large chancre as it is in a small one, for every part of the chancre
being equally affected by the mercury, is equally easily  cured.  But
the skinning is different; for a large sore is longer in skinning than a
small one.   A large chancre, therefore, may be deprived of its venereal
action long before it is skinned over; but a small one may probably
skin over before the venereal poison is entirely subdued.   In the latter
case, both on account of the chancre and constitution, it will be erring
on the safe side to continue the  medicine  a little longer, which will
most certainly in the end  effect a cure; for we may reasonably sup-
pose  that the quantity of mercury capable  of  curing a local  effect,
although assisted  by local applications, or of producing in  the con-
stitution a mercurial irritation sufficient to  hinder the venereal irrita-
tion from  forming, will  be nearly as much as will cure a slight lues
venerea.
   I have formerly laid it down as a principle that no new action will
take place  in another part of the body, however contaminated, whilst
the body is under the beneficial operation of mercury;  but there are
now and then appearances which occur under the cure that will at first
embarrass  the practitioner.   I have suspected that the mercury flying
to the mouth and throat has sometimes produced sloughs in the tonsils,
and  these have been taken for venereal.  The following  cases in some
degree explain this:—
  A  young gentleman had  a chancre  on  the prepuce,  with  a  slight
pain in a gland of one groin, for which I ordered mercurial ointment
to be rubbed into the legs and thighs, especially on the side where the
gland was swelled, and the chancre to be dressed with mercurial oint-
ment.  While he was pursuing this course the chancre became cleaner,
the hardness at the base went off, and the pain in the groin was entirely
removed.   About three weeks after the first appearance of the disease
he was attacked with a sore throat, and, on  looking into the mouth, I
found the right tonsil with a white slough, which appeared to be in its
substance, with only one point yet exposed.  From my mind  being
warped by the opinion that these complaints proceeded from the chan-
cre, I immediately suspected that it  was venereal; and the only way
that  I could account for this seeming contradiction, in one part healing
while another was breaking out, was, that the healing sore was treated
locally as well as constitutionally; while the tonsil, or the constitution
at large, was only treated constitutionally, which was insufficient.
  Soon after this another gentleman was under my care for venereal 
342                       'CHANCRES.
scurfs, or eruptions on his skin, for which he used mercurial friction till
his mouth became sore; and in this state he continued for three weeks,
in which time the eruptions  were all gone, discolorations being left
only where the eruptions had been ; yet, at the end of three weeks, a
slough formed in one of the tonsils, exactly  as  in  the former case.
This made me doubtful how far such cases were venereal.   I ordered
the friction to be let off, to see what course the ulcers would take; the
slough came  out and  left a foul sore.   I waited still longer, and in a
day or two it became clean and healed up.
  The first-mentioned case I did not see to an  end;  but I learned that
the patient continued the mercury and  got well, and  the ulcer  in the
throat was supposed to be venereal; but, from  the circumstances of
the other case, I now very much doubt of that.
  It is more than probable that these effects of mercury only take place
in constitutions that have a tendency to such complaints in the throat.
I know this to be the case with the last-mentioned gentleman;  and it
is also probable that there may be an increased disposition at the time,
either in consequence of the  mercury or some accidental  cause.  I
have reason to suppose that  mercury, in  some degree, increases  this
disposition, which I shall farther take notice of  when treating of the
cure of lues venerea.
  In  the cure of chancres I have sometimes seen, when the original
chancre has been doing well and probably nearly cured, that new ones
have  broken out upon the prepuce, near to the first, and have put on
all the appearance of a chancre; but such I have always treated as
not venereal.  They may be similar to some consequences of chancres,
which will be taken notice of hereafter.
   As swellings of the  absorbent glands take place in consequence of
other absorptions besides that of poisons, we should  be careful in all
cases to ascertain the cause, as has been already described; and  here it
may not be improper still to observe farther, that in the cure of chancres
swellings of the glands shall arise, even when the constitution is  loaded
with mercury sufficient for the cure of the sores;  but then the mercury
has been  thrown into  the  constitution by the lower extremity, and
therefore there is great room for suspicion that such swellings are not
venereal, but arise from the mercury; for a real bubo, from absorption
of venereal matter,  if not come to suppuration, will  give way to mer-
cury  rubbed into the  leg  and  thigh.  In such cases I have always
desisted from giving the mercury in this way when I could  give it by
the mouth.                                             '
   [Ricord.—In the preceding section, Hunter's imagination has  played
a far more important part than careful, practical observation. Most of
the propositions which he lays down are, in fact, inferences from theo-
retical ideas, which are contradicted by every day's experience.
   Thus, at  the present day, no one but he who abandons himself to
blind empiricism will administer mercury in all cases of chancre with-
out distinction.   It is an established fact, that many chancres get well
without this remedy, and that, far from being always indicated, it  is
frequently injurious, and  should give place to the  rational  means
which are required by the peculiar state of the venereal ulcer. 
CONSTITUTIONAL TREATMENT.             343
   With the idea that mercury is the only neutralizing  agent  of the
 syphilitic virus, men have sought, and still seek, to ascertain the abso-
 lute quantity which must be administered to cure primary symptoms.
 Hunter says that the quantity should be proportioned to  the  size,
 number, and duration of the  ulcers; but these data are false, whether
 the disease be regarded as a local affection or capable of exciting con-
 stitutional symptoms.
   Looking  at it as a local affection, it is not true that in all cases the
 progress  of chancres toward  a cure is proportioned to their size' and
 number.  Some chancres covering  a large surface heal very soon;
 whilst small ulcerations sometimes last much longer.  A patient, who
 has several ulcers, is often sooner rid of  them than another who has
 only one, and  these  cases are so frequent that they cannot be con-
 sidered mere exceptions to  the rule which Hunter would  establish.
 As  to  duration, an  ulceration which requires  mercury will, without
 doubt, need a larger quantity  of it the more time it takes to heal; but
 that is all.
   If, on the other hand, we regard  mercurial treatment as a prophy-
 lactic against constitutional infection, and endeavor to introduce into
 the  economy a quantity of mercury proportioned to  the quantity of
 the  virus absorbed, here, again, neither the size, number, nor duration
 of the  ulcers can serve as guides.  In fact, daily experience proves
 that the frequency, number, and intensity of the secondary symptoms
 are  not proportioned to these conditions of the primary ulcers.
   A single chancre, of small size  and short duration, is often sufficient
 to cause constitutional  syphilis, which,  in very many cases, is not
 induced by numerous and extensive ulcerations, though they may last
 a very  long time.
   The  most exact therapeutical indications which we possess are the
 following:—
   All  indurated chancres require mercurial treatment, which is then
 the most powerful and most  promptly efficacious  means that we pos-
 sess.
   Commencing with an arbitrary dose, it should  be increased  from
 day to day, until curative effects are observed, or until mercurial symp-
 toms such as salivation, etc.,  warn us that  the remedy is  no longer
 tolerated.
   The  absolute quantity required for the whole treatment is to be
• determined not only by the  cicatrization of the ulcer and the disap-
 pearance of constitutional symptoms, when they are already developed,
 but also  by the complete resolution of the  induration, which is the last
 primary symptom to disappear, and a very valuable guide when pre-
 sent. For it must be understood that, so long as the induration remains,
 the  disease is not cured, no matter what other morbid symptoms, have
 been made to disappear, or  what quantities of mercury have  been
 given, or what effects have been produced.
   It would doubtless be convenient to be able to say: " For so many
 lines of surface in a chancre, or for so long a duration, employ so many
 grains of corrosive sublimate, or so many drachms of mercurial oint-
 ment.  For the cure of a primary symptom, employ a quantity neces- 
344
CHANCRES.
sary for the cure of slight secondary symptoms.  Continue the treat-
ment after the cure of a small ulcer; suspend it before the cicatriza-
tion of a large one;  for, in the first case,  the venereal  poison  still
exists, while in the second it has been subdued."   But the truth is,
such rules can have  no value for those who  understand  the course
which diseases take, and who know the different phases they present
in different individuals.
   In  cases where we do not have specific induration of the chancre
for our guide, mercury should be used only when other syphilitic symp-
toms require it. And when we are obliged to employ mercurial treat-
ment, we  should continue it, if nothing occur to contra-indicate it, not
only till the symptoms are perfectly cured, but a long time after; for
experience teaches, every day, that the longer it is  wisely prolonged,
the more securely does it protect from consecutive accidents.  Very
often six months of uninterrupted treatment  are necessary for success!
What shall we say, then, of the one hundred and ten pills of Dupuy-
tren, which one of our colleagues announced in the  Bulletin de Thera-
peutique, would always assure a cure ?
   Mercury acts more powerfully when administered by the stomach
than  by the skin.   It affects the economy  in two ways:  either as a
curative or as a morbific agent.  As soon as mercury acts in the latter
way, as shown by the appearance of salivation,  intestinal irritation,
cutaneous irritation, &c, its curative effects are  obstructed  or com-
pletely inverted, so that it may even  act sometimes  as an adjuvant of
the disease, which we wish to subdue.
   Some constitutions  seem refractory to  this  metal;  and, in these,
syphilis generally produces  its greatest ravages.
   Hunter, too confident in the anti-syphilitic virtues of mercury, and
true to his principle that two distinct  morbid actions cannot  exist at
the same time in the system, believes that the symptoms, which appear
during the course of mercurial treatment, cannot be venereal.  This
doctrine, which is so poorly supported by Hunter's reasoning and by
the observations which he reports, is very dangerous; since it leads us
to attribute to mercury constitutional symptoms, which often require
more than ever a continuance of the remedy.
   If mercury can produce any subsequent symptoms—which has not
been  accurately determined—at  any rate it is very certain that its
action is generally rapid, and that its  morbid effects  last only while its
use is continued. So that we may truly say  of mercury, sublatd causa\
tollitur effectus; whilst, in syphilis, the symptoms continue when the
remedy is stopped, and improve or disappear as soon as it  is resumed.
—Ricord.]
   [Editor.—Whether the  treatment of a chancre should be confined to
local  remedies or include the internal  administration of mercury, depends
entirely upon whether it is a simple or infecting  chancre.  The distinguish-
ing characters of these two important varieties have been sufficiently dwelt
upon in a preceding note.   In the great majority of cases the  character of
the ulcer and the condition of the neighboring lymphatic ganglia will be 
CONSTITUTIONAL TREATMENT.
345
sufficient to establish the diagnosis on the first examination.  In other cases
it is necessary to wait for a few days  to  decide;  and the instances  are  ex-
tremely rare in which our judgment as to the prognosis of any primary sore
must be suspended for any length of time.
  The presence of an indurated base to  the ulcer and of a pleiad of indu-
rated  ganglia in the groin indicate that the constitution  is already infected,
and that a corresponding constitutional course  of treatment  should  be at
once commenced and be continued according to the  rules to be  laid  down
hereafter.  The absence of these  symptoms, on the contrary, will show that
the disease is purely local, and  that local remedies are alone  required.  In
the exceptional cases, in which  it is impossible to  decide as to  the character
of the sore, it is better to wait and see if  secondary symptoms manifest them-
selves, than to resort to a mercurial course which  may not be required.  The
lapse  of a few months  will  determine this,  since constitutional  symptoms
always appear within six months after an infecting coitus, and their  absence
for this period, provided no  mercury has been administered, will  show that
the chancre was a simple one.
  The common method pursued by many  practitioners, of subjecting  every
patient who has a chancre, to the use of mercury for  two or  three weeks, is
entirely unjustifiable.   Mercury has no special curative action upon primary
sores  ; if it be a specific at  all in  syphilis, it is  only so for secondary phe-
nomena, among which  the induration of an infecting  chancre should be
included.   In spite  of  the  opinion of Hunter and  the generally received
impression to the contrary, we  may confidently state  that there is no  proof
whatever that the use of mercury in the early stages  of a primary sore offers
any obstacle to the absorption  of the virus or affords  any guarantee  against
constitutional infection.
   It is only in cases of  simple  chancres that the  short course of mercurials
so much in vogue, is apparently successful in averting subsequent symptoms;
and in this class of chancres, there  would be the same immunity without  the
mercury.  A mercurial  course of  two or three weeks is  entirely inadequate
to protect the system from the effects of a truly infecting chancre.
  But there  is another strong objection  against the indiscriminate use of
mercury in all cases of  chancres.   It is liable  to  leave the patient and  the
surgeon in doubt, whether constitutional infection has taken  place  or not.
If the character of the primary sore has  not been determined, and mercury
has been administered, we are at a loss to know whether the non-appearance
of secondary symptoms  for a given time is  owing  to their being retarded  by
the treatment, or to the nature of the chancre;  and in such  a  disease as
constitutional syphilis, which so profoundly modifies  the system and  exposes
the patient to its manifestations for life, it is not  a matter of indifference to
know  whether one has it or not.
  The rules then which  we would adopt  for the  constitutional  treatment of
chancres are the following:— 
846        TREATMENT OF  CHANCRES IN WOMEN.
  I.  In indurated chancres, subject the patient to a  mercurial  course, the
same as for secondary syphilis.
  II.  In simple chancres, abstain from mercury.
  III. In case of doubt as to the character of the ulcer,warn the patient of
the uncertainty in the case, and keep him under careful observation, until time
shall have determined whether the system has been infected or not.—Editor.]
                      CHAPTER  IV.

            OF THE CURE OF  CHANCRES IN WOMEN.

  The  parts generally affected with chancres in this sex are more
simple than in men, by which means the  treatment  in  general is also
more simple; but, in most cases, they require nearly the same, both in
the local application of mercury and in throwing it  into the constitu-
tion.  It may be supposed, however, that  it will be necessary in many
cases to throw into the constitution more mercury than in men, because
in general there are more  chancres, and  the surface of absorption of
course larger.
  As it is difficult to keep dressings on the female parts, it is  proper
they should be washed often with solutions of mercury; perhaps corro-
sive sublimate is one of the best, as it will act as a specific, and also as
a stimulant when that is wanted; but in chancres that are very irritable,
the same mode of treatment as was recommended in men is to be put
in practice.  Afterwards, the parts may be besmeared with a mercurial
application, either oily or watery,  to be frequently repeated, according
to the circumstances of the case.
  If the ulcers should have spread,  or run  up the vagina, great atten-
tion should be paid to the healing of them; for it sometimes happens
that the granulations contract considerably, so as to draw the vagina
into a small canal;  at other times  the granulations will unite into one
another, and close the  vagina  up  altogether; therefore, in such cases,
it will be necessary to keep some substance in the vagina till the sores
are skinned, for which purpose probably lint may be sufficient.
   [Ricord.—Chancres are generally neither more numerous nor larger
in women than in men, and when  they require mercurial treatment, it
need not be longer  continued in one sex than in the other.
  Dressings are very easily kept in place in women.
  As to obliteration of the vagina, it must be very rare, for  I have
never seen it.] 
CONSEQUENCES  OF  CHANCRE.
347
                     CHAPTER V.

  OF SOME OF THE CONSEQUENCES OF  CHANCRES, AND THE
                     TREATMENT OF  THEM.

  After the chancres have been cured, and all venereal taint removed,
it sometimes happens that the prepuce still retains a considerable de-
gree of tumefaction, which keeps up the elongation and tightness which
it acquired from the disease, so that it cannot be brought back again
upon the penis to expose the glans.                            m  .
  For  this perhaps there is, in many cases, no cure;  however,  it is
necessary to try every possible means.  The steam of warm water,
fomentations with hemlock, and also fumigations  with cinnabar, are
often of singular service in this case.
  But  if the parts still retain their size and form, it may be very proper
to remove part of the overgrown prepuce;  how much, must be left to
the discretion of the surgeon. I should suppose that all that part which
projects beyond the glans penis may be cut away.
   The best way of removing it is by the knife; but great care should
be taken  to distinguish first the projecting  prepuce from  the glans.
When this is perfectly ascertained, the penis being held horizontally,
an incision may be made on the upper surface, and  followed down with
caution; because if the incision should be too near  the glans there may
be danger of cutting it.                                  .       .
   The parts may be allowed to heal with any common dressings, as it
is to be considered as a fresh wound; however, it will not heal so readily
as a fresh wound made in an entirely sound part, because the operation
consists in taking away only a superfluous part of a  diseased whole; and
what is left is diseased, but  not so  as to produce any future mischief.
   Some care may be necessary in the healing of the parts, for it is very-
 possible that the cicatrix may contract, and still form a phimosis.  This
 will be best prevented by the patient himself if he brings the prepuce
 often back upon the penis;  but it  should not be attempted till the part
 is nearly healed; and it is to be performed with great care, and slowly.1


    § 1.  Of Dispositions to New Diseases during the Cure of Chancres.

   Chancres, both in men and women, often acquire new dispositions in
 the time of the cure,  which are of various kinds, some  of which retard
 the cure, as described, and, when the parts are cured, leave them  tume-
 fied and indolent, as in the enlarged prepuce.  In others a new disposi-
 tion takes place, which prevents the cure or healing of the parts, and
1 See Ricord's addition on page 311. 
348              CONSEQUENCES OF CHANCRE.
often produces a  much worse  disease than  that from which it arose.
They also become the cause of the formation of tumors on these parts,
which will be taken notice of hereafter.
  Such new dispositions take place oftener in men than in women,
probably from the nature  of the  parts themselves.  They seldom or
never happen but when  the inflammation  has been violent,  which
violence arises more from the nature of the parts than the disease, and
therefore belongs more to the nature of the parts or constitution than
to the disease. However, I can conceive it may also take place where
the inflammation has not been violent.
  In general,  they are supposed  to be cancerous, but I believe they
seldom  are, although it is not impossible that some may be so.
   Of this kind may be reckoned those continued and often increased
inflammations, suppurations, and ulcerations, becoming diffused through
the whole prepuce, as also all along the common skin of the penis, which
becomes of a  purple hue;  the  cellular membrane everywhere on the
penis being very much thickened, so  as  to increase  the size of the
whole considerably.
   The ulceration on the inside  of the prepuce will sometimes increase
and run between  the skin and the body of the penis,  and eat holes
through in different places till  the whole is  reduced to  a number of
ragged  sores.   The glans often shares the same fate, till  more or less
of it is  gone; frequently the urethra at this part is wholly destroyed
by ulceration, and the urine is  discharged some way farther back.  If
a  stop  is  not put  to the progress of the disease, the ulceration will
continue till  the parts are entirely destroyed.  I suspect that some of
these cases are scrofulous.
   As this is an acute case, immediate relief  should  be given, if possi-
ble ; but as it may arise from various peculiarities in the constitution,
and as  these  peculiarities are not at first known, no  rational method
can be here  determined.  The decoction of sarsaparilla is often of
service  in such cases, but requires to be given in large quantities.
   The  German diet-drink1 has been of singular service; I knew a
case of this  kind cured  by it, after every known remedy had been
tried.   The extract  of  hemlock is sometimes of service.   I have
known sea-bathing cure these complaints entirely.  A  gentleman came
from Ireland with a  complaint of this  kind, and after having tried
every common and known method without effect, as sarsaparilla, hem-
lock, German diet-drink, and  after having used  a great variety of
dressings (which were all  at last laid aside, and opium only retained

   1 The  following formulae have been much  recommended as diet-drinks: Take of
crude antimony, pulverized, tied up in a bit of rag, pumice-stone, pulverized, tied np
in the same, of each one ounce; China-root, sliced, sarsaparilla-root, sliced and
bruised,  of each half an ounce ; ten walnuts, with their rinds, bruised; spring-water,
four pints, boil  to half that quantity; filter it, and let it be drunk daily in divided
doses.
   Take  sarsaparilla, Saunders-wood,  white and red, of each three  ounces ; liquorice
and mezereon, of each half an ounce; lignum rhodium, guaiacum,  sassafras, of each
one ounce ; crude antimony, two ounces ; mix them and infuse them in boiling water,
ten pints, for twenty-four hours, and afterwards boil them to five pints, of which let
the dose be from a pint and a half to four pints a day. 
CONSEQUENCES  OF  CHANCRE.
349
to quiet the pain), he bathed in the sea and got well. It may be some-
times necessary to pass  a bougie, to hinder the orifice of the urethra
from closing or becoming too small in  the time of healing  in such
cases.
  [G. G. B.—The description of the author is so vague that it is diffi-
cult  to  know with certainty what species of sore he here intends to
designate.  But it  is probable  that he chiefly  refers  to those sores
which are called phagedenic, and which are of sufficient importance to
require a particular description.
  The name phagedenic has been given to them because they have
been supposed to be the  same with the ulcers described  by Celsus
under the name of phagedasna.   Though the correctness of this sup-
position may be questioned, yet  there is a convenience in retaining a
name which  not  unaptly characterizes  the ulcer, whether we regard
the  occasion,  the rapidity of its  progress, or the most remarkable
features which distinguish its aspect.
  It can scarcely be doubted that phagedenic ulcers  arise from  the
application of a virus, since there is no satisfactory evidence that they
ever occur where the party has not been  exposed to infection,  and
since they are as  constantly followed by secondary symptoms as  the
genuine forms of  chancre which have been previously  described.
Nor, though much attention has been paid to the subject, has it been
possible to  trace such  a constant distinction  as would establish that
the virus which  produces them is different  from  that which gives
origin to the common Hunterian chancre.   The characters of the pha-
gedenic sore are very different from those of a common chancre;  and
if there is a diversity of virus, this diversity should be constant,  and
should  be capable of  being traced equally  in the  giver and  the
recipient; in the  party  from which the infection  is derived, as well as
in that  to which  it is communicated.  But it has not been found pos-
sible to ascertain that this is the  case. On the contrary,  the phage-
denic sore has in  several instances appeared to have been derived from
individuals who have suffered from the  common  forms of chancre.
  The phagedenic sore  begins with slight tumefaction of the part and
slight excoriation of the surface.  This excoriated surface soon becomes
foul, being covered with a yellowish slough, and  discharging a watery
sanies of a brownish tinge.  As the sore destroys the part on which
it is situated, the surface becomes uneven, and the outline of the sore
irregular in shape, and, as it were, scolloped.  These  appearances are
produced by the  mode of progress, which is  not regular and uniform
in every direction, but  proceeds more rapidly in some parts than in
others.   The central part, and perhaps one of the edges, then ceases
to spread, and becomes clean, while on other sides the foul character
remains, and the  sore continues to extend.  The part which is spread-
ing  is always somewhat tumefied, but the tumefaction is that of com-
mon inflammation, and is not distinctly defined, like that of an ordinary
chancre.  It. does not  terminate  abruptly, but  passes imperceptibly
into the surrounding structure.   In fact, it is merely caused by the
irritation of the spreading sore; the clean edge is altogether free from
it.  As soon as  a  part cleans, the  tumefaction  subsides, though the 
350
CONSEQUENCES OF  CHANCRE.
ulceration may remain long afterwards unhealed.   The tumefaction
cannot be said to precede the ulceration; it rather attends the slough-
ing,  if that  can be called sloughing which  is in general only foul
ulceration.
  The phagedenic sore may destroy any part on which it is placed,
but its ravages involve the cellular membrane more readily than either
the prepuce  or the body of the penis.  The consequence is, that in
most cases it burrows  between the body  and the skin of the penis,
dissecting, in its  course, the corpora cavernosa from the integuments,
and creeping upwards between these parts,  often as far as the os pubis.
Under these circumstances, the bottom of the sore cannot  be fully
exposed;  the part which is within view is  generally clean, and some-
times slowly  healing, while the portion which is concealed is  foul and,
yellow,  and  secretes large  quantities of a thin  brownish discharge.
This spreading edge is attended by the usual tumefaction, which may
be felt externally as a hard ring encircling  the body of the penis,
marking the distance to which the sore has extended, and in the pro-
gress of the  complaint approaching nearer and nearer to the root of
the penis.  As long as this thickened edge is to be felt, so long  the
sore is spreading.  If the bottom of the sore  cleans and tends to heal,
the improvement may be known by the subsidence of this thickening,
as immediately and as  certainly as if the  whole  of the surface were
exposed to view.
  Under common circumstances the  phagedenic sore spreads by foul
ulceration, and eats its way very slowly, and almost imperceptibly.
But  it is  subject to occasional accesses of sloughing, in which large
portions of the prepuce, the glans, or the corpus spongiosum, mortify
and  separate.  There are few cases of long  standing  in which such
sloughing has not occurred; and  in most instances, a portion of  the
urethra  has been destroyed by it, and an opening has been formed, at
which the urine escapes, about an inch above  the natural meatus.  The
suddenness of these attacks, and the irremediable destruction which
they occasion, render it necessary that the treatment should always be
conducted with a view to their occurrence.
  The discharge from  the  phagedenic sore is profuse and unhealthy;
but it does  not seem, like the discharge of  the common chancre, to
affect the surfaces with which it comes into  contact.  It is common that
the prepuce  and the  glans should be almost constantly bathed in it;
yet it is very rarely or never that other sores arise on these parts  in
consequence.  Again, the contiguous surfaces are not affected.  The
sore may  be situated on the body of the penis, while the prepuce  in
contact with it shall remain free from ulceration.  It is not uncommon
that  the phagedenic sore should be situated on one side of the meatus
urinas, and should destroy a considerable portion of the glans before
it is arrested; yet the affection will not extend to  the other side of the
meatus, although the ulcerated surface is allowed to remain perpetually
in contact with it.
  The phagedenic sore is  attended  with  some,  but not with acute
inflammation.  The pain, except during an attack of sloughing, is not
very severe.  The prepuce  is usually red, sometimes purple, almost 
CONSEQUENCES  OF CHANCRE.
351
always loaded with serum, and tumid; but it is not generally indurated,
or firm  to  the  touch;  nor is the color of that bright scarlet which
attends acute phimosis from common chancre.   There is more consti-
tutional disturbance; the pulse is  generally quick and excitable, the
skin hot, the appetite indifferent, and the sleep restless and disturbed.
  It is  rare that a suppurating bubo should arise from a phagedenic
sore.  A gland in the groin sometimes  enlarges, but it is seldom very
painful, and generally subsides spontaneously in less than a week.
  The secondary symptoms which follow the phagedenic sore are pecu-
liarly severe  and intractable.   They commonly consist  of rupia,
sloughing of the throat, ulceration  of  the nose, severe and obstinate
muscular pains, and  afterwards inflammation of the periosteum and
bones.  Similar complaints will follow the ordinary chancre; but when
they follow a phagedenic sore they  are very difficult to be cured; and
it is not uncommon that the constitution of the patient should at length
give way under them, and that the case should terminate fatally.
  If the description of these sores is compared with that of a common
chancre, which has been given  in a former chapter, the distinction  is
sufficiently evident.  The  common chancre is preceded and followed
by induration of a peculiar character, which holds its course in some
measure independently of the ulceration itself.  No such induration is
found in the phagedenic sore;  the thickening which does occur does
not differ from that which is met with in other sores, and is merely an
attendant on the unhealthy state of the ulcer.   The common  chancre
spreads equally in all directions.  The phagedenic  sore spreads irregu-
larly, and frequently heals at one edge while it is spreading at another.
The common chancre tends  to multiply and to produce similar ulcers
on  the  surfaces which are  in contact with it.  The phagedenic sore
remains single, and the contiguous surfaces are unaffected.  There is
also a difference, though less clearly defined, in the secondary symp-
toms which follow these two species of sore, and a different treatment
must be adopted in the cure.
  If the phagedenic sore is treated with a full course of mercury, it is
most frequently found  that  the improvement  in  the first instance  is
more immediate and more decided than in the case of a common chan-
cre.  In a very few days, the inflammation subsides, the surface cleans,
and the sore begins to heal.  But this amendment  is usually only tem-
porary ; it generally  happens that, in a  few days more, if the mercury
is continued, and especially if the effect on the system is at all exces-
sive, the aspect changes, the color of the surrrounding parts becomes
dark and purple, sudden sloughing comes on, and  the whole surface of
the sore, and often much of the prepuce and of the penis is involved
in it.  On the other hand, if mercury is  entirely avoided, and such
treatment only is adopted as would be employed in a common sore, the
ulcer obstinately retains its  unhealthy  character, and makes constant,
though less rapid, progress by foul ulceration.
  Mercury is of great service in the treatment  of the phagedenic sore,
but if its depressing  effects  are allowed to come  on, the consequence
is, almost always, sloughing.  It must, therefore, be so employed as to
avoid these effects; it must  be administered in those doses and  in those 
352
CONSEQUENCES  OF  CHANCRE.
forms which least depress the circulation;  and it  must be combined
with such medicines as are calculated at the same time  to support the
system.  The oxymuriate of  mercury, given in the dose of an eighth
of a grain twice in the day, and in unison with decoction  of sarsapa-
rilla, is the  safest and most  efficient preparation.   But even in this
form, the effect must be watched; and if the integuments in the neigh-
borhood of  the sore should become pale or livid,  or if much general
languor is induced, the remedy must be  intermitted and resumed only
after these symptoms of impeding sloughing have  disappeared.
  It must not be omitted, that the  internal use of the hydriodate of
potash has often great effect on this  form of disease.—G. G. B.]
  [Ricord.—I cannot allow Mr. Babington's note to pass, without
pointing out some assertions in it which are entirely incorrect.
  Secondary symptoms are never observed after  chancres which are
phagedenic immediately on their first appearance.
  Experience has taught me, that in those  cases where constitutional
symptoms are observed to follow  phagedenic chancres,  the phagedena
is preceded by  induration.
  These apparent  exceptions which phagedenic  chancres present, are
rarer when the phagedena is gangrenous from the first; for gangrene
rapidly destroys the specific property of  the  ulcers and  the tissues
they rest upon, and thus  prevents infection.
  My  experiments have  also proved that a phagedenic chancre has
nothing peculiar in its first appearance;  inoculation giving at first the
same results in all varieties of chancre.
  Pus from  a diphtheritic, phagedenic, or serpiginous  chancre inocu-
lates the  neighboring  parts just as well as pus from an indurated
chancre; nay, more, it continues inoculable a  longer time; it is not
so with pus from a true gangrenous phagedenic chancre.
  Buboes are  far  from being  rare after diphtheritic phagedenic
chancres; nothing, on the contrary, is more common than to see them
themselves assume the phagedenic form, before or after the disappear-
ance of the preceding ulcers.   But it is true that buboes are rare after
gangrenous  phagedenic  chancres, and that not unfrequently,  when
they had already begun to be developed, they disappear on  the appear-
ance of gangrene in the ulcer.
  When secondary symptoms follow chancres which have  become
phagedenic,  their  gravity is not dependent on the  gravity of the
primary ulcer, but on the cause which rendered the ulcer grave; and
this cause is found in the individual condition of the patient.
  When we remember the principal varieties  and the infinite shades
of difference which chancres may present, we feel  of how little value
the absolute differential diagnosis  is  which  Mr.  Babington would
establish; it is only applicable, and that very imperfectly, to ill-defined
phagedenic chancres.
  In phagedenic chancres, mercury  is frequently more  injurious than
beneficial.  Given in insignificant doses, its effects  are illusive.  Cases
of its success are exceptional.   But  there is no remedy which can be
said to be universally beneficial or injurious in phagedenic chancres.
Up to the present time, no one method has been found  for their treat- 
CONSEQUENCES OF  CHANCRE.
353
 ment.   The main thing is to  discover  the  cause  which gives the
 syphilitic ulcer its unfavorable form;  and this  cause, which so often
 depends on a scrofulous diathesis, contra-indicates the use of mercury,
 which is a powerful remedy when the syphilitic ulcer alone remains to
 be treated.
   I will also observe, that  corroding  or  cancroid ulcers, as some  of
 Hunter's remarks have already indicated, may be mistaken for phage-
 denic chancres.   These ulcers sometimes  succeed syphilitic ulcers  or
 occur after suspicious antecedents, and are from the  first foreign to
 syphilis, or become  so at a later period.  See additions  to pages 291
 and 323, and an excellent treatise by Dr. Huguier, Sur Testhiomlne de
 la vulve.—Ricord.]1


                § 2. Of  Ulceration resembling Chancres.

   It often happens that after chancres are healed,  and  all the virus
 gone,  the cicatrices ulcerate again, and break out in  the  form  of
 chancres.
   Although this is most common in the seat  of the former chancres,
 yet it is not always confined to them, for sores often break out on
 other parts of the prepuce; but still they appear to  be a consequence
 of a venereal complaint having been there, as they seldom attack those
 who never had gonorrhoea or chancres.   They often have so much
 the appearance of chancres, that I am  persuaded many are treated  as
 venereal that are really not such; they differ from a chancre in general
 by not spreading  so fast, nor so far;  they are not so painful, nor  so
 much inflamed,  and have not those hard bases that the venereal sores
 have, nor  do they produce buboes.  Yet a malignant kind of them,
 when they attack a bad constitution, may be taken for a  mild  kind of
 chancre, or a chancre in a good constitution.2
   Some stress is to be laid upon the account that the patient gives of
 himself; but when there is any doubt, a little time will clear it up.  I
 have seen  the same appearances after a gonorrhcea, but  that  more
 rarely happens.  It would appear that  the venereal poison could leave
 a disposition for ulceration of a different kind  from what  is peculiar to
 itself.   I knew one case where they broke out regularly every two
 months, exactly to a day.
   As they are not venereal, their treatment becomes difficult; for the
 cure consists more in  preventing a return than in the healing up  of
 the present sores.
   They require particular attention ;  for although they  are not dan-
 gerous, they are often troublesome, keeping the mind in  suspense for
 months.
   I have tried a great variety of means, but with little  success; yet
they have in general got well in the end.   In  the following case, the
lixivium saponarium produced a speedy cure:—
   A gentleman had three sores break out on the prepuce, which had

   ' Memoirs of the National Academy of Medicine, Paris, 1849, vol.  xiv. p. 501.
   8 Added : "I have seen several that have puzzled me extremely."—Home.
      23 
354             CONSEQUENCES  OF CHANCRE.
very much the  appearance of mild chancres.   As I was  doubtful of
their nature, I waited some  time, and only ordered them to be kept
clean.  As they did not get well, several things were tried.  Mer-
curial dressings were applied, but they always produced considerable
irritation, and it was necessary to  leave them  off.  The mercurius
calcinatus was given by way of trial, and to secure the constitution,
but the sores continued the same.  They were eat down with the
lunar caustic, which  appeared to have a better effect than any other
thing tried; but still they were not healed at the end of five months.
I ordered forty drops of the lixivium saponarium to be taken every
evening, and morning in a basin of broth.  After using it three days
he observed a considerable alteration in the sores, and in six days they
were perfectly skinned over.  He had formerly had such sores often,
which had always been treated  as venereal;  but he began to doubt
whether  they were really so, from their getting so soon well  in the
present instance by the lixivium.
  I knew a gentleman who had these sores breaking out and healing
again for years.  By bathing in the sea for a month or two, they healed
up, and never afterwards appeared.
  [Ricord.—Besides ulceration of a  different nature, such as  herpes
and eczema, which may  occur in patients who have, or  have had, pri-
mary syphilitic symptoms, the genital organs, like other parts of the
body, sometimes become the seat of secondary symptoms, which  puzzle
the diagnosis of persons who are little versed in the order of succession
of syphilitic phenomena, because they confound them with primary
symptoms, as Wallace appears to have done frequently.]

          § 3. Of a Thickening and Hardening of the Parts.

  In some cases the parts do not ulcerate, but appear to thicken  and
become hard or firm;  both the glans  and prepuce seem  to swell, form-
ing a tumor or excrescence from the end of the penis, in  form a good
deal like a cauliflower, and, when cut into, showing radii running from
its base or origin towards the external surface,  becoming extremely
indolent in all its operations.  This gives more  the idea of a cancer
than the  first, being principally a new-formed substance.  However, it
is not always a consequence of the venereal disease, for  I have known
it to arise spontaneously.
  This disease appears to be a tumor of so indolent a kind that I do
not know any medicine  that stands the  least  chance of performing a
cure.  I  have amputated them, and have also seen the same thing done
by others, from the idea of their being cancerous, and  the remaining
part of the penis has healed kindly.
  In most of these cases a considerable part of the penis  must  be re-
moved.  Immediately after the amputation, a suitable catheter  should
be introduced into the urethra; for if no such precaution is made use
of, the consequences must be troublesome; for the first dressings be-
come cemented to the orifice by the extravasated blood, and prevents.
the patient's making water, which must be attended with  obvious in- 
CONSEQUENCES  OF CHANCRE.              355
conveniences.   This was the case with a patient whose penis I ampu-
tated.
  [Ricord.—A chancre may leave behind it oedema, which is often
hard like scirrhous; engorgement of the  neighboring lymphatic ves-
sels to a greater or less extent, presenting canals which often become
fistulous;  or it may leave inodular tissue, and especially specific indu-
ration.  But a chancre sometimes assumes a fungous form, and passes
into a mucous tubercle with various  degrees of hypertrophy.  These
tubercles, from ignorance or inattention, may be mistaken for  true
vegetations; or, what is worse, for  cancer.  In consequence of such
mistakes, I have seen organs amputated which might have been saved,
if they had been more carefully examined.]

                          § 4. Of Warts.

  Another disposition which  these  parts acquire from the venereal
poison is the disposition to form excrescences  or cutaneous tumors,
called warts.  This disposition is strongest where the chancres were,
and indeed  chancres  often  heal into warts; but, perhaps, the parts
acquire this disposition from the venereal matter having been long in
contact with their surfaces, for it often happens after gonorrhcea, where
there had been no  chancres; and, probably, it is  only in those cases
where the venereal matter had produced  the venereal stimulus upon
the glans and prepuce, forming there what may be called an insensible
gonorrhoea.
  A wart appears  to be  an excrescence  from the cutis,  or a  tumor
formed upon it, by which means it  becomes covered with a cuticle,
which, like all other cuticles, is either strong and hard, or thin and
soft, just as  the cuticle  is which covers the parts from whence they
arise.   They are radiated from their basis to the circumference, the
radii  appearing at  the surface pointed or granulated, much like  granu-
lations that are healthy, except that they are harder and rise above the
surface.  It would  appear that the surface on which each is formed has
only the disposition to form, and  because the surrounding and  con-
necting surface does not go into the like substance;  thus,  a wart once
begun does not increase in its basis, but rises higher and higher.  They
have  an increasing power within themselves; for, after rising above
the surface of the skin, on which they are not allowed to increase  in
breadth at the basis, they swell out into a round thick substance, which
becomes rougher and rougher.
  This structure often makes them liable to be hurt by bodies rubbing
against them;  and often from such a cause they bleed very profusely,
and are very painful.
  These excrescences are considered  by many not as simply a  conse-
quence of the venereal poison,  but as possessed of its specific disposi-
tion, and therefore they have recourse to mercury for the cure of them;
and it is asserted that such treatment  often removes them.  Such an
effect of mercury I have never seen, although given in such a quantity
as to cure in the same person recent chancres and sometimes a pox.
  As these substances are excrescences from the body, they are not to 
356
CONSEQUENCES OF CHANCRE.
be considered as truly a part of the animal, not being endowed with
the common or natural animal powers, by which means the cure  be-
comes easier.   They are so little of the true animal, and so much of a
disease, that many trifling circumstances  make them  decay; an  in-
flammation in the natural and sound parts round the wart will give it
a disposition to decay;  many stimuli applied to the surface will often
make them die.  Electricity will produce action in them which they are
not able to support; an inflammation is excited round them, and they
drop off.
  From this view of them, the knife and escharotics must  appear not
always necessary, although these modes will  act more quickly than
any other in many cases, especially if the neck is small.  In such-formed
warts perhaps a pair of scissors is the best instrument;  but where cut-
ting instruments of any kind are horrible to the patient, a silk thread
tied around their neck will do very well;  but, in whichsoever way it
is separated, it will be  in  general  necessary to touch the base with
caustic.
  Escharotics act upon warts in two different ways; namely, by dead-
ening a part and stimulating  the remainder; so that by the applica-
tion of escharotic after  escharotic the whole decays tolerably fast, and
it is seldom necessary to  eat them down to the very root, as the basis
or root often separates and is thrown off.   This, however, is  not always
the case, for we find that  the root does not always separate, and that it
will grow again; therefore, in such cases, it is necessary to eat down
lower than the general surface to remove the root.
  Any of the caustics,  such as the  lapis septicus, as also the metallic
salts, such as the lunar caustic, blue vitriol, &c, have this power.  The
rust of copper and  savine leaves mixed are one of the best stimulants.
  After they have  been to appearance sufficiently destroyed, they often
arise anew, not  from any part being left, but from  the surface of the
cutis having the same disposition as before.  This requires a repetition
of the same practice, so as to take off that surface of the cutis.
  [Ricord.—Hunter's short section on warts is far from giving a true
idea of all the varieties  of vegetations which have been justly or un-
justly ascribed to syphilis.
  Frequently, these growths  are mere ordinary warts,  due to disease
of the cutaneous or mucous follicles, and preceded  by little sebaceous
tumors.   In this case, the secretion, furnished by the affected follicles,
becomes more and more  concrete, and the follicles themselves finally
undergo a kind of eversion, and present a granulated floor, from which
asperities spring up that give them some  resemblance to poireaux}
But more commonly venereal vegetations, so called, consist of an epi-

  1 Poireau originally signifies a leek. The name is also applied to one of the varieties
of warts which the French admit, from its resemblance to this vegetable, viz.: to those
warts which are pediculated, and consist of a small  trunk, springing from the surface
of the skin or mucous membrane, and giving off minute secondary branches, which are
swollen at their extremities, forming a little furrowed head.  If several heads spring
from the same trunk, it is called a chou-fleur.   Again, the sessile  variety, without a
pedicle, extending its flat and cleft surface over the skin, receives the name of venue.
The sessile vegetations  are usually the palest; the others are variously colored.—Ed- 
CONSEQUENCES  OF CHANCRE.
357
genie tissue of new formation, which generally  tends to increase.1
These vegetations possess various degrees of vascularity, and, in some
cases, considerable sensibility; they are sometimes sessile and some-
times pediculated.  In  the first case, they vary in number and  size,
and present a granulated, plane or convex  surface, more or less  red;
the  appearance of which reminds one of  strawberries, or rather of
raspberries, to which  they  are  often compared.   When they are
pediculated, we find a single  trunk, varying in diameter, from which
branches radiate in all directions.  When, from their situation,  they
are not cramped in their development, they resemble tolerably well a
cauliflower; but when compressed or flattened, they may assume the
form of a cock's crest;  moist, friable, easily  excited to bleed, and often
bathed with a muco-purulent secretion, when  they are situated  on a
protected mucous membrane ; they become  dry, hard, and even horny,
on the parts of the skin exposed to the air.
   Moreover, to whatever variety they belong, these vegetations do not
always spring up under the same  circumstances; and very frequently
their cause escapes us.  In some cases, they  succeed eczematous or
herpetic irritation.  Pregnancy in females,  and want of cleanliness in
both sexes, may give  rise to  them.  The different  varieties of gonor-
rhcea sometimes seem to be the exciting cause which produces them:
whilst, in other cases, they are a consequence of chancres which  have
followed an abnormal process in healing, or are the product of mucous
tubercles.
   Vegetations may be situated on the mucous  membrane of the glans
or prepuce, and are common  in the neighborhood of the frasnum  and
in the groove at the base of the glans;  also at the entrance of the vulva,
on the  anfractuosities of the  carunculas myrtiformes,  which are often
mistaken for them; in different parts of the vaginal canal; on the os
tineas, and in the cavities of the uterus; in the urethra and the inferior
portion of the rectum  in  both sexes; on the tongue, especially at its
base, where the fungiform papillas sometimes resemble them'; on the
velum palati, and particularly on the edges of the uvula; in the larynx,
where my  learned  fellow-student, M.  Senn, of Geneva, has  well de*
scribed them ; and, finally, on different parts of the skin, and especially
in the neighborhood of the genital organs and the anus.
   As to the special cause which excites and keeps up these vegetations,
it cannot be sought for in the virus of syphilis, after what I have said
elsewhere.  Their distinction  into primary  and secondary is without

   1 M. Lebert, in his Physiologie Pathologique, thus describes the microscopical struct-
ure of these vegetations :—
  " A feeble power shows their internal vascular structure and numerous sebaceous
follicles about their base.  With a high power, the papillae appear to be composed of
an outer rind, consisting of concentric layers and  of an internal substance; the two
differ from each other only in density ; for, besides their vascular element, they con-
sist only of simple epidermic cells.  In the outer layers, these cells are more densely
packed, and present a longer and narrower outline, which, at first sight, gives them a
fibrous appearance.  The internal portion is also composed of epidermic cells in close
juxtaposition, but round and finely dotted on their surface.
  "They are nothing else than a development of the papillae of the epidermis, and, in
their anatomical composition, do not differ much from certainpapilliform warts.''—Ed. 
358             CONSEQUENCES OF  CHANCRE.
value; for they are always materially the same, and cannot  in  any
case serve to distinguish a local infection from constitutional syphilis.
The assertion that they are contagious, advanced by some persons, is
false.   Individuals may be found, who, having  had connection with
persons affected with  vegetations, have  afterwards  had them them-
selves, without, however, having caught  them.  In such cases, which
are very rare, it  is certainly only  a simple coincidence, and not an
instance  of  contagion; similar examples are met with  even more
frequently in cases of phthisis and cancer.
  Vegetations are not a proof of recent infection, nor of contamination
of the system.
  When they are preceded by primary or constitutional syphilis, they
appear to be an accidental consequence of the local irritation which
these  affections may produce, but  not a specific effect, since other
causes may give rise to them.
  Vegetations may be complicated with primary  or secondary venereal
symptoms, situated on  the same part or at a distance.  The complica-
tions which  may exist  in the neighborhood are, gonorrhcea; chancres
in their progressive or reparative stage; indurated chancres, which may
also serve as their base; mucous tubercles, etc.   They often excite, or,
at least in many cases,  keep up gonorrhoid  discharges, interfere with
certain functions, or give rise to more or less serious symptoms, accord-
ing to their  situation.
  Their diagnosis is generally easy, and a surgeon must be very inat-
tentive to confound them with the normal tissues of certain regions, or,
by a more common mistake, with tumors dependent on hypertrophy of
the tissues without any epigenic growth, as occurs in some cases of
mucous tubercles.  When they are developed to an enormous size and
confined within a narrow prepuce, the glans  is often compressed and
atrophied, or adhesions take place between it and the prepuce.   Then,
they become indurated in one part and softened  in  another,  and their
circulation being  obstructed, they are attacked by gangrene, and dis-
charge a fetid and ichorous pus, when they may  be  mistaken for can-
cerous degenerations.  This mistake is more readily made in some
cases, where, independently of the disfiguration of the parts from their
great  development and abundant suppuration, they give rise to a pallor
of the surface which often resembles the straw-colored complexion of
a cancerous  cachexia.
  With regard to the prognosis of vegetations, though it may be serious,
it is never so except in consequence of the accessory circumstances.
  As to their treatment, I am entirely of Hunter's opinion.   General
treatment with gold, mercury, sudorifics, etc., has no effect upon them.
They  frequently continue to increase during treatment, and disappear
or fall off when nothing  more is  done for them, without our always
being able to discover the cause of their persistence or disappearance.
  When they have been apparently cured by mercurials or other con-
stitutional remedies, it was because  they consisted only of mucous
tubercles or indurated  chancres, which served as  a base to the vegeta-
tions.   We are no longer at the age, when Fabre and some other syphil-
ographers, believers in gold and mercury, after they had administered 
CONSEQUENCES OF  CHANCRE.
359
constitutional  treatment, said  the virus was  destroyed, although the
vegetations remained or had even increased.  At the present day, the
rational course to take consists in treating the complications, when such
really exist, and in making local applications to the vegetations as to a
local disease.  It must be confessed, that science has added little to the
local remedies since the time of Hunter, unless it be the acid nitrate of
mercury as a powerful caustic, and a concentrated solution of opium,
the effects of which are doubtful.  Swediaur's powder is  generally in-
efficacious.  We should, in most cases, resort to  cauterization, and es-
pecially to excision.—Ricord.]

           § 5.  Of Excoriations of the  Glans and Prepuce.
  It very often happens that the surface of the glans and inside of the
prepuce excoriate, becoming extremely tender, and then a matter oozes
out.  The prepuce in such cases often becomes a little  thickened, and
sometimes contracts in its orifice, both which circumstances render the
inversion of it difficult and painful.  Whether this complaint ever arises
from a venereal cause is not certain, as  it often takes place where there
never has been any venereal taint.
  This disease is in the cutis;  and under such a disposition it has no
power of forming a good cuticle.  It  is very similar to a gonorrhcea in
this part, but it is not venereal.
  Drawing the prepuce back,  and steeping the parts in  a  solution of
lead often takes off the irritation, and  a sound cuticle is formed.  Spirits
diluted often produce the same effect;  the unguentum citrinum of the
Edinburgh Dispensatory, lowered by  mixing with it equal parts of hog's
lard, is often of  singular service in such cases.  But there are  cases
which bid defiance to all our applications, in which I have succeeded
by  desiring the person to leave the glans uncovered, which produced
the stimulus of necessity for the formation of a  natural cuticle. 
 
PAET   Y.
                      CHAPTER  I.

                           OF  BUBO.

  A knowledge of the  absorbing system, as  it is now established,
gives us  considerable information respecting many of the effects of
poisons, and illustrates several symptoms of the venereal disease, in
particular the formation of buboes.  Prior to this knowledge we find
writers at a loss how to give a true and consistent explanation of many
of the  symptoms of this disease.  The  discovery of the lymphatics
being a system of absorbents has thrown more light on many diseases
than the  discovery of the circulation of the blood;  it leads  in  many
cases directly to  the cause of the disease.
  The immediate consequence of the local  diseases, gonorrhoea and
chancre,  which is called  bubo, as also the remote, or  lues venerea,
arise from the absorption of recent venereal matter from some surface
where it  has either been applied or formed.   Although this must have
been allowed in  general ever since the knowledge of the disease and
of absorption, yet a true  solution of the formation of bubo could not
be given till we  had acquired the knowledge of the lymphatics being
the only  absorbents.   Upon the old opinion, of absorption being per-
formed by the veins, the lues venerea could easily have been accounted
for, because it could as readily be produced by the absorbing power
of the veins, if they had such, as by the lymphatics; but the difficulty
was to say how the bubo  was formed.  There they seemed to be at a
loss to account for this disease, yet  they sometimes expressed  them-
selves as if they had some idea of it, although at the same time they
could have no clear notions of what  they advanced; nor  could they
demonstrate what they said from  the knowledge of the parts and their
uses.
  Buboes are by some imputed to the stopping of a gonorrhoea, or, as
they express it, driving it to  the  glands of the  groin, conformably to
the idea  they had of the  cause of the swelling of the  testicle.  But
this is not just, for we know  of no such power as repulsion; and if it
was driven there it could  not be by stopping the formation of matter,
but by increasing the absorption,  of which they had no idea.
  When  we examine the  opinion of authors concerning the formation
of bubo,  prior to the knowledge of the  power of absorption in  the 
362
BUBO.
lymphatics, we shall find them making use of terms which they could
not possibly  understand.  For instance, Heister says: "They are  of
two kinds, one venereal, and the other not;" but he does not say that
the venereal arises only from impure coition.
  Astruc says, p. 326, that some  buboes arise immediately from im-
pure coition, and  these  he  calls essential; others from suppressed
gonorrhcea, or a small discharge, or from chancres of the penis, and
these he calls symptomatic: lastly, that they arise spontaneously with-
out any immediate previous coition, and are a  pathognomonic sign  of
a hidden pox.
  In p. 327, he shows the impossibility of this last happening from
what we now call or understand by a lues venerea; but in p. 328, he
explains what he calls a latent lues venerea, which is a local affection,
produced, as he supposes, from a lues venerea,  but  which most  proba-
bly never yet happened; and if  ever they had arisen from such a
cause, even the absorption of  their matter could not produce a vene-
real bubo, as  will be explained.  In short, as  he  understood not the
true absorbing system, his ideas are become now unintelligible.1
  We  find Cowper, Drake, and Boerhaave, as well as Astruc,  speak-
ing of  the vitiated lymph not passing the glands, therefore inflaming
them; • also of the inspissated  lymph passing, either by the circulation
of the  blood,  that is, from the constitution to these glands (an opinion
held by some to this day), or  by a shorter course,  viz., the lymphatic
vessels  which go  to the inguinal  glands.   They also  speak  of the
swelling of the inguinal glands, or venereal buboes, from the contagion
being communicated by the resorbent lymphatics.   Drake even speaks
more pointedly;  and, if we consider him no farther, he would  almost
make us believe that he  knew that the lymphatics were the absorb-
ents ; but as he has no such ideas when treating of those vessels ex-
pressly, we are not to give him credit  for it.   His words are: "The
venereal bubo may very likely take its rise from some parts of the
contagious matter of claps sucked up by the lymphatics of the penis,
and thence imported to the inguinal glands, where they  deposit their
liquor; and thence it well behooves the surgeon to be as early as  may
be in the opening of such tumors, before by the exporting vessels  of
that class the poison  is carried  farther into  the  blood, which very
probably may be the case where such tumor ariseth immediately upon
the stopping of a gonorrhoea, as  does  the  hernia humoralis.  But
when the same appears some  months after that was removed, we are
to suppose, as in cases of other poisons laying hold of  the blood, by
the strength of nature  it is thrown forth, either by means of the lym-
phatics of the bloodvessels  themselves, if not spewed  out  of the
nervous  tubes, as Wharton surmised, and deposited in  these emunc-
tories."
  Here he compares it to the formation of  a hernia humoralis, which
plainly shows that he understood  neither of them.
  Even so late as the year 1748, we do not find any new ideas on this
subject.  Freke says:  " By sealing up the mouths of the glands of the

   1 The above  extracts are from the English edition, published in the year 1754. 
bubo.                         363
urethra, the poison is thence, by  the ducts leading to  the inguinal
glands, conveyed to them."
  In the year 1754, eight years after Dr. Hunter had publicly taught
his opinion of the lymphatics being a system of absorbents, we find a
treatise on this disease by Mr. Gataker, where as little new is advanced
on this subject as in any of the former.
  When we come so  low down as the year 1770, in an abridgment of
Astruc, by Dr. Chapman (2d edit.), in  which he introduces his own
knowledge and ideas,  we find the absorbing power of the lymphatics
brought in as a cause  of the formation of buboes; but by this time the
knowledge of the lymphatics being the  system of absorbents was in
this country generally diffused.
  The doctrine of absorption being now perfectly understood, we have
only to explain the different modes in  which it may take place.
  The venereal matter is  taken up by the absorbents of the part in
which  it is placed;  and although the absorption of the matter and the
effects  after absorption are the same, whether from the matter of the
gonorrhoea or chancre, yet I shall  divide the absorption into  three
kinds,  according to the three  different surfaces from which the matter
may be absorbed, beginning with the least frequent.
  The first and most simple is where the matter either of a gonorrhcea
or chancre has  only  been applied to some sound surface, without
having produced any  local effect on the part, but has been absorbed
immediately upon its  application.   Instances of this I  have seen in
men, and  such are  perhaps  the  only instances that can  be depended
upon;  for it  is uncertain in many cases whether a woman  has a
gonorrhoea or not.  I think, however,  I  may venture to affirm that I
have seen it  in women, or at least  there was every reason to believe
that they had neither chancre nor gonorrhcea preceding,  as there was
no local appearance of it, nor did they communicate it to others who
had connection with them.
  It must  be allowed that this mode of absorption is very rare; and
if we  were to examine the parts  very carefully, or inquire  of the
patients very strictly,  probably a small chancre might be discovered
to have been the cause, which I have more than once seen.  For, when
we consider how rarely it happens from a gonorrhcea, in which the
mode of absorption is similar, we can hardly suppose it probable that
it should here arise from simple contact, the time of the application of
the venereal  matter being commonly so very  short.  We might,  in-
deed, suppose the frequency to make up for the length of time, which
we  can hardly allow,  for the  same  frequency should give the chance
of producing it locally.  Therefore very particular attention  should
be paid to all the circumstances attending such cases.
  There is, however, no great reason why it should not  happen, and
the possibility of it lessens the faith that is to  be put in the supposi-
tion that the disease may be years in the constitution before it appears;
for whenever it does appear  in a lues venerea, its date is always car-
ried  back to the last local affection, whether gonorrhoea or chancre,
and the latter connections are never regarded.
  The  second mode of absorption of this matter is more frequent than 
364
bubo.
the former, and  it is when the matter applied has produced  a gonor-
rhoea; and  it may happen while the complaint is going on, either
under a cure or not.  Some of the matter secreted by the inflamed
surfaces having been absorbed and  carried into the circulation, pro-
duces the same complaints as  in the former case, by which means the
person gives himself the lues venerea.
  The third mode is the absorption of the matter from an ulcer, which
may be either a chancre or a bubo.  This mode is by much  the more
frequent, which, with many other proofs, would show that a sore or
ulcer is the surface most favorable for absorption.  Whether ulcers in
every part of the body have an equal power of absorption, I  have not
been able to determine; but I suspect that an ulcer on the glans is not
so good a surface  for  absorption as one on the prepuce, although I
have seen both buboes and the lues venerea arise from the former, but
not so often as from the latter.
  To these three methods may be added a fourth—absorption from a
wound, which, I have already remarked, is perhaps not so frequent as
any of the former.
  As the venereal poison  has the power of contaminating whatever
part of the body it comes in contact with, it contaminates the absorb-
ent system,  producing in it local venereal complaints.  It is hardly
necessary to observe, that  what is  now commonly understood by a
bubo is a swelling taking place in the absorbing system, especially in
the glands, arising from the absorption of some poison, or other  irri-
tating matter; and when such swellings take place in the groin, they
are called buboes, whether from absorption or not, but are most com-
monly supposed to  be venereal,  even  although there has  been no
visible preceding cause.  This has  been so much  the case that all
swellings in this part have been suspected to be of this nature; femoral
ruptures and aneurisms of the femoral artery have been mistaken for
venereal buboes.
  I shall call every abscess in the  absorbing system, whether in the
vessels or the glands, arising in consequence of the absorption of vene-
real matter,  a bubo.
  This matter, when absorbed from either  of the four different sur-
faces, which are common surfaces, wounds, inflamed surfaces,  and
ulcers, is carried along  the absorbent vessels to  the common circula-
tion, and its passage often  produces  the specific inflammation in these
vessels, the consequence of which is the formation of buboes, which
are venereal abscesses, exactly similar in their nature and effects to a
chancre, the only difference being in  size.   As the absorbents with the
glands are immediately irritated  by the same specific matter which
has undergone no change in  its passage, the consequent inflammation
must therefore have the same specific quality, and the matter secreted
in them be venereal.1
  As this system of vessels may be  divided  into two classes, the ves-

  1 I do not know how far this reasoning will hold good in all  cases of poisons, for I
very much suspect that the bubo, that is sometimes formed in consequence of inocu-
lation of the smallpox, does  not produce variolous matter.  The natural  poisons, in
producing buboes, certainly do not form a poison similar to themselves. 
bubo.
365
sels themselves and  their ramifications and convolutions, called the
lymphatic glands, I shall follow the same division in treating of their
inflammations.
  Inflammation of the vessels is not nearly so frequent as that of the
glands.  In men, such inflammations, in consequence of chancres upon
the glans or prepuce, generally appear like a cord leading along the
back of the penis  from the chancres.  Sometimes they arise from the
thickening of the prepuce in gonorrhoeas, that part in such cases being
generally in a state of excoriation, as was described when I treated of
that  form of the disease.   These cords often terminate insensibly on
the penis, near its root, or near the pubes;  at other times they extend
farther, passing to a lymphatic gland in the groin. This cord can be
easily pinched up between the finger and thumb, and  it often gives a
thickness to the prepuce, making it  so stiff at this part as to make the
inversion of it difficult, if not impossible, producing a kind of phimosis.
  I think I have observed this appearance to arise as  frequently from
the gonorrhcea, when attended with the before-mentioned inflammation
and tumefaction  of the prepuce, as  from  chancres; which, if my ob-
servation is just, is not easily accounted for.  I have observed that
absorption is more common to ulcers than inflamed surfaces, or at least
the formation of a bubo in the gland, and its effects in the constitution
are more common from an  ulcer; but it may  be  remarked, that the
inside of the prepuce, from whence this cord appears to arise, is  in an
excoriated  state.   It is possible that  this effect may arise from the
lymphatics sympathizing with the inflammation of the urethra,  but I
believe the affection is truly venereal; or it is possible that even the
absorption of the  coagulable lymph, which was  produced from the
venereal inflammation, and which is  the cause of the tumefaction, may
have the power of contamination, as  appears  to  be  the  case in the
cancer.
  The thickening, or the formation  of this hard cord, probably arises
from the thickening of the coats of the absorbents,  joined with the
extravasation of coagulable lymph,  thrown in upon its inner surface,
as in inflamed veins.
  This cord often inflames so much  as to suppurate, and sometimes in
more places than  one; forming one, two, or three buboes, or small
abscesses in the body of the penis.   When this is going on, we find in
some parts of this  cord a circumscribed hardness; then suppuration
takes place in the centre, the skin begins to inflame, the matter comes
nearer to it, and  the abscess opens like any other abscess.
  I have seen a chain of these buboes, or little abscesses, along the
upper part of the penis, through its whole length.
  This maybe supposed to be exactly similar to the inflammation and
suppuration of a vein after being wounded and exposed.
  Inflammation of the glands is much more frequent than the former,
and arises from the venereal matter  being carried on to the lymphatic
glands, the structure of which appears to be no more than the ramifi-
cations  and reunion of the absorbent vessels,  by which means they
form these bodies.
  From this structure, we may reasonably suppose that the fluid ab- 
366
BUBO.
sorbed is in some measure detained in these bodies, and thereby has a
greater opportunity of communicating the disease to them than to the
distinct vessels, where its course is perhaps  more  rapid, which  may
account for the glands being more frequently contaminated.
  Swellings of these glands are common to other diseases, and should
be carefully distinguished  from those that arise  from the venereal
poison.  The first inquiry should be into the cause, to see if there is
any venereal complaint  at  some  greater distance from the heart, as
chancres on the penis,  or any preceding disease on the penis;  to learn
if mercurial ointment has been at all applied  to the legs and thighs of
that side, for mercury applied to those parts, for the cure of a chancre,
will sometimes tumefy the glands, which  has been supposed to be
venereal.  We should farther  observe, if there be  no  preceding dis-
ease in the constitution, such as a cold, fever, &c, the progress of the
swelling with regard to quickness is also to be attended to, as also to
distinguish it from a rupture, lumbar abscess, or aneurism of the crural
artery.
  Perhaps these bodies are more irritable,  or more  susceptible  of
stimuli than the vessels.   They  are  certainly more  susceptible  of
sympathy; however, we are not yet sufficiently acquainted with  the
use of these glands to be able to account satisfactorily for this difference.
  It would appear in some cases that it is some time after the absorp-
tion of the venereal  matter before it  produces its effects upon  the
glands; in some it has been six days  at least.  This  could  only be
known by the chancres being healed six days before the bubo began
to appear;  and in such cases it is more than probable that the matter
had been absorbed a much  longer time before, for the last matter of a
chancre most probably is not venereal;  and indeed it is natural to
suppose that the poison may be as long before  it produces an action
on the parts, when applied in this way, as it is either in the urethra or
in forming a chancre, which I have shown  to be sometimes six or
seven weeks.
  The glands nearest to the seat of absorption are in general the only
ones that are attacked, as those in the groin, when the matter has been
taken up from the penis in  men; in the groin, between the labia and
thigh, and  the  round  ligaments, when absorbed,  from the vulva, in
women.  I think there is commonly but one  gland at  a time that is
affected by the absorption  of venereal matter, which, if so, becomes
in some sort a distinguishing mark between venereal buboes and other
diseases of these bodies.  We never find  the lymphatic vessels or
glands, that are second in order, affected, as those  along the iliac ves-
sels or back; and I have also  seen when the  disease has been  con-
tracted by a sore, or cut  upon the finger, the bubo come on a little
above the bend of the  arm, upon the inside of the biceps muscle; and
in such where the bubo has come in that part, none has formed in the
armpit, which is the most common place for the glands to be affected
by absorption.
  But  this is not universal, although common, for I was informed by a
gentleman who contracted  the  disease in the before-mentioned way,
that he had buboes both on the inside of the  biceps muscle and in the 
BUBO.
367
armpit.   Another case of this kind I have heard of since; why it is
not more common is perhaps not easily explained.
  It might be supposed that the matter was weakened, or much diluted
by the absorptions from other parts by the time it gets through these
nearest ramifications, and therefore has not power to contaminate those
which are beyond them;  but it is most probable that there are other
reasons for this.  I once suspected that the nature of  the poison was
altered in these glands as it passed through them, which was the reason
why it did not contaminate the second or  third series  of glands; and
also why it did not affect the constitution in the same way as it did the
parts to which it was first applied;  but this explanation will not account
for the next order of glands to suppurating buboes not being affected
by the absorption of venereal matter.  It appears to me that the inter-
nal situation of the other glands prevents the venereal irritation from
taking place in them;  and this opinion is  strengthened  by observing
when one of these external glands suppurates and forms a bubo, which
is to be considered as a large venereal sore or chancre, that the absorp-
tion from it, which must be great, does not contaminate the lymphatics
or glands next in order, by the venereal matter going directly through
them.
   If this be  true, then, the  skin would seem to  be the cause of the
susceptibility of the absorbents to receive the irritation.  Whether the
skin has the  power inherent in itself, or acquires  it from some other
circumstance, as air, cold, or sense of touch, is not easily ascertained ;
but whichever it be, it shows that the venereal matter of itself is not
capable of irritating, and that it requires a second principle to complete
its full effect; that is, a combination of  the nature of  the poison and
the influence of the skin, and that influence must be by sympathy, and
therefore weaker than  if  acting in the  same part; that is,  the  skin
itself, which, perhaps, is  the reason why the venereal matter does not
always affect those vessels and glands, while it always does  the  skin,
if inserted into it.
   The situation of buboes  arising from the venereal  disease  in the
penis is, in men, in  the absorbent  glands of the groin;  if a gonorrhcea
is the cause of a bubo, one groin is not exempted more than the other;
both maybe  affected; but if a bubo arises in consequence of a chancre,
then the groin may be generally determined by the seat of the chancre,
for if the chancre is on one side of the penis then  the bubo will  com-
monly be on that side; however, this is  not universally the case; for
I have known instances, although  but  few, where a chancre on one
side of  the prepuce or penis  has been the cause of  a bubo on the
opposite side, which, if arising from that chancre, is a proof that the
absorbents either anastomose, or decussate  each other.   If the chancre
be on the frasnum, or  on the middle of the  penis, between the two
sides, then it is uncertain which side will be affected.
  The situation of the glands of the groin is not always the same, and
therefore the course of the absorbent vessels will vary accordingly.  I
have seen a venereal bubo, which arose from a chancre on the penis, a
considerable  way down the  thigh; on  the contrary, I have seen it
often as high as the lower part of the belly, before Poupart's ligament, 
368                         bubo.
and sometimes near the pubes, all of which three situations may lead
to some variations in the method of cure; therefore it may be proper
to attend to them.
  As the disease most commonly arises from copulation, the situation
of buboes is generally in the groin ; but as no part of the body, under
certain circumstances, is exempt from this disease, we find the nearest
external glands between the part of absorption and  the heart, every-
where in the body share the same  fate with  those of the  groin, espe-
cially if external.
                     CHAPTER  II.

                   of buboes in women.

  The same diseases in the absorbents, in consequence of the absorp-
tion of the venereal matter, take place in this sex as well as in men. I
never saw but one case where the absorbent vessels were diseased; but
this is nearly in the same proportion as in men, when 1 consider  the
proportion the number of the one sex bears to that of the other who
apply to me for a cure of the venereal disease in any form.   The case
was a gonorrhcea, with violent itching and soreness when the patient
sat or walked, but she had very little pain in making water.  When I
examined the parts I could  see no difference between them and sound
parts, excepting that the left labium was  swelled, or fuller than the
other, and a hard cord passed from the centre of that labium upwards
to the os pubis, and passed  on to the groin of the same side, and was
lost in a gland as high as Poupart's ligament.   It was  not to be felt
but by pressing the parts with some force, and it gave considerable
pain upon pressure.
  The swelling of the labium appeared to be somewhat similar to the
swelling of the prepuce in  similar  cases in men, so that they would
appear to arise from the same cause.
  One would naturally suppose that what  has been said of this com*
plaint  in the lymphatic  glands in men, would be wholly applicable to
women, and also that nothing peculiar to women could take place;  but
the seat of absorption is more extensive in this sex, and the course of
some of the absorbents is also different, from whence there are three
situations of buboes in women, two of which are totally different from
those in men, and these I suspect to be in the absorbents.
  The third situation of buboes  in this sex is similar to that in men,
and therefore they may be divided into three,  as in men.
  When buboes arise in women  where there is no chancre, it is more
difficult to know whether they are venereal or not than in men; for
when they arise in men without  any local complaint it is known that
no such complaint exists, and therefore the bubo  cannot be venereal,
excepting by immediate absorption ; but in women it is often difficult 
bubo.
369
 to know whether there be any infection present or not; and, therefore,
 in order to ascertain the nature of the bubo, attention must be paid to
 its manner of coming on, progress, and other circumstances.
   When chancres are situated forward, near to the meatus urinarius,
 nymphas, clitoris, labia, or mons Veneris, then we find that the matter
 absorbed is carried along one or both of the round ligaments, and the
 buboes  are formed in those ligaments just before they enter the abdo-
 men, without, I believe, ever going farther.  These buboes I  suspect
 not  to be glandular, but inflamed absorbents; and if so, it strengthens
 the  idea that it  is only an external part that  can be affected in this
 way.
   When the chancres are situated far back, near the perineum or in
 it, the matter absorbed is  carried forwards along the angle between
 the  labium and the thigh to the glands in the groin;  and often in this
 course there  are formed small buboes  in the absorbents, similar  to
 those on the  penis in men; and when the effects of the poison do not
 rest here, it often produces a bubo in  the groin, as in men.
   [Editor.—A simple chancre may, an  infecting chancre must exercise an
 appreciable  influence upon the lymphatic ganglia in anatomical  connection
 with it.
   Whenever such influence takes place, it is a remarkable fact that it is exer-
 cised only upon the superficial ganglia, and is confined to  the first group of
 glands in which the lymphatic vessels from the neighborhood of the chancre
 terminate.   A specific  bubo—that is, a bubo secreting inoculable pus, such
 as will presently be described—is never met with in the deep  ganglia, nor in
 the lymphatics emanating from them. It  would  therefore appear that the
 first group of ganglia, in connection with  a chancre, presents a barrier, which
 the virulent pus cannot pass.   This fact has already been noticed by Hunter.
 An apparent exception to this law exists  in cases, which are not unfrequent,
 of a bubo occurring on  the  opposite side to that on which  the  chancre is
 situated, but this is explained by the anatomy of the lymphatic vessels which
 are found to interlace upon the median line.
  The most important point to be remembered, is  the fact that each of the
 two  varieties of chancre has its special influence on the neighboring ganglia.
  A simple, non-indurated chancre does not necessarily affect the lymphatic
 ganglia  at all; indeed, in the majority of cases, the latter remain in their
 normal condition.  But if they be affected, the symptoms are peculiar, and
 entirely distinct from those of a bubo dependent upon an indurated chancre.
 In the former case, it is always an inflammatory bubo, painful from the out-
 set, and progressing rapidly towards suppuration.   Moreover, as a  general
 rule,  only one  ganglion is affected.  But  here it is necessary to admit two
 varieties, corresponding to the two modes in which a simple chancre may
 affect these ganglia.  These varieties are simple buboes and virulent buboes.
  A  simple bubo  is produced, when the chancre acts like  any ordinary irri-
tant:—as, for instance, a thorn implanted in the flesh—and gives rise to simple
inflammation of the neighboring ganglion.  We then have a simple adenitis
       24 
370                             bubo.
which is identical in its development and progress with any ordinary case of
adenitis.  It may terminate by resolution, or it may suppurate, but its pus is
never virulent.
  This is  not the case with a virulent bubo, which is due to another cause
than simple irritation, namely, to absorption of the specific pus of the chan-
cre.   Like the simple bubo, a virulent bubo is  acute and inflammatory, but
its  termination is  quite different.   Its  resolution is impossible; it always
suppurates, and its pus is virulent pus, capable of being inoculated.   More-
over, the wound produced by the opening  of a  virulent bubo,  becomes
inoculated by  this virulent pus,  and  assumes the  character of a specific
ulceration, which it in reality is.
  The following is the manner in which a bubo of this  variety is produced:
the virulent pus covering the surface of the chancre,  penetrates the ulcerated
and open mouths of the lymphatic vessels; it passes through these canals,
which it  generally leaves intact,  probably in consequence of the rapidity
with which its  passage is effected; finally,  it  arrives within the ganglia, the
function of which  is  to retard the course  of the  lymph, and elaborate  its
constituent parts.  Here it exercises its specific action, and produces a true
inoculation, which  is  soon followed by the formation of  a chancre.   A viru-
lent bubo, therefore, is a true chancre, showing a tendency to ulceration, and
secreting virulent  and inoculable  pus; and  hence it is readily  understood
why it invariably suppurates.
   But the order of events is  not always as simple as we have described it.
We have spoken of the inflammatory  bubo, and the bubo  by absorption, as
two distinct affections, but the two frequently, and  in fact, generally, are in
 a measure  combined, though each preserves its normal characteristics.  A
 ganglion is inoculated by absorption of the virus, and  is transformed into a
 virulent abscess ; this sets up inflammatory action in the neighboring cellular
 tissue which also terminates in suppuration.   Hence, there  are  two collec-
 tions of pus formed: one  encysted within the ganglion;  the other diffuse,
 and external to it.   If  now by a  careful incision, we reach the more superfi-
 cial collection of matter, and inoculate it upon the integument of the patient;
 and afterwards cutting  deeper, take a drop of pus from within the  ganglion-
 ary abscess, and inoculate it also, we shall find that the first inoculation will
 fail while the  second will succeed.
    The wound formed by the opening  of  a  purely inflammatory bubo, is  a
 simple wound, and rapidly cicatrizes, but that of a virulent bubo is trans-
 formed into a true chancre.   In a few days it assumes all the characters of a
 primary ulcer; its edges are everted, its  floor  grayish, its suppuration spe-
 cific, its pus inoculable, its tendency  progressive, &c.   It is liable also to all
 the complications of a chancre, and, among others, to phagedena, of which
 examples are  always to be met with in our large hospitals.
    To recapitulate, a simple chancre,  if it  affect the lymphatic ganglia at all,
 may produce  two kinds of bubo : one simply  inflammatory or  sympathetic, 
bubo.
371
susceptible of resolution,  or, if it  suppurates, furnishing simple pus;  the
other, a specific or virulent bubo, necessarily suppurating, its pus inoculable,
and its opening being transformed into a true chancre.
  The value of these symptoms will be better appreciated after  describing
the kind of bubo which attends an  infecting chancre.  An additional point
of distinction between the two is to  be found in the date of their appearance.
The affection of the lymphatic ganglia attendant upon an infecting chancre,
generally coincides with the appearance of the induration of the  chancre,
while in the case  of a bubo accompanying a simple chancre, there is no fixed
period for its development.  It may take place late, even as late  as three
years after the chancre is formed, as in a case observed by M. Puche.
  The bubo which sometimes attends a gonorrhcea belongs to the same variety
as the simple or inflammatory bubo.  It can  only be virulent when the  dis-
charge  from the  urethra  depends upon, or is coexistent with a concealed
chancre.
  Another variety of bubo, the one which  always  accompanies an infecting
chancre, will next engage our attention.  As already stated, the time of the
appearance of this  kind of bubo generally coincides with the induration of
the chancre, or very near it; during the course of the first or second week
following coitus,  and it is very rare for it to appear after  this time.  This
bubo at first consists of a simple fulness of the ganglia, free from all inflam-
matory symptoms, and generally unobserved by the  patient.   In a few days
it acquires its full development.  We then find a series of small tumors, of
an oval form, very hard, independent of each other and movable.   They are
entirely indolent, causing no pain, not tender on pressure, and exciting no
inconvenience except that which may be supposed  to be due to the pressure
of their increased volume on the neighboring tissues.
  They are very  hard, and their hardness is of a peculiar kind—elastic  and
cartilaginous.  It is in  fact of the same nature and  presents the same cha-
racters as the induration of the base of the chancre.
  These tumors are independent of each other.  They are never fused together,
nor closely adherent to the surrounding cellular tissue, so that they move freely
beneath the finger.
  Unlike the single  inflamed ganglion which accompanies a simple chancre,
they are multiple.  All the ganglia  corresponding to the  affected region are
involved, and hence the  name oipleiad, which Ricord has applied to this form
of bubo.   It is rare for these tumors to assume any considerable size.  They
seldom are larger than an almond;  but among the number we generally find
one which is larger than the others ; and this is the one in which the lympha-
tics from the ulcer terminate.  This ganglion is probably influenced  directly
by the  chancre by continuity, while the neighboring  ganglia are  affected
through sympathy and the constitutional diathesis.
  Whenever an infecting chancre is situated upon one side of the median line
of the penis, a pleiad of indurated ganglia will always be found on the same 
372
bubo.
side in the groin, but there generally exists another similar pleiad in the op-
posite groin, perhaps not so well developed, but equally characteristic.
  The bubo attending an indurated  chancre  shows no tendency by itself to
become inflamed, nor to take on  specific suppuration.  Through its whole
course it is free from all symptoms of inflammation.   It is not to be under-
stood by this, however, that an indurated bubo is  protected from the action
of all causes capable of exciting simple inflammation.  On the contrary, the
induration of the ganglia may be  said  to favor such action; and hence we
not unfrequently find an indurated bubo, in a strumous subject, the starting
point of a scrofulous enlargement of the gland, which may terminate in sup-
puration.   But independently of other causes an indurated bubo  never sup-
purates, nor in any case gives exit to inoculable pus.
  The symptoms of an indurated bubo, which have now been described, are
so well marked that they evidently  afford a most valuable aid to the diagnosis
of an infecting chancre.  Fortunately this bubo preserves its characteristics
long after the primary sore, to which it  was due, is healed.  Though the in-
duration of the  chancre may, in some  instances, rapidly  disappear, yet the
attending bubo is  usually well marked for months, and sometimes for years.
It may remain as the only sign to indicate the point of origin of constitutional
symptoms, which have declared themselves after all traces of the primary
ulcer have disappeared.   Whenever therefore a patient with secondary symp-
toms denies the existence of any suspicious antecedent, do not fail to examine
the lymphatic ganglia in the various  parts of the body.  The discovery of an
indurated bubo will not only show  that  there has been an infecting chancre,
but will indicate its seat.
  Thus an indurated bubo situated above one of the  condyles of the humerus
or in the axilla will point to a chancre upon the corresponding extremity, and
usually upon the finger; if situated in the submaxillary region, to a chancre
on the lip ; and if you find the most external of the inguinal  ganglia alone
involved, you have reason to suspect a chancre of the anus.
  The variety of bubo just  described  belongs exclusively to the infecting
chancre ;  nay more, it always attends this kind of chancre.   It may vary in
the degree of its development, and be  more  or less marked in the different
periods of its existence, but it never fails to accompany an  indurated primary
ulcer.  There can be no infecting chancre without a corresponding indurated
bubo.
  Some authors admit what are called non-consecutive buboes, that is, buboes
which are not preceded by a chancre,  and Which are therefore to be considered
as primary symptoms; but  M. Ricord rejects this class of buboes  entirely.
The irritation of excessive coitus may indeed cause a swelling of the inguinal
glands, but in this case it has nothing whatever to do with syphilis, and it is
impossible to admit that the syphilitic virus  can  be  absorbed  and conveyed
to the ganglia without giving rise to a chancre at its point of entrance.
  We will add a few words  on  the  influence which chancres exert upon the
lymphatics themselves. 
bubo.
373
  When pus is absorbed from a simple chancre, it usually passes through the
lymphatic vessel with such rapidity as not to affect it, so that lymphangitis
symptomatic of  a  simple chancre is rare, compared with buboes.   If, how-
ever, the pus be delayed in its passage through the lymphatic, it inoculates
the part, and  an abscess is formed, which, when opened, constitutes  a true
chancre, secreting  virulent pus, and identical with the chancre which follows
the opening of a virulent bubo.
  An indurated  chancre likewise has its peculiar action on the lymphatic vesr
sels.  If these be  affected, no inoculation takes place, there is no inflamma-
tion, and no suppuration.  There is merely an effusion of plastic lymph.
The vessel becomes tumefied and indurated, like an indurated bubo,  and may
be felt like a cord beneath the finger, sometimes presenting a series of swell-
ings from point to point, like a string of beads. This indurated or plastic lym-
phangitis is far from always accompanying an indurated bubo; it is not, there-
fore, like the latter, a necessary attendant of  the indurated chancre.
'  After what has now been said, the importance of consulting the condition
of the  neighboring lymphatics and  their ganglia, in forming our diagnosis
as to the character of a chancre, will at once be recognized.  The symptoms
already described of the two varieties of primary ulcers are not always clearly
marked, and if we relied upon them alone, we should often be led into error;
but an  examination of  the neighboring ganglia will supply what is here
wanting, and enable us to arrive at a certain conclusion as to the nature of
the primary sore.  An infecting chancre, which it is so important to recog-
nize, may always be known by the induration of its base and by its attendant
indurated bubo.—Editor.]
                       CHAPTER  III.

OF THE INFLAMMATION OF  BUBOES  AND  THE MARKS THAT
  DISTINGUISH THEM FROM  OTHER  SWELLINGS  OF  THE
  GLANDS.

   The bubo  commonly begins with a sense of pain, which leads the
patient to  examine the part,  where a small  hard tumor is to be felt.1
This increases like every other inflammation that has a  tendency to
suppuration; and, if not prevented, goes on to suppuration and ulcera-
tion, the matter coming fast to the skin.
   But we find cases where they are slow in their progress, which, I

  1 It must be remarked, here, that whenever a person has either a gonorrhoea or a
chancre, he becomes apprehensive of a bubo: and as there are in the gonorrhoea, and
sometimes in the chancre, sympathetic  sensations in or near the groin, they are sus-
pected by the patient to be beginning buboes, and the hand is immediately applied to
the part; and if he feels one of the glands, although not in the least increased, the
suspicions are confirmed, from the belief that he has no such parts naturally. 
374
BUBO.
suspect, either arises from the inflammatory process being kept back
by mercury or other means, or being retarded by a scrofulous tendency,
such a disposition in the parts not so readily admitting the true vene-
real action.
  At first, the inflammation is confined to the gland, which is movable
in the cellular membrane;  but as it increases in size, or as the inflam-
mation, and more  especially  the  suppuration, advances, which in all
cases produce rather a common than a  specific effect, the specific dis-
tance is exceeded; the surrounding cellular membrane becomes more
inflamed, and the tumor is more diffused.  Some buboes become ery-
sipelatous, by which means they are rendered  more diffused and cede-
matous, and do not readily suppurate, a circumstance often attending
the erysipelatous inflammation.
  To ascertain what a disease is, is the first step in the cure; and when
two or more causes produce similar effects, great attention  is necessary
to distinguish one  effect from another, so  as to come at the true cause
of each.
  The glands of the groin, from their situation, are liable to suspicion,
for, besides being subject to the common diseases, they become exposed
to others, by allowing whatever is absorbed to pass through them; and
as the route of the venereal poison to  the constitution is principally
through them, and being oftener ill from this cause than any other,
they often are suspected of this disease without foundation.
  To distinguish with certainty the true venereal bubo from swellings
of those glands arising from  other causes, may be very difficult.  We
must, however, examine all  circumstances, to  ascertain in what the
bubo differs from the common diseases of those glands, whether in the
groin or elsewhere, in which examination the apparent  causes are not
to be  neglected.   I have  already given the character of  the venereal
bubo in general terms; but I shall now be more particular, as the two
are to be contrasted.
  The true' venereal bubo, in consequence of chancre, is most com-
monly confined to one gland.  It keeps nearly its specific distance till
suppuration has taken place, and then becomes more diffused."  It is
rapid in its progress from inflammation to suppuration and ulceration.
The suppuration is commonly large for the size of the gland, and but
one abscess.  The pain is, very acute.   The color of the skin which
the inflammation attacks is a florid red.
  It may be observed that the buboes, in consequence of the first mode
of  absorption, viz., where no  local disease has been  produced, will
always be attended with a greater  uncertainty of  the nature of the
disease than  those  attended or  preceded by a disease in the penis,
because a simple  inflammation and  suppuration of these glands are
not sufficient to mark it to be venereal;  but as we always have this
disease in view when the glands of the groin are the seat of the disease,
the patient runs but little risk of not being cured, if it should be vene-

  1 It may be observed here, that the glands and surrounding parts being dissimilar,
inflammation does not so readily become diffused as when it takes place in a oom-
mon part. 
                             BUBO.                         QiD

real; but I am afraid that patients have often undergone a mercurial
course when there has been no occasion for it.
  It will, perhaps, be difficult to find out the specific difference in the
diseases themselves; but I think that such buboes as arise without
any visible cause are of two kinds;  one similar to those arising from
chancres or gonorrhoea; that is, inflaming  and suppurating briskly.
These I have always suspected to be venereal; for although there is
no proof of their being so, yet from these circumstances there is a
strong presumption that they are.
  The second are generally preceded and attended with slight fever,
or the common  symptoms of a cold, and they are  generally indolent
and slow in their progress.  If they are more quick  than  ordinary,
thev become more  diffused than the venereal, and may not be con-
fined to one gland.  When very slow they give but  little  sensation,
but when more quick, the sensation is more acute, though not so sharp
as in those that  are venereal; and most commonly they do not sup-
purate, but often become stationary.  When they do suppurate it is
slowly, and often in more glands than one, the inflammation being
more diffused, and commonly small in proportion to  the  swelling.
The matter comes  slowly to the skin not attended with much pain,
and the color is different  from that of the other, being more  of  the
purple.  Sometimes the suppurations are very considerable, but  not
painful.
   Now let us see what other causes there are for the swelling of these
 glands besides venereal infection, to which I have ascribed one of the
 modes of swelling; for there must be other causes to  account for  the
 other  modes of  it.
   The first thing to be attended to is, whether or not there are  any
 venereal  complaints; and if not, this becomes a strong presumptive
 proof that they may not be venereal, but proceed from some unknown
 cause.  If the swelling is only in one gland, very slow in its progress,
 and gives but little or no pain, it is probably merely scrofulous ;  but
 if  the swelling  is considerable, diffused, and attended with some in-
 flammation and  pain, then it  is most probable that there is a consti-
 tutional action consisting in slight fever, the  symptoms of which are
 lassitude, loss of appetite, want  of  sleep, small quick pulse, and an
 appearance of approaching hectic.   Such swellings are slow in their
 cure, and do not  seem to be affected by mercury,  even when very
 early  applied.
   A gentleman had all the symptoms of a slight fever; the pulse a
 little quick and hard,  loss of appetite, and of course loss of flesh; a
 listlessness, and a sallow look.  While he was in this state a swelling
 took place in the glands of one of the groins.  He immediately  sent
 for me, because  he imagined  it to be venereal.  From the history of
 the case, I gave it as my firm opinion it was not; in  this, he had not
 much faith.  The  swellings were not very painful, and, after having
 acquired a considerable size, they became stationary.   To please him,
 I gave him a box of mercurial ointment, to be rubbed on the leg and
 thigh only of the  side affected, that it might have a sufficient local
 effect, and as little go into the constitution as possible; but it did not 
376
BUBO.
appear to be of any service to the swellings in the groin, they remain-
ing stationary, and almost without pain.  His friends became uneasy,
and sent their  surgeons to him, who, without knowing he was  my
patient, and of course without knowing my opinion, imagined that the
disease was venereal, and talked of giving mercury.  With respect to
the cure, I thought he should go to the sea and bathe.
  Allowing the chance of the disease being venereal or not venereal
to be equal, I reasoned upon that ground.  His present want of health
could not be supposed to arise from any venereal cause, as it was prior
to the swelling  in the groin; and therefore, though the swelling might
be venereal, he was not at present in a condition to take mercury, as a
sufficient quantity of that medicine for the cure might kill him; and
if it  should not be venereal, that a still greater quantity of mercury
must be given than what was necessary if it were venereal; because its
not giving way readily would naturally make  the  surgeon push  the
mercury farther;  and, besides this disagreeable circumstance, the dis-
ease in the groin  might be rendered more difficult of cure.  But by
going to the sea his constitution would be restored; and if the disease
in the groin proved to be venereal, he would be in a proper condition
to go through a mercurial course,  and by that means get rid of both
diseases by the two methods.  But if I should be  right in my opinion
that there was nothing venereal in the case, then he would probably
get well by the  sea bathing.
  These arguments had the desired effect; he went directly to the sea,
and began to recover almost immediately.  About a fortnight after, a
small suppuration  took place in one of the glands.  I directed that a
poultice should be made with  sea water and applied ; and, in case  of
the breaking of the abscess, that it should not be  farther opened, but
poulticed till healed.  In six weeks he came back perfectly recovered
in every respect.
  The above-mentioned appearance, with the  constitutional affections,
I have  seen take place when there were chancres, and I have been
puzzled to determine whether  it was sympathetic  from a derangement
of the constitution, or from the absorption of matter.
  I have long suspected a mixed case, and I am now certain that such
exists.  I have seen cases where the venereal matter, like  a  cold or
fever, has only irritated the glands to disease,  producing in them scro-
fula, to which they were predisposed.
  In such cases the swellings  commonly arise slowly, give but little
pain, and seem  to  be rather  hastened in their progress if mercury is
given to destroy the venereal disposition.   Some come to suppuration
while under this resolving course, and  others, which probably had a
venereal taint at first, become so indolent that mercury has no  effect
upon them, and in the end get well either of themselves or by  other
means, which, I imagine, may have induced some to think that buboes
are never venereal.  Such cases  require great attention, that we may
be able  to determine  them properly; and  I  believe this requires in
many cases so nice a judgment that we shall be  often liable to mis-
takes.
  Buboes are undoubtedly local complaints, as has been explained. 
TREATMENT.
377
  How far the lymphatic glands are to be considered as guards against
the farther progress of this or any other disease caught by absorption,
is not easily determined.  We must, however,  allow that they cannot
prevent the  poison from  entering the constitution in cases where it
produces buboes, for whenever it affects these glands in its course it
produces the same disease in them which is capable of furnishing the
constitution with an increased quantity of  the same kind of poison.
                     CHAPTER  IV.

     GENERAL  REFLECTIONS ON THE CURE OF  BUBOES.

  From what  has  been offered on  the history  of buboes, it will be
needless here to enter into a discussion of the opinion of their being
a deposit from the  constitution, and  of the conclusion drawn from this
opinion, that they  ought not to be dispersed;  for according to  this
theory, to disperse them would be to throw the  venereal matter upon
the constitution.  But if this were  really the case, then there would
be no  occasion for the use of  mercury,  provided that the bubo be
allowed to proceed, as it would prove its own  cure; but even those
who were of this opinion were not satisfied with the cure which they
supposed nature had pointed out, but gave mercury, and in very large
quantities.  From the same history  of a bubo, I have also endeavored
to show that there are several buboes which are not in the least vene-
real, but scrofulous; and that there are also buboes which  appear to
be only in part venereal, or perhaps only a gland disposed to scrofula,
brought into action by the venereal  irritation, similar to what happens
often from the matter of the smallpox in inoculation.  Therefore, prior
to the speaking of the method of cure, the true venereal bubo is to be
distinguished from others, if possible.   When it is well ascertained to
be venereal, resolution is certainly to be attempted, if the bubo be in
a state of inflammation only.  The  propriety of the attempt depends
upon the progress  which the disease has made.   If it  be very large,
and suppuration appears to be near at hand, it  is probable  that reso-
lution cannot be effected; and if suppuration has taken place I should
very much doubt the probability  of success, and an attempt might
now possibly only retard the suppuration and protract the cure.
   The resolution  of these  inflammations depends  principally upon
mercury, and almost absolutely upon the quantity that can be made
to pass through them; and the cure of them, if allowed to come to
suppuration, depends upon the same circumstances.  The quantity of
mercury that can  be made to pass  through a  bubo depends princi-
pally upon the quantity of  external surface for absorption beyond the
bubo.
   Mercury is to be applied in the most advantageous manner; that is,
to those surfaces by an absorption from which it may pass through the 
378
BUBO.
 diseased gland; for, the disease there being destroyed, the constitution
 has less chance of being contaminated.   The powers of mercury may
 often be increased from the manner in which it is applied.   In the
 cure of buboes, it should always be made to pass into the constitution
 by the same way through which the  habit  received the poison; and,
 therefore, to effect this it must be applied to the mouths of those lym-
 phatics which pass through the diseased part, and  which will always
 be placed on a surface beyond the disease.
   But the situation of many buboes is such as not to have much sur-
 face beyond them, and thereby not to allow of a  sufficient quantity of
 mercury being taken in in this way;  as, for instance, those buboes on
 the body of the penis arising from chancres on the glans or prepuce.
   These two surfaces are not sufficient to take in the necessary quan-
 tity to cure those buboes in its passage  through them; therefore,
 whenever the first symptoms of a bubo appear, its situation is well to
 be considered, with a view to determine if there be a sufficient surface
 to effect a cure, without our having recourse to other means.  It is
 first to be observed whether the absorbent vessels on the  body of the
 penis are affected, or the glands in the groin.  If $e disease be in the
 groin, it must be observed in which of the three situations of the bubo,
 before taken notice of, it is; whether on the upper part of the thigh
 and groin, on the lower part of the  belly before Poupart's ligament,
 or near to the pubes.  If they are on the body of the penis, this shows
 that the absorbents leading directly from the surface of absorption are
 themselves diseased.   If in the groin, and  on the upper part of the
 thigh, or perhaps a little lower down than what is commonly called
 the groin, then we may suppose it is in the glands common  to the
 penis and thigh.  If high up, or on the lower part of the belly, before
 Poupart's ligament, then it is to be supposed that  these absorbents that
. arise from about the groin, lower part of the belly, and pubes, pass
 through the bubo; and, if far forwards, then it is most probable that
 only the absorbents of  the  penis and skin about the pubes pass that
 way.  The knowledge of  these situations is very necessary for the
 application of mercury for the cure  by resolution, and for the cure
 after suppuration has taken place.
   The propriety of this practice must appear at once when we consider
 that the medicine cannot pass to the common circulation without going
 through the diseased parts: and it must  promote the cure in its pas-
 sage through them;  while  at the same time it  prevents the  matter
 which has already passed, and is still continuing  to pass, into the con-
 stitution from acting there, so that the bubo is cured and the constitu-
 tion preserved.
   But  this practice  alone  is not always sufficient; there are many
 cases in which mercury by itself cannot cure.   Mercury can only cure
 the  specific disposition of  the  inflammation; and we  know that this
 disease is often attended with other kinds of inflammation besides the
 venereal.
   Sometimes the common inflammation is carried to a great height; at
 other  times the inflammation  is erysipelatous,  and, I suspect, often
 scrofulous.  We must, therefore, have recourse to other methods. 
TREATMENT.                       379
  Where the inflammation rises very high, bleeding, purging, and
fomenting are generally recommended.  These will certainly lessen the
active power of the vessels, and render the inflammation more languid;
but they can never lessen  the specific effects of this poison, which were
the first cause, and are still in some degree the support of the inflam-
mation.  Their effects are only secondary, and if they reduce the in-
flammation within the bounds of the specific, it is all the service they
can perform.  If the  inflammation be  of the erysipelatous kind, per-
haps bark is the best medicine that can be given; or if it be suspected
to be scrofulous, hemlock and poultices  made with sea-water may be
of service.
  Vomits have been of service in resolving buboes, even after matter
has been formed in them, and after they have  been nearly ready to
burst; this acts upon the principle of one irritation destroying another;
and sickness and the  act of vomiting, perhaps, give a disposition for
absorption.   A remarkable instance of this kind happened in an officer
who had a  bubo at  Lisbon.  It came to fair  suppuration,  and was
almost ready to  burst.  The skin was thin and inflamed, and a  plain
fluctuation felt.  I intended to open it, but as he was going on board
a ship for England on the day following, I thought it better to defer
it.  When he went on board, he set sail immediately, and the wind
blew so very hard that nothing could be done for some days, all which
time he was very sick, and vomited a  good deal;  when the sickness
went off, he found the bubo had disappeared, and it never afterwards
appeared.  When he  came to England, he went through a regular
course of mercury.

 § 1.  Of Resolution of the Inflammation of the Absorbents on the Penis.

  The surface beyond the seat of the disease in  this case, that  is, all
that part of the penis  before the bubo, is not large enough to take in a
quantity of mercury sufficient to prevent the effects of absorption, and
therefore recourse is  to be had to other means; yet this application
should by no means be neglected, and this surface, small as it is, should
be constantly covered with mercurial ointment, which will assist in the
cure of the  local disease.   It may be disputed whether any medicine
can pass through diseased lymphatics, so as to  have any  effect upon
them, but I  judge from experience that it certainly can.  As this sur-
face is too small, and  as it is necessary that a larger quantity should
be taken in, it becomes proper to  give  it either  by the mouth, or by
friction on some larger surface; this is necessary to prevent the lues
venerea, as well as to cure the parts themselves.   The quantity cannot
be determined; that must be left to the surgeon, who must  be directed
by the appearances  of  the original complaint, and the readiness with
which the disease gives way.
  The same method is to be followed in women;  but as there is a
larger  surface in this  sex, more mercury may possibly be absorbed;
and there should be a constant application of ointment to the inside
and outside  of the labia. 
380
BUBO.
            § 2. Of the Resolution of Buboes in the Groin.

  The inflammation of the glands is to be treated exactly upon the
same principle with the other; but we have in general a larger surface
of absorption, so that we can make a greater quantity of mercury pass
through the diseased parts.
  It will be proper to apply the mercury according to the situation of
the inflamed gland.  If the bubo be in the groin, according to our first
situation, then it is necessary to rub the mercurial ointment upon the
thigh.  This surface will in general absorb as much  mercury as will
be sufficient to resolve the bubo, and to preserve the constitution from
being contaminated by the poison that may get into it; but if resolu-
tion does not readily take place, then we may increase the surface of
friction by rubbing the ointment upon the leg.
  But if the bubo be on the lower part of the belly, that is,  in the
second situation, then the ointment should be  rubbed also  upon  the
penis, scrotum, and belly; and the same if the bubo  should be still
forwards; for probably those glands receive the lymphatics from all
the surfaces mentioned, as well as from the thigh and leg.
  The length of time for continuing the frictions must be determined
by circumstances.   If the bubo gives  way, they must be continued
till it  has entirely subsided, and perhaps longer, on  account of  the
cause of it, a chancre, which may not yield so soon as the bubo.   If
it still goes on to  suppuration, the frictions may or may not be con-
tinued, for I do not know for certain if  anything is to be gained by
their continuance in this state.
  The quantity here recommended  may affect the mouth; and this
effect must also be regulated according to circumstances.

             § 3.  Of the Resolution of Buboes in Women.

  When treating  on the seat  of  buboes in women, I observed that
two situations were peculiar to them, the others similar to those in
men.
  In  the first and second situations,  especially the first, the surface of
absorption beyond the  bubo  is by  much  too  small  to be  depended
upon for receiving a sufficient quantity of mercury to produce resolu-
tion ;  but in the second, that is, between the labia and thigh, the mer-
cury may be rubbed in all about the  anus and buttock, as all  the
absorbents of those parts probably pass that way; we know, at least,
that they do not pass into the pelvis  by  the anus, but go by the groin.
Other means of introducing mercury must be recurred to, as is recom-
mended in the case of men; but still, it will be proper to rub  in on
those surfaces as much as possible.
  In the situations common to both sexes, we have a larger field; yet
as they are divisible into  three, the same observations hold good, and
a similar mode of  practice is to be followed in women as in  men. 
TREATMENT.
381
                   § 4. Of Buboes in other Parts.

  As venereal buboes arise from other modes  of application of the
poison besides coition, they are to be found in different parts of the
body, but more frequently in the  hands.  They arise in the armpit,
from wounds in the hands or fingers being contaminated by venereal
matter, and reduced to a chancre.  In such cases, it becomes necessary
that the ointment should be rubbed on the arm and forearm; but this
surface may not be  sufficient, therefore we  must apply it  in another
way, or to other parts, to produce  its effects upon the constitution.
  I have seen a true venereal chancre on the middle of the lower lip
produce a bubo on  each side of  the neck, under the lower jaw, just
upon the maxillary gland.  By applying strong  mercurial ointment to
the under lip, chin, and swellings, they have been resolved.

 § 5.  Of the  Quantity of Mercury necessary for the Resolution  of a Bubo.

  The quantity of mercury necessary for  the  resolution  of a  bubo
must be  proportioned to the obstinacy of the bubo, but care must be
taken to stop short of certain effects upon  the constitution.  If it be
in the first situation, and yields readily to  the first  half a drachm of
mercurial ointment, made of equal parts of quicksilver and hog's lard,
every night, and  the mouth does not become  sore, or, at most, only
tender, then it will be sufficient to pursue this course till the gland is
reduced to its natural size; and this, probably, will be a good security
for the constitution, provided that the chancre,  which may have been
the cause of the bubo, heals at the same time. If the mouth is not
affected in six or eight days, and the gland does not readily resolve,
then  two scruples or a drachm may be applied every night; and if
there be no amendment, then more must be rubbed in; in short, if the
reduction is  obstinate, the mercury must be pushed as far as can be
done without a salivation.
   If there be a bubo on each side, then there cannot be so much mer-
cury applied locally to each; for the constitution most probably could
not bear double the quantity which is  necessary for the resolution of
one.  But in such cases, we must not so much attend to the soreness
of the mouth as when there is but one; however, we must allow the
buboes to go on to suppuration, rather than affect the constitution too
much by the quantity of mercury; and, therefore, when there are two
buboes, they are more likely to suppurate than where there is only
one.
   In the second and third situation of buboes, if we find that most
probably a sufficient quantity of mercury does not pass through them
for their resloution, it may be continued to be thrown in by the leg
and thigh to act upon the constitution, as has been already observed.
The quantity admitted in this way must be greater than what would
be necessary if the whole  could be  made  to pass through the bubo.
The mouth must  be affected, and that in proportion to the state and
progress of  the bubo.
   The method of  resolving buboes occurred to me at Belleisle, in the 
382                         bubo.
  year 1761, where I had good opportunities of trying it upon the sol-
• diers; and I can say, with truth, that only three buboes have suppu-
  rated under my care since that time, and two of these were in one per-
  son, where a small quantity of mercury had considerable effects on
  the constitution, and, therefore, a sufficient quantity could not be sent
  through the two groins for their resolution; but in both cases, the sup-
  purations were small in comparison to what they threatened to be.
    Many  buboes, after  every attempt, remain swelled without either
  coming to resolution or suppuration, but rather become hard and scir-
  rhous.   Such, I  apprehend,  were  either scrofulous at first, or became
  so when  the venereal disposition  was removed.  The cure of them
  should be attempted by hemlock, sea-water poultices, and sea-bathing,
  as will be farther taken notice of.

           % 6. Of the Treatment of Buboes when they suppurate.

    After every known method  has been used, buboes cannot, in all
  cases, be resolved, but come to suppuration.  They then become more
  an object of surgery, and are to be treated in some respects like any
  other abscess.  If it  be thought proper to open a bubo, it should be
  allowed to go on thinning the parts as  much as possible.  The great
  advantage arising from this is, that these parts, having become very
  thin, lose the disposition to heal, which gives the bottom of the abscess
  a better chance  of healing along with the superficial parts; by this
  means, too, a large  opening is avoided, and the different modes made
  use of for keeping  the skin from healing till the bottom is healed
  become unnecessary.
    It may admit  of dispute, whether the application of mercury should
  be continued or not through the whole suppuration.   I  should be
  inclined  to continue it, but in a smaller quantity;  for although  the
  parts  cannot set about a  cure till opened,  yet I do imagine that they
  may be better disposed to it; and I think that I have seen cases where
  suppuration has taken place, although under the  above  mentioned
  practice, that were very large in their inflammation, but very small in
  their suppuration, which I imputed to the patient's having taken mer-
  cury in the before-mentioned way,  both before and while suppuration
  was going on.
    It has  been disputed more in  this kind of abscess than in others,
  whether it should be opened, or allowed to burst of itself; and like-
  wise, whether the opening should be made by incision or caustic.
    There appears to be nothing in a venereal abscess different from any
  other to  recommend one  practice  more  than another.   The surgeon
  should in some degree be guided by the patient.  Some patients  are
  afraid of  caustics, others have a horror of cutting instruments; but
  when it is left wholly to the surgeon, and the bubo is but small, I sup-
  pose a slit with a lancet will be sufficient; in this way, no skin is lost.
  But when a bubo is very large, in which case there is a large quantity
  of loose skin, perhaps the caustic will answer better, both on account
  of its destroying some skin, and  because the destruction is attended 
TREATMENT.
383
with less inflammation than what attends incision. If done by a caus-
tic, the lapis septicus is the best ;l but it is not necessary to open every  .
bubo, and perhaps it may be difficult  to point out those where open-
ing would be of service or necessary.
  The bubo is to be dressed afterwards according to the nature of the
disease, which, I have already observed, is often so complicated as to
baffle all our skill.  The constitution at the same time is to be attacked
with  mercury, either by applying it internally or externally; if ex-
ternally, it should be applied to that side and beyond where the bubo
is, as I before  directed in treating of the resolution of buboes, for it
may have some influence on the disease in its passing  through the
part.
   Mercury, in these cases, answers two purposes;  it assists the ex-
ternal application to cure the buboes, and it prevents the effects of the
constant absorption of the venereal matter from the sore.
   How far it is necessary to pursue the mercurial course with a view
to prevention,  it is not possible to determine; but it may be supposed
that it is necessary to give the same quantity to prevent a disease that
would cure one that has  already taken place.   It will be necessary to
continue the course till the bubo is healed, or till it has for some  time
lost its venereal appearance; but it may be difficult to ascertain this
last fact;  therefore, we must have recourse to experience, not theory,
and continue the course  in general till the whole is healed, and  even
longer, especially if the bubo heals very readily; for we find in many
cases that the constitution shall be still tainted  after all.   However,
some restrictions are here necessary; for I have already observed that
it often happens that  buboes assume  other dispositions  besides the
venereal, which mercury cannot cure,  but will  even make worse.  It
is therefore very necessary to ascertain the  distinction, which will be
taken notice of.
                      CHAPTER  V.

         OF SOME OF THE  CONSEQUENCES  OF BUBOES.

  I formerly observed that the venereal disease is capable of bring-
ing latent dispositions or susceptibilities into action.   This is remark-
ably the case with buboes;  and I believe the disposition is  more of
the scrofulous kind than any other.  Whether this arises from  the
buboes being  formed in lymphatic glands or not is probably not easily
determined.

  1 I once opened  two buboes in the same person, one immediately after the other.
The first was with the lapis infernalis, which gave him considerable pain, and, there-
fore, he would have the other opened, with a  lancet, as the pain would only be mo-
mentary.  But it was great, and the soreness continued long, while there was no pain
in the other, deadened by the caustic, after it had done its business. 
384                          bubo.
  It sometimes happens that these  sores, when losing  or  entirely de-
prived of the venereal disposition, form into a sore of another kind,
and most probably of various kinds.  How far it is a disease arising
from a venereal taint and the effects of a  mercurial course jointly is
not certain; but most probably these two have some share in forming
the disease.  If this idea of it were  just, it would become a specific
disease, and be reducible to  one method of cure; but I should suspect
that either the constitution or the part hath some, if not the principal
share in it;  that is, the parts fall into a peculiar disease independent
of the constitutional disease  or method of cure; for, if it arose out of
the two first entirely,  we might expect to meet with  it  oftener.  So
far as the constitution or the part has a  share in forming this disease,
it becomes more uncertain what the disease is, because it must in some
degree partake of the constitution or nature of the part.
  Such diseases make the cure of the venereal affection  much more
uncertain, because when  the sore becomes stationary, or the  mercury
begins to disagree, we  are ready to suspect  that the virus is gone; but
this is  not always  the case; the virus is perhaps only less powerful
than the new-formed disease, and, as it were, lies dormant, or ceases to
act; and when the other becomes weaker, the venereal influence begins
to show itself again.
  The proper  treatment  in  such cases is  to attack the predominant
disease ; but still, the difficulty is to find out the disease, and to know
when it is or is not venereal.  The  following case explains this  diffi-
culty very well:—
  A gentleman  had a very large venereal  bubo, which was opened.
He took a great deal of mercury for about two months; but, I suspect,
not in sufficient doses,  which produced a mercurial habit.  The bubo
had no disposition to heal, and I was consulted.  From the account he
gave me, I suspected that he had then too  much of a mercurial habit
to receive at this time  any farther good  from that medicine.  I there-
fore advised him to use a good nourishing diet for near a month;  after
that I put him upon a brisk mercurial course by friction;  and the
parts put on a better appearance.  This course he continued for  near
two months, and then the sore, although much mended, began to be
stationary.  I did not conceive that the venereal action was destroyed,
and therefore immediately left off the mercurial course, and  put him
upon a  milk diet, and sent  him into the country.  But not gaining
much ground, he had a strong decoction of the sarsaparilla with me-
zereon  given  him,  which,  although  continued for above a month,
produced little or no effect.  I also gave him the cicuta as much as he
could bear, with the bark almost the whole time, without  effect;  new
sinuses  formed, which were  opened, and the sore became extremely
irritable, with  thickened lips.  The  dressings were  poultices made
with the juice of hemlock, sea water, opium, and a gentle  solution of
lunar caustic; but nothing  seemed to affect it.  I suspected  scrofula,
and therefore proposed he should bathe in the sea; but this then could
not be done.  These different treatments, after  mercury had  been left
off, took  up about  four months without  the least benefit.  Being
doubtful whether there might not be still  something venereal in the 
                          TREATMENT.                      385

 sore, especially as appearances were growing worse, and it was now
 four months since he had taken any mercury, I was inclined to try it
 once more, and sent him two portions of ointment, half an ounce each,
 to rub in in two nights.  He had caught a little cold, and therefore
 did not rub in the mercury the two evenings as ordered; and called
 upon me the third  day and told me he was much better.  The sore
 now became easy, the watery or  transparent inflammation began to
 subside, the lips became flatter and thinner, and the edges of  the sore
 began to heal.  I then desired him not to  rub in the ointment, but
 wait a little.  In eight or ten days  the  sore had contracted to three-
 quarters of its former size, and had all the appearance of a healing
 sore.
   Quasre: What conclusions should be drawn from this case ?  I think
 the following: that the virus may be gone, although the sore may have
 no disposition to heal; therefore, we are not to look upon the not heal-
 ing of a bubo as a sign of the presence of the original disease.  Secondly,
 that the sarsaparilla, mezereon, cicuta, and the bark will not succeed in
 all such cases; and, thirdly, that some of these diseases are  capable of
 wearing out the unhealthy disposition of themselves, and that we should
 not be too ready to attribute cures to our treatment; for if the mercury
 had been rubbed in, and the same effects had still taken place, I should
 then have certainly pursued the mercury with vigor, and attributed the
 cure to it; but I should not have rested here; I should have related the
 case, as  an instance of the disease continuing after repeated  courses of
 mercury, and  should have contended that it is necessary in such cases,
 where the mercury appears to lose its  power, and even do harm, to
 wait, and season the constitution to strength, and the loss of the mercu-
 rial habit; and that even four months are sometimes necessary for this
 purpose, after which we must begin again to give mercury.
   A gentleman  had a common gonorrhcea, which  was severe.   I gave
 him an injection of a grain of corrosive sublimate in eight ounces of
 water with a few mercurial pills. After having continued the injection
 for ten or twelve days, without any visible benefit, I gave it as- my
 opinion  that it would be of no service to  continue it any longer, and
 therefore desired he would be quiet for a little time.  About this time
 a swelling in each groin took place, and supposing them to be venereal,
 I ordered mercurial ointment to be rubbed into both the legs and thighs,
 to resolve them  if possible. He appeared to be less uneasy about the
 buboes than he was about the gonorrhcea, but I told him that the cure
 of that complaint would be insensibly involved in the resolution of the
 buboes.   I spoke too confidently of my power with respect to the  re-
 solution of  the buboes, for they both suppurated, although the sup-
.puration was small in comparison to the  magnitude of the buboes when
 they first inflamed.  The frictions were  left off.
   While we were attempting to resolve the buboes he got well of the
 gonorrhcea.  The skin covering the buboes became thin;  they were
 both opened, one with a caustic the other with a lancet; he then was
 ordered  to rub in mercury again on the thighs and legs for  their cure.
 They began soon to look well, and to close fast; but when  about half
 healed they became stationary.  I suspected  that a new disease was
       25 
386
BUBO.
  forming.  On continuing the frictions  a  little longer they began to
  inflame and swell anew, and  a  suppuration took  place about half an
  inch above each of the first suppurations, which  broke into the first.
  I left off the mercury immediately upon their inflaming, and said that
  now a new disease  had formed.  I ordered  poultices made with sea-
  water to be applied, and also a  decoction of sarsaparilla to be taken;
  but this appeared not to be sufficient for the cure of this new disease.
  I then ordered him to go into  the tepid  sea-bath every evening, the
  heat of the water to be about ninety degrees.  By the time he had been
  in the bath four times the inflammation and  swelling had very much
  abated, and the first sores, or original buboes, were beginning to heal.
  He went on with the  bathing  every evening for about three weeks,
  when the sores rather  began to look worse;  I then suspected that the
  venereal disposition was become  predominant, and I ordered the fric-
  tion as before.  In  about a fortnight the first buboes  healed; but the
  second suppurations were not yet healed;  then I supposed it to be en-
>. tirely the new-formed  disease, and he went into  the country, where I
  desired he might go  into the  open sea every day, as he then  could
  have an opportunity,  which he did, and  got perfectly well, and has
  continued so.
    This case plainly shows that there was another disposition formed
  besides the venereal, which was put into action by the venereal irrita-
  tion.
    I have seen some buboes most  exceedingly painful and tender to
  almost everything that touched them, and the more mild that the dress-
  ings were, the more painful the parts became.
    In some the skin seems only  to admit the  disease, ulceration going
  on in the surrounding skin, while a new skin forms in the centre, and
  keeps pace with the ulceration,  forming  an irregular sore like a worm-
  eaten groove all round.  This, like the erysipelatous inflammation, as
  also some others, appears to have only the power of contaminating the
  parts that have not yet come into action; and those that have already
  taken it seem to lose the diseased disposition, and heal readily.
    In some  they spread to an  amazing extent, as the following case
  shows, the circumstances of which are very  remarkable:—
    A young gentleman, aged eighteen years, in consequence of a vene-
  real infection, had two buboes,  which were both opened.  They were
  treated in the usual manner, and at first put on a favorable appearance;
  but when they were nearly healed they began  to ulcerate at their edges,
  and spread in all directions, rising above the pubes almost to the navel,
  and descending upon  each thigh.   His nights became restless, and his
  general health was  affected.  A great variety of medicines were tried,
  particularly mercury in different forms, with little or no effect.  Extract
  of hemlock did more good than  anything else, and was taken in unusual
  quantities.  An ounce was swallowed in the course of the day for some
  time, which was afterwards increased to an ounce and a half, two ounces,
  and even two ounces and a half.  It produced indistinct vision and
  blindness, loss of the voice, falling of the lower jaw, a temporary palsy
  of the extremities,  and once or twice a loss of sensation;  and notwith-
  standing he was almost every night in a state, as it were, of complete 
TREATMENT.
387
intoxication from the hemlock, his general health did not suffer; but,
on the contrary, kept pace in his improvement with the ulcers.  They
could not, however, be healed by the hemlock; and, among many other
things, Ethiop's mineral and Plummer's pill were liberally given, seem-
ingly with advantage.  Recourse was had to the hemlock from time to
time. A great many different kinds of dressings were made  trial of,
none of which were found to exceed dry lint.  The ulcers were nearly
all healed, after having tormented him upwards of  three years, when
committing some irregularities in diet, and the sores getting worse, he
returned to the extract of hemlock, which he had for some time laid
aside, and  of himself  swallowed in the course of  the  morning ten
drachms.   This quantity was only the half of  what he had formerly
taken in twenty-four hours, but his constitution had been at that time
gradually habituated to  the  medicine.   The ten drachms produced
great restlessness and anxiety; he dropped insensible from his chair,
fell into convulsions, and expired in two hours.
  To return to the cure of buboes:  Where they only become  station-
ary, and appear to have but little disposition to spread (which is most
common), and where perhaps a sinus or two may be  found running
into them from some other gland, I have often  seen them give way to
hemlock sooner  than to anything I am  acquainted with, especially if
joined to the bark.  If the hemlock is applied both internally  and ex-
ternally, it  answers better.
  Sarsaparilla is often of singular service here, as well as in other cases
arising seemingly from the same cause; and I have seen sea-bathing of
great service, as also sea-water poultices.
  At the Lock Hospital, they use gold-refiners' water as an application,
which is of service in some cases.  Dr. Fordyce recommends the juice
of oranges to be drunk in large quantities, which I have seen good
effects from  in  some cases.  The mezereon  is, in some instances, of
singular use.
  [Ricord.—Hunter justly observes that, in the treatment of  buboes,
attention should be' paid not only to  the specific cause to which they
may be due, but also to all the  attending circumstances in the case.
In some instances, the latter deserve to occupy our attention alone,
either throughout the whole case, when the bubo is entirely dependent
on them, or for  the  time being, so long as they constitute a serious
complication; then, after  their disappearance, we may return to the
special treatment of the virulent disease.   But having established this
point, Hunter, true  to his doctrine, seeks nothing  farther, than to
ascertain the quantity of mercury which should be taken into the
system,  and the most suitable mode for administering it.  To Hunter's
practical observations, I will append  the following propositions:—
  We should endeavor to prevent the development of buboes.  For
this purpose, whenever a person is  affected  with  a primary  disease
which may lead to a bubo, we should recommend  the most perfect
repose, both of the diseased parts and of the whole system.
  The cure of those affections which  ordinarily precede a bubo should
be  as rapid as possible, since so long  as they last, a bubo may  be
developed. 
388
BUBO.
  In the treatment of the precursory affections, general stimulants and
local irritants should  be avoided;  yet, after what we have said of the
cauterization of chancres,  this rule should not prevent our employing
all necessary means for a cure.
  The moment a gland swells in a suspicious manner, its  resolution
should be attempted as soon as possible.
  The most powerful  agents at  the outset, in the abortive  treatment,
are cold, compression, mediate cauterization, and mercurials.
  The application of ice  is often  successful, when made at the very
outset.  If the tumor  increase or become painful under its influence,
it does more harm than good, and it should immediately be omitted.
  Compression is a powerful abortive means, and may be applied by
bandages.  A warm brick  has lately been proposed, to act on the tumor
by its weight and its heat.  Compression, to be beneficial, must excite
no pain.   A fact  to be noted is, that buboes rarely appear under  well-
applied bandages in persons affected with hernia.
  A method, which has recently occupied the attention of practitioners,
and which was first proposed by M. Malapert, and afterwards by M.
Reynaud, consists in  attempting the rapid resolution of buboes by
cauterizing the integument over them.  This is done by  covering the
tumor with a blister, and afterwards applying to the denuded  surface
a pledget  of lint, soaked  in a solution of twenty grains of corrosive
sublimate to an ounce of water.  This pledget is left in  contact  with
the vesicated  surface  about two hours, and is then  replaced  by a
linseed-meal poultice, with the addition of laudanum.   On the fall of
the eschar, according  to its depth and the effect produced, the applica-
tion is repeated, or  the denuded surface is  touched with the  solution
by means of a camel-hair pencil.
  This active treatment is far  from being successful in so many  cases
as has been  asserted.  In most cases where it has been used, an  accu-
rate diagnosis  of the  nature of  the  tumor could not  be made; it is
therefore  probable, and I  may say certain, that the larger part of the
cures obtained have been in simple and non-virulent buboes.  And
this is not an unimportant fact, since, if it be true, we can effect a cure
by other  and much less disagreeable means than this cauterization,
which is  always  very painful, and is almost invariably followed by
unsightly and indelible scars.
  The objective and direct actual  cautery should never be applied at
the outset, nor the potential cautery and seton, which have lately been
recommended.
  When  the  affection preceding the bubo requires mercury, this
mineral may prevent  the development of the bubo, and it may also be
efficacious as an heroic resolvent and active antiphlogistic, at the outset
of any glandular  swelling.  We should therefore never fail to employ
it  in the abortive treatment, except when it is  positively contra-
indicated.
  The best mode of administering mercury in the particular case under
consideration, is by the skin.  As Hunter  directs, regard  should be
paid, as far as possible, to the connection existing between the absorbing
surface and  the affected ganglia; but precision on this point  is  often 
TREATMENT.
389
impossible and even useless, for it is enough to use those neighboring
parts, having sufficient extent, and which especially are the seat of no
local  irritation, liable to interfere with the  absorption.  The mode
which I decidedly prefer, and  which I employ at the outset of very
many indolent buboes, as well as at a more advanced stage when there
is no  inflammation, is a blister, afterwards dressed twice a day with a
scruple and a  half of strong mercurial  ointment, and covered with a
rye-meal poultice, which should be changed two or three times in the
twenty-four hours.
  If the bubo goes on enlarging and is attended with acute symptoms,
antiphlogistic  treatment of appropriate energy should be applied,
whether the bubo is virulent or not.  Among the ordinary antiphlo-
gistic agents, which it is useless to enumerate, leeches are generally
the most  effectual.  In  applying  them, they  should  be placed at a
greater distance from the bubo the nearer the latter is to the  time of
opening, especially when it is thought to be virulent; for in that case,
as soon as it is  opened, the leech-bites will  be  inoculated, become
chancres,  and  spread the disease to a wide and pernicious extent.
  As soon as pus has formed in a bubo, if it is supposed to be virulent
and its progress has been acute, it is entirely useless to attempt resolu-
tion.  No matter what means are employed, if the walls of the abscess
are chancrous surfaces inclosing virulent pus, resolution is no longer
  Sossible;  and the purulent perspiration pretended to  be  obtained by
  [M.  Malapert and Reynaud's method, is only an infiltration of the
matter through sieve-like openings made by the caustic in the skin
overlying the abscess.  If, in  any case, resolution has been obtained
after the formation of an abscess, it could  only have  been in simple
non-virulent buboes.  In doubtful cases, where, after pus has formed,
we are led to attempt resolution on account of our fear of a cicatrix
or the  timidity of the patient,  the attempt must not  be  continued if
the abscess extends or the skin over it becomes thin.
  Contrary, then, to  the advice given by Hunter, we should  open
buboes  early in the great majority of cases, so as to avoid the inevita-
ble bad effects which result from the incarceration of  virulent pus.
  When a bubo is indolent, either at the outset or after an acute stage,
or still more frequently after a subacute stage, antiphlogistic remedies
are less frequently applicable.   The means which were mentioned in
speaking  of the abortive treatment are here of use.  In cases of indo-
lent buboes, which invariably accompany indurated chancres, we see
the powerful effects of local mercurial frictions, of the emplastrum de
Vigo, and especially of constitutional treatment.
  A combination, very often efficacious in the treatment of non-specific
indolent buboes, consists in the use of blisters, mercurial ointment,
and cataplasms, as above directed, so  long  as  the  bubo continues to
improve;  but as soon as it remains in statu quo, the blister is allowed
to heal, and compression is applied and continued while the swelling
diminishes in  size, but  is abandoned and the blister resumed if it
ceases to have any effect; thus  the two are alternated until a  cure is
obtained,  or so long as any benefit is derived.
  Those indolent and indurated buboes which do not yield to the 
390
BUBO.
above treatment  are generally dependent  on  something  more than
syphilis.  In most cases, especially of deep buboes, there is  some other
cause, and this cause is frequently scrofula.   If the  ordinary remedies
for scrofula, such as the bitter herbs, preparations of iodine, cod-liver
oil, M. Personne's iodized oil,1 quinia, the various tonics, suitable diet,
and a healthy residence,  have no effect, even when  aided by  local
resolvent applications, such  as salves  of iodide of lead, of iodide of
potassium, and of antimony, cauterization with Gondret's salve,* alka-
line or sea-baths, etc., we  may resort to extirpation of the diseased
ganglia, or destroy them by inducing simple suppuration, or by caustic.
  But as it is not always easy to dissect them out, they are most fre-
quently destroyed by the  latter means.   The ordinary modes of pro-
moting maturation and suppuration are too feeble to succeed in  this
case;  and  more  powerful agents must  be looked for.   Escharotic
troches, which are, perhaps, too much  neglected at the present day;
setons, which have been extolled  beyond measure  as  a  new remedy,
which they are  not;  crushing or bruising the diseased  ganglia, a
method proposed by the ingenious and  learned M. Malgaigne, but a
little too  painful, and above all, unsafe—these  means  and the actual
cautery may be applicable to  some cases of these obstinate glandular
swellings, the cause of which is obscure.   It has also been proposed to
make numerous punctures in  the buboes, in  order to stimulate them
and hasten their resolution.   But a method  which I prefer to all
others, and which is the most easily managed,  and the most certain in
its results, is the application of Vienna paste.    This caustic is applied
over an extent of two-thirds of the diseased ganglion, so as to destroy
the cutaneous surface; then, on the  fall  of the eschar, which is has-
tened by basilicon ointment and other digestives, the indurated ganglia
are  attacked  layer by layer; increasing  our caution, however, as we
proceed  in depth, and  stopping within accessible limits, or when we
approach the neighborhood of vital parts.  This method is generally
very rapid, and the deep ganglia  undergo resolution as the superficial

  1  Bulletin de l'Acadfimie de Medecine.   Paris, 1851, t.  xvi. p. 1141.
  [Not being able to refer to the above work, I give another formula for iodized oil,
said to be superior to that of M.  Personne. (See Repertoire de Pharmacie, 1852, p. 31.)
                       R..—Iodinii puri gr. xxv;
                           Olei amygdala) Oij.—M.
  The iodine is rubbed up in a mortar with a small quantity of the oil, the rest of the
oil added, and the whole heated in a porcelain vessel over a slow fire, until the color
is reduced to that of oil of sweet almonds;  it  is then withdrawn from the fire and
allowed to stand ten hours.
  A syrup of this oil is thus prepared:—
                         R>—Olei iodinii §j ;
                              Aquae §j ;
                              Sacchari puri |ij;
                              Acacise 3 v.—M.
  When cod-liver oil is imperfectly assimilated by the stomach, M. Trousseau replaces
it with advantage, chiefly in his private practice, by the  following composition: Fresh
butter |iv;  iodide of potassium gr. j ; bromide of potassium gr. iv. This butter i3
consumed in the  course of the day, spread  upon  bread in the ordinary manner.
(L'Union Mtdicale.)—Ed.]
  2 For the formula for this ointment, see the United States Dispensatory, page 84.— 
TREATMENT.
391
ones are destroyed.   However, some glandular swellings, which are at
first considered venereal buboes, afterwards undergo  such degenera-
tions that they are no longer included within the limits of our present
subject; they consist  of incurable scrofulous or carcinomatous  deve-
lopments, which neither steel nor fire can prevent from proving fatal.
  In indolent buboes, resolution is still possible after suppuration has
taken place, and the pus should never be so speedily evacuated as  in
acute buboes.  These buboes are more commonly simple than virulent,
and we can also rely on the internal suppuration to produce resolution
of the rest of the swelling more than in acute buboes.
  Suppuration  in buboes is generally easily recognized; but some-
times it takes place  in the deeper layers of ganglia, and then although
very abundant it does not escape above the indurated masses which
cover it, except by means of little fistulous passages which appear on
the surface  as  small, soft, and  fluctuating  points,  surrounded by  a
hardened and adherent border.
  As soon as it is necessary to  open a bubo, care should always be
taken to avoid as much as possible the deformity of a large cicatrix.
It should be a rule  to make only very small openings, unless we are
compelled to make larger by the abundance of the suppuration, by its
extent beneath the surface, or by the thinness and morbid changes of
the skin.  In some cases, several punctures are  to be preferred to one
large incision.  Caustics should rarely be used to give vent to the pus
except in indolent buboes, where it is also desired  to produce some
degree of  stimulation.  Escharotics are to be preferred when the skin
is so much changed that there is no hope of preserving  it, and they
are especially applicable to virulent buboes, since the edges of a wound
made by caustic are less likely to be inoculated than those made by a
cutting instrument.
  Still, some buboes,  in which the skin is extensively detached, may
be induced to cicatrize, without paring away the skin, by the repeated
application of blisters after the  buboes are opened,  and especially by
filling the cavity with powdered cantharides for several days in suc-
cession,  until healthy  granulations spring up.
  In conclusion, a bubo when opened is either simple or virulent.  In
the latter case, it constitutes a  true chancre, and should receive the
treatment of a chancre.—Ricord.] 
 
PAET   VI.
                        CHAPTER  I.

                    OF THE LUES  VENEREA.

  The lues venerea, I have already observed, arises in consequence
of the poisonous matter being absorbed and carried into the common
circulation.  This form of the disease, which I have called the consti-
tutional,1 would appear to be  much more complicated, both in the
different ways in which it may be  caught, and in its effects when
caught, than either a gonorrhcea or chancre.  It generally arises from
the local complaints before taken notice of, the matter being absorbed
and carried into the constitution.  The matter, however, appears to be
capable of being taken into the constitution by  simple application,
without first  having  produced  either  of  the  before-mentioned  local
effects, as  I observed in treating of the formation of  the bubo; but
this seems to  be only when  it is applied to some particular  parts of
our body,  such as may be called a half internal surface, as the glans
penis.  I think it is  not capable of being  received by the absorbents
of the sound skin ;2 but this is matter only of  opinion.
  It may likewise be received into the constitution  by being applied
to common ulcers, although not necessarily rendering  these  ulcers
themselves venereal; also by wounds, as  has  been observed;  but, I
believe, always previously producing ulceration in the wound.
  Many other modes  of infection have  been supposed, but, I believe,
erroneously, such suppositions most probably having taken their rise
from ignorance or deceit, two great sources of error in this disease.
  It is most likely that contamination takes place about the  beginning
of the local complaints,  especially when that is a chancre; for there is
in most cases less chance of its happening  afterwards,  because the

  1 The term constitutional is, perhaps, not strictly a proper term, for by constitutional
disease strictly I would understand that in which every part of the body is acting in
one way, as in fevers of all kinds, either sympathetic or original; but the venereal
poison appears to be only diffused through the  circulating fluids, and, as it were, to
force certain parts of the body to assume the venereal action, which action is perfectly
local, and takes place in different parts in regular succession of susceptibilities ; there
are but few parts, therefore, acting  at the same time ; and a person may be constitu-
tionally affected in this way, and yet almost every function may be perfect.
  2 Added: "Atleast I know no instance of it."—Home. 
394
CONSTITUTIONAL  SYTHILIS.
 patient commonly flies to medicine, which generally becomes a  pre-
 vention of contamination.  For  if  it could take place through the
 whole time of the cure, we should have  the  parts contaminated at
 different periods, coming into action at different times, each according
 to its stated time, although in similar parts both in  their nature  and
 other circumstances;  but as these similar parts do not vary much in
 the time of coming into action, it is reasonable to suppose that they
 were contaminated at or near the same time, and therefore that no con-
 tamination takes place in the time of the cure, although we may sup-
 pose that the power of absorption is  equally strong then as at  any
 other time.
   In cases of contamination from gonorrhcea, where no mercury has
 been taken, we might expect this irregularity in similar structures;
 but as contamination so seldom takes place in this way, we have  not
 a chance of a great variety from such;  however, it would be worth
 while to ascertain the matter, which from a great many cases might be
 done.
   Without being very exact in ascertaining the different proportions
 in those who have the lues venerea originating from the three several
 modes above described, I think we may venture to say, from general
 practice or experience, that where one contracts it from the first cause;
 that is,  where no local effects have been produced, a hundred have it
 from the second, or gonorrhcea; and where one has it from the second,
 a hundred have it from the third, or chancre;  and perhaps not one in
 five hundred who have connection with venereal women have it in the
 first way, and not one in a hundred have it from the second ; while not
 one in a hundred would not escape it from the third, if the means of
 prevention were not made use  of in the common method of cure of
 the chancre.
   [Ricord.—Syphilography, like all other branches of pathology,  has
 in every  age received its  share  of influence from the doctrines in
 vogue.  Whenever a great system has ruled the public mind, syphilo-
 graphers have hastened to adapt  preceding treatises to the fashion of
 the day.
  At one time  the lymphatic vessels were  assigned  as  the means of
 transport, and the fat-globules as the reservoir  of the  virus in that
 affection which Hunter has designated under the generally received
 name of constitutional syphilis, and which has also  been called con-
 firmed syphilis, secondary, consecutive, or general symptoms, &c; at
 other times, it has been thought that the virus existed in all the fluids
 of the body, as Hunter supposed, or that it was conveyed by the blood
 alone, either suspended in it without intimate combination, or else as
 an element which had profoundly modified that fluid.  On the other
hand, while solidism sought for material organic changes alone, with-
out any intermediate vitiated fluids, certain metaphysicans and pure
vitalists could see in constitutional syphilis nothing but the ordinary
effects of sympathy, or the results of an expansive  electro-syphilitic
fluid.
  But without losing ourselves in the field of hypotheses, from which
our more positive age tends to depart farther and farther, I will place 
CONSTITUTIONAL  SYPHILIS.              395
the following propositions by the side of the principal propositions of
Hunter:—
  Constitutional syphilis is the result of the absorption of the syphilitic
virus.
  There  can be no absorption without previous ulceration; a chancre
being a  necessary  antecedent, no matter what  symptoms reveal or
conceal it. Since Benardin Tomatino, the assertions of Hunter, Fabre,
Benjamin Bell, &c, in favor of the existence of non-consecutive syphilis
have proved nothing.   Not a single  one of their facts is incontro-
vertible with  the knowledge  of the  present day.   The proportions
which Hunter gives  prove that the  exceptional case, which  he sup-
posed he had  observed, was  only an apocryphal or  badly explained
fact.
  Constitutional syphilis, without a pre-existing chancre, is only pos-
sible by hereditary descent.
  Experimental inoculation  has proved that  no temperament  nor
idiosyncrasy is refractory to the primary action of syphilitic virus.
  The most careful observation has demonstrated, contrary to the
assertions of Hunter and his  followers, that every person is not  sus-
ceptible  of  constitutional infection;  and this  immunity cannot  be
explained on the ground of either the constitution, temperament, age,
or sex.
  Experience has, however, shown that an individual who has already
had constitutional syphilis, is incapable of contracting a new general
infection; and, if new chancres occur in  such a person, they will not
present specific induration.  _Nv
  There are three things to be considered with reference to constitu-
tional syphilis: the relative or absolute predisposition  of the individual,
without which infection cannot take place; the  diathesis or  peculiar
modification which is impressed on the constitution by this infection,
and which may exist a  certain time without manifesting itself; and,
finally, the various symptoms of constitutional syphilis.
  If the dogmas of  humoral pathology had ever been  lost, syphilis
would suffice to revive them.   For, in this disease, the blood becomes
charged with the poisonous principle ; and the tissues, thus subjected
to a vicious nutrition, are infected, and undergo successive and regular
changes, to a certain degree in the order  of their vitality.
  But something more than a syphilitic diathesis is necessary for the
development of constitutional symptoms; for a person may continue a
long time under its influence alone without showing any constitutional
symptoms, and the different times and various seats of the appearance
of the latter, in the same or different individuals, prove the necessity of
accessory causes.
  There must be, then, some accidental interruption of the integrity of
the functions of the body for  secondary symptoms to occur under the
influence of a syphilitic diathesis ; and their appearance may be  re-
tarded or definitely put off by physiological, hygienic, or therapeutic
means.
  At the present day, when many primary ulcers are left to themselves
without treatment, we can better observe the time and regular order 
396
CONSTITUTIONAL  SYPHILIS.
of appearance of syphilitic symptoms.  When nothing interferes with
the course of the disease, it is  always composed of three periods, viz.,
the period of the primary ulcer, the consequence of direct contagion,
and capable  of inoculation, but without the power to descend from
parent to child; the period of secondary symptoms, the consequence
of absorption of the  virus, and transmissible by hereditary descent,
without being inoculable;  and, finally, the  period  of tertiary symp-
toms, which not only are not  inoculable, but which cannot  be trans-
mitted by hereditary descent under their peculiar type,  although, in
consequence of a kind of degeneration or modification of the syphilitic
virus, they are perhaps one of the most fruitful sources of scrofula.
   Primary symptoms appear immediately after contagion, and within
the time of  evolution that I have  elsewhere  specified; secondary
symptoms rarely occur before the third week following the appearance
of the primary symptoms, and more rarely still after the sixth month;
whilst tertiary symptoms scarcely ever appear before the sixth month,
and may not until after several years.
   Primary symptoms consist of chancres in their different  modifica-
tions or varieties.
   To secondary symptoms are referred certain  affections of  the skin,
and of some parts  of the mucous membranes and their dependencies;
also,  some peculiar pathological  affections of the eyes, lymphatic
ganglia, etc.  Finally, tertiary symptoms consist of  certain changes
which take place in the subcutaneous or submucous cellular tissue, in
the testicles, in  the fibrous and osseous tissues, and in the deep organs.
If we could properly admit a period of incubation in syphilitic diseases,
as Jacques CataneV understood  it, the time intervening  between the
primary ulcer and constitutional symptoms could alone be considered
as such.
   Proper treatment of primary symptoms may prevent the develop-
ment of secondary symptoms.  Very often this treatment cures the
primary, and arrests only  the secondary symptoms; in this way is
explained the late appearance of diseases of the periosteum and bones,
for example, without the secondary intermediate link, in patients who
have taken mercury.
   When once  the primary ulcer is  healed, it cannot be  reproduced
except by a new contagion; while secondary and tertiary symptoms
may appear repeatedly, and at various intervals, within periods which
cannot be limited.
   An apparent inversion in the succession of secondary and tertiary
symptoms is observed only in persons who have undergone treatment.
   After the appearance of  constitutional symptoms, the syphilitic dia-
thesis may cease either spontaneously by the vis naturae, or  in conse-
quence of appropriate treatment, and yet the  symptoms still persist
under the influence of purely local causes, as is observed especially in
many cases of diseases of the bones.—Ricord.]
1 Jacques Cataneo.—De morbo gallico, 1505.—Ed. 
constitutional syphilis.
397
   § 1. Of the Nature of the Sores or Ulcers proceeding from the Lues
                             Venerea.

  In consequence of the blood being contaminated with real venereal
pus, it might naturally be supposed that the local effects arising there-
from would be the same with the original which produced them;  but
from observation and experiment, I have reason to believe that this is
not so.
  In considering this subject, we may first  observe that local effects,
from the constitution, are all of one species, that is ulcers, let the  sur-
face upon which  they appear be what  it  will, whether  the throat or
common skin, which is not the case in the local  application of the
matter in gonorrhcea and chancre; for there I  observed that it pro-
duced effects according to the nature of the surfaces.  Now, if the
matter, when in the constitution, were to act upon  the  same specific
principles with that  which is applied, we should  have gonorrhoeas
when it attacks a canal, sores or chancres when it attacks other  sur-
faces ;  but it has never been yet known to produce a gonorrhcea from
the constitution, though this has, indeed, been  suspected.  For some
gonorrhoeas, the origin of which has not  been clear, and which have
not easily given way to the common methods of cure, have been sup-
posed to have arisen  from  the constitution.1   Whenever the disease
affects the mouth and nose, it has always been looked upon as produc-
ing a true chancre; yet even here I find that such ulcers in their first
appearance  are very different from chancres.  The true chancre, I ob-
served, produces considerable inflammation, which of course brings on
quickly suppuration, attended often with  a great deal of pain; but the
local effects, from the constitution, are slow in their progress, attended
with little inflammation, and are  seldom  or never  painful, except in
particular parts.  However, this sluggishness in  the effects of  the
poison is more or less according to the nature of the parts which be-
come diseased; for when  the  tonsils,  uvula, or nose are affected, its
progress is  rapid, and the sores  have  more of the chancre  in their
appearance  than when it affects the skin; yet I do not think that the
inflammation is so great in them as in chancres that are ulcerating
equally fast.
  It has been supposed that even all the secretions  from the contami-
nated blood could be affected so as to produce a like poison in them;
and as the parts of  generation  are thrown in the way of receiving it,
when fresh  contracted, so they still lie under  the censure of having it
returned upon them from  the constitution.  Hence it  has been  sup-
posed that the testicles and vesiculas seminales may be affected by the
disease; that the semen may become venereal, may communicate the
disease to others, and, after impregnation, may even grow into a pocky

  1 The existence of gonorrhcea from this cause is still believed by M. Vidal, who
says : " On the mucous membrane of the genital organ, constitutional syphilis may
assume all the forms which we  have observed in primary syphilis.  Thus, cases of
constitutional urethral gonorrhoea have been met with, and also of balano-posthitis.
In this case, the affected mucous surface tends to  assume the copper color which is
characteristic of secondary affection."  (Op.  cit., p. 412.)—Ed. 
398
CONSTITUTIONAL  SYPHILIS.
child.  But all this is without foundation:  otherwise, when a petson
has the lues venerea, no secreting surface could be free from the state
of a gonorrhoea, nor could any sore be other than venereal.   Contrary
to all which, the secretions are the same as before;  and if a sore is
produced by any other means in a sound part, that sore is not vene-
real, nor the matter poisonous, although formed  from the same blood.
  The saliva in the case of a mad dog, being a natural secretion ren-
dered poisonous, may be brought as an argument in  contradiction to
this theory;  yet  it is easily accounted  for, and might be produced
rather as an argument in support of it.  In the dog, there is an irrita-
tion peculiar to the hydrophobia in the salivary glands; but the other
and natural secretions of the same dog are  not capable of giving this
infection, because they are not susceptible of the same specific irrita-
tion.
  The breath and sweat are supposed to carry along with  them con-
tagion, the milk of the breast is supposed to be capable of  containing
venereal poison and of affecting the child who sucks it; but there are
several reasons which overturn these opinions.   First, we find that no
secretion  is affected  by this poison, excepting  where the secreting
organs have been previously affected by venereal inflammation or irri-
tation, or  its specific  mode of action.  Again, if they were contami-
nated so as to produce matter similar to that of an ulcer in  the throat,
such matter would not be poisonous, nor possess a power of communi-
cating the  disease, as will be explained more fully hereafter.  Farther,
true venereal matter, even when taken into the stomach, does not
affect either the stomach or constitution, but is digested, as was evident
in the two following cases.
  A gentleman who  had  chancres which discharged largely, used to
wash the parts with milk in a teacup with some lint, and generally let
the lint lie in  the cup with the milk.  A little boy in the house stole
the milk and  drank it, but whether  or not he swallowed the lint was
not known.  No notice was taken of this by  the gentleman either to
the family or the boy; and attention, unknown to the family, was paid
to the boy even for years, but nothing  happened that could  give the
least suspicion of his having been affected either locally in the stomach
or  constitutionally.
  A gentleman had a most violent gonorrhcea, in which both the in-
flammation and the discharge were remarkably great.  He had also a
chordee, which was very troublesome at night.   In  order to cool the
parts, and  keep them clean, he had a small basin of milk by the bed-
side, in which, when the chordee was  troublesome, he got up and
dipped or  washed the- penis.  This operation he frequently repeated
during the night.   Under such complaints he allowed a young lady
to  sleep with  him.  Her custom was to have by the bedside a basin of
tea to drink in the morning  before she got up;  but  unfortunately for
the lady, she drank one morning the milk  instead of the tea.  This
was not known till she got up, which was five or six hours  afterwards.
I was sent for directly, and in the mean time she endeavored to vomit,
but could  not.  I ordered ipecacuanha, which proved slow in its ope-
ration.  She vomited, but it  was more than eight hours after drinking 
CONSTITUTIONAL SYPHILIS.
399
 the milk and water, and what came up was nothing but slime, mucus,
 or water, the milk  being digested.  I was attentive to what might
 follow; but nothing uncommon happened, at least for many months.1
  It is also supposed that a foetus in the womb of a pocky mother may
 be infected by her.  This I should doubt very much, both from what
 may be observed of the  secretions, and from finding that even the
 matter from such constitutional inflammation is not  capable of com-
 municating the disease.   However, one can conceive the  bare possi-
 bility  of a child  being affected in the womb  of a pocky mother, not
 indeed from  the disease of the mother, but from  a  part of the same
 matter which contaminated the mother, and was absorbed by her; and
 whether irritating her solids to action or not may possibly be conveyed
 to the child, pure as absorbed; and if so, it may affect the child exactly
 in the same way it did or might have done the mother.  This idea has
 been carried still farther; for it has been supposed that such a conta-
 minated child  could contaminate the  breasts of a clean woman by
 sucking her; the possibility of which  will be considered presently.
 We may observe that even the blood of a pocky person has no power
 of contaminating, and is not capable of giving the disease  to another
 even by inoculation; for if it were capable of irritating a sound sore
 to a venereal inflammation, no person that has this matter circulating,
 or has the lues venerea, could escape having a venereal sore whenever
 he is bled or receives a scratch with a pin, the part so wounded turn-
 ing into a chancre.  For  if venereal matter  may be on the point of
 the lancet, or  on the point of the  pin, the  punctures  must become
 chancres.
   [Ricord.—Hunter is perfectly right when  he says that secondary
 syphilitic symptoms are different from primary; but the difference is
 less in their physical form than in the nature of their morbid secretion.
 The truth is, that the aspect of  an ulcer, its  situation, the time of its
 appearance, the degree of inflammation attending it, and our apprecia-
 tion of the mode of action of its  supposed cause, may often deceive
 us; but the nature of the pus, inoculable only in  primary ulcers, will
 never  fail to establish the difference.  Who would venture to say, at
 the present day, that the local effects of constitutional syphilis are all
 of one kind, always ulcers slow and indolent  in their course, while
 primary symptoms,  appearing in the form  of gonorrhcea or chancre,
 according to  their seat, are more rapid in  their progress, and attended
 with inflammation and pain ?  Indeed, when we reflect on what I have
 had occasion to say relative to primary ulcers, the diversity of the tis-
 sues which may be affected by constitutional syphilis, and the second-
 ary and tertiary forms which the latter assumes, dependent on the situa-
 tion of the affected tissues, the physiological functions of the diseased

  1 These two cases, conformable to all that is positively known of the transmission
 of syphilis, and all that has been proved by experiment, are appropriately recalled to
 mind at the present day, when certain  persons report, without commentary, the case
of a man who, to be revenged on his faithless wife and punish her lover, contrived to
give the latter a gonorrhoea by administering to him every morning some milk, to
which he added muco-pus from a discharge that he had contracted for the purpose!
—Ricord. 
400
CONSTITUTIONAL  SYPHILIS.
organs, the period at which the symptom is observed, and the complica-
tions and influences which it receives from a multitude of modifying
circumstances, often appreciable, but sometimes unknown, we are con-
vinced that the general rule laid down by Hunter is susceptible of too
many exceptions not to be called in question.
  The truth is, that the secretions of constitutional syphilis do not
possess the same prerogative as the pus of a primary ulcer, which alone
is inoculable.  Thus, as Hunter has shown, neither the blood, saliva,
milk, semen, nor sweat of an infected person, can contaminate the tis-
sues on which they are deposited; and, as a complement of  the excel-
lent reasons and good observations which Hunter has given to support
this opinion, I will add the still more conclusive results of experiment;
inoculation  with these fluids having  always been negative.  If the
existence of facts opposed to this doctrine has gained credence, it  is
because  they were  imperfectly appreciated, though sanctioned by the
authority of any name, even that of Bell.  It is doubtless true that
the  saliva or semen may become impregnated with inoculable pus,
and give positive results on inoculation, from coming  in contact with
a primary ulcer; but they will have no effect without this direct mix-
ture.
  Yet the blood, though it produce no more effect when inoculated,  is
the vehicle which conveys  the virus produced by the primary ulcer.
But, as we have  elsewhere seen, so soon  as the virus is mingled with
the circulation, it undergoes a modification, in consequence of which
it is no longer inoculable; and, though it still act on the infected indi-
vidual, it does  so from the fact that it passes through various organs
which are subjected to this vitiated nutrition only because they possess
certain inherent susceptibilities due to their situation,  their  functions,
or more commonly to accessory causes, without which no effect is pro-
duced.  These  causes  explain  the times of development, the relative
situations, the  forms,  &c, of secondary symptoms in different indi-
viduals.
  Again, in the fact that the blood is poisoned, and the nutrition of the
tissues consequently vitiated, we have an  explanation—clearly antici-
pated by Hunter, in spite of his doubts—of the transmission of consti-
tutional syphilis from mother to offspring.  In proof of this transmis-
sion, we  need no evidence (which must often be questionable) of the
morality of the mother, such as is  required in cases of direct transmis-
sion from father to child, without the mother apparently being diseased,
and can rely on the simple observation of facts, which, we find, incon-
testably demonstrate its existence.—Ricord.]

  § 2. Of the Matter from Sores in the Lues  Venerea compared with thai
                    from Chancres and Buboes.

  When the matter has affected the constitution, it from thence pro-
duces many  local effects on different parts of the body, which are
in general a kind of inflammation, or at least an increased action occa-
sioning a suppuration of its own kind.  It is supposed  that the matter
produced in consequence of these inflammations, similar to the matter 
                  CONSTITUTIONAL SYPHILIS.              401

from a  gonorrhcea or chancre, is also venereal or poisonous.   This, I
believe, till now, has never been denied; and, upon the first view of
the subject, one would  be inclined to suppose that it really should be
venereal;  for, first, the venereal matter is the cause;  and, again, the
same treatment cures both diseases; thus mercury cures both a chan-
cre and a  lues venerea; however, this is no decisive proof, as mercury
cures many diseases besides the venereal.  On the other hand, there
are many  strong reasons for believing that the matter is not venereal.
There  is  one curious fact which shows it is not venereal, or, if it be,
that it  is  not capable of acting in some respects on  the same body or
same state of constitution as the matter does which is produced from
a chancre or gonorrhcea.  The pus from these latter, when absorbed,
generally  produces a bubo, as has been described;  but we never find
a bubo from the absorption of matter from a pocky sore.  For instance,
when there is a venereal ulcer in the throat, we have no buboes in the
glands  of the neck; when there are venereal sores on the arms, or
even suppurating  nodes on the ulna, there are no swellings of the
glands of  the armpit;  although such will take place if fresh venereal
matter is applied to a common sore, on the arm, hand, or fingers.  No
swelling takes place in the glands of the groin from  either nodes or
blotches on the legs and thighs.  It may be supposed that there is no
absorption from such sores;  but I think we have no grounds for such
supposition.  Its mode of irritation, or the action of the parts affected,
is very different from  what happens  in  the chancre, gonorrhcea, or
bubo, being  hardly attended  with inflammation, which in them is
generally  violent.
  It might be supposed that a constitution truly and universally pocky
is not to be affected locally by the same species of matter; but from the
following experiments it would appear that matter  from a gonorrhoea
or chancre is capable of affecting a man locally that  is already poxed;
and that  matter from pocky sores, arising from the constitution, has
not that power.
  A man  had been affected with the venereal disease a long time, and
had been  several times salivated, but the disease still broke out anew..
He was taken into St. George's Hospital, affected with a  number of
pocky sores; and before I put him under a  mercurial course  I made
the following experiment.  I took some matter from one of the sores
upon  the  point of a lancet, and made three small  wounds upon the
back, where the skin was smooth and sound, and deep enough to draw
blood.   I  made a wound similar to the other three with a clean lancet,
the four wounds making a quadrangle; but all the wounds healed up,
and none  of them ever appeared afterwards.
  This experiment I have repeated more than once, and with the same
result.   It shows that a pocky person cannot be affected locally with
the matter proceeding from the sores produced by the lues venerea.
But to see how far venereal matter was capable of producing chancres
on a pocky person, I made the following experiment.
  A man,  who had venereal  blotches on  many parts of his skin, was
inoculated in  sound parts with matter from a chancre, and also with
matter from  his own sores.   The wounds inoculated with the  matter
      26 
402
CONSTITUTIONAL SYPHILIS.
 from the chancres became chancres; but the others healed up.  Here,
 then, was a venereal constitution capable of being affected locally with
 fresh venereal matter.  This experiment I have likewise repeated, more
 than once, and always with the same effect.
   I ordered a person at St. George's  Hospital to be inoculated with
 the matter taken from a well-marked venereal ulcer on  the tonsil, and
 also with matter from a gonorrhcea, which produced the same effects as
 in  the preceding experiment; that is, the matter from a  gonorrhcea
 produced a chancre, but that from the tonsil had no effect.
   A woman, aged twenty-five, came  into St. George's Hospital, August
 21, 1782, with  sores on her legs, and blotches over her  body.  Her
 husband gave her the venereal  disease December, 1781.  Her symp-
 toms then were  a discharge from the vagina, and a small swelling of
 the glands of the groin, which were painful.  She had taken some pills
 supposed to be mercurial.   February,  1782, about three months after
 being infected, the discharge stopped; but the swelling, which had been
 gradually increasing ever since its first appearance, had now suppurated.
 She applied some ointment to it, which was brought to her by her hus-
 band, and in two months  it got well, that is, in April, 1782.  After
 the bubo got well a discharge from the vagina came on, for which she
 took more of the same pills she had  taken  before.  After this time
 blotches  came out over  her whole body; some  about her legs, under
 her arms, and upon her nipples, ulcerated.
  Twins, which she brought forth at eight months, in March, 1782, at
 the time  the bubo was healing, had blotches upon them  at their birth,
 and died soon after.
  Another girl, about two years old, whom she suckled, was also covered
 with blotches when she came to the hospital.
  To ascertain whether her secondary ulcers were infectious, that is,
 whether the matter of them would have the specific effects of venereal
 matter, she was inoculated with some matter from one of her own ulcers,
 and with some matter from a bubo of  another person where mercury
 had not been used.  This was done  September 18, 1782.  September
 19, the puncture where she was inoculated with  her own matter gave
 her pain  three hours from the time of inoculation, and the day follow-
 ing inflamed a little.  The other had not then inflamed at all.
  September 20, both the punctures had suppurated, and had the ap-
 pearance of a smallpox pustule; they spread considerably, and were
 attended  with much inflammation.  That from her own  matter healed
 with common poultices, and ointments without mercury;  but the other,
 although treated in a similar way, continued in the same state, attended
 with much pain and inflammation.
  September 22, the child was inoculated with some matter from one
 of its own ulcers, and with  some common pus.   The punctures both
 inflamed  in a small degree, but neither of them suppurated.
  The mother and the child went into the ward appropriated to saliva-
tion, October 21,1782.  The child took no mercury.  It was supposed
that its gums became a little sore; and the blotches got well.
  During the time that the mother was using mercury the ulcer from
inoculation began to get well, and her venereal symptoms disappeared. 
CONSTITUTIONAL  SYPHILIS.
403
What shall we say of this case ?  Were the blotches venereal ?  There
was every leading circumstance to make us think so, and our opinion
was strengthened by the method of cure.   If they were venereal, my
opinion, that the constitutional appearances of the disease do not pro-
duce matter of the same species that produce them, is confirmed.   If
they were not venereal, then we have no absolute rule by which to judge
in such cases.
  It has been supposed, and asserted from  observation, that ulcers  in
the mouths  of children from a constitutional disease, which  constitu-
tional disease has been supposed to be derived from the parent, have
produced the same disease upon the nipples of women who had been
sucked by them; that is, the children were contaminated either by their
mothers or fathers having the disease in form of a lues venerea, of which
I have endeavored  to  show the impossibility.  If, however, it were
possible to contaminate once in this way, it would be possible to con-
taminate forever.1
   How far the observations, upon which the before-mentioned opinion
is founded, have been made with sufficient accuracy to overturn those
which  I made with a view to ascertain the truth, I know not.  But
from a more accurate investigation of some of those cases, which were
by most of the faculty  called venereal, they appeared evidently not to
be such.   To say what they were would lead us into the consideration
of other diseases.  The following case may lessen our faith in the his-
tories of such as have been supposed to be venereal.
   Before I describe the case, I shall first mention some of the circum-
stances leading to it.
   A child was supposed to have infected its nurse with the venereal
disease.  The parents had been married about twelve years when this
child was born.  The father was a very fond husband, and the mother
a mild and most affectionate woman.  The father had  a venereal  go-
norrhoea two years before  he  married, that is, fourteen years  before
the birth of the  child.   About  nine months after  marriage  they had
a child, and afterwards a second, both of whom were extremely healthy
at birth, and still continue so.  The mother fell into a weakly state of
health, and miscarried of her third child at the end of five months.
The fourth child was born at seven  months, but was puny, weak, and
had hardly any  cuticle when born.  It  was immediately  after birth
attacked with a violent dysentery.  It died in a  few  days  and was
opened by me.  The whole skin was  almost one excoriated surface.
The intestines were much inflamed and thickened.
   With her fifth child, from great care, she went eight  months, and it
was now hoped that she might go the full time, and also that this child
might  be more healthy than the former.   When she was delivered,
the child was very thin, but free from  any visible disease.
   Some days after birth, it became blistered in a vast number of places
on its  body, which blisters  were filled  with a kind  of matter, and,
when they broke, discharged a thinnish pus.  The inside of the  mouth
was in the same  condition.   Bark was given to the nurse.   Bark, in
See observations on this subject in notes to Part VII. 
404
CONSTITUTIONAL SYPHILIS.
 milk, was given to the child by the mouth, and it was fomented with
 a decoction of bark, but in about three weeks after birth it died.
   Some weeks after the death of the child, the nurse's nipple, and the
 ring round the nipple, inflamed, and sores or ulcers were formed with
 a circumscribed base.1  They were  poulticed, but without benefit.
 She also complained of a sore throat, but the sensation she complained
 of was so low in the throat that no disease could be seen.  A swelling
 took place in the glands of the armpit, but  they did not  suppurate.
 She applied to a physician, and according to the account which she
 gave, he pronounced that her  disease was venereal,  and that she had
 given suck to a foul child; and he ordered  ten  boxes of mercurial
 ointment to be rubbed in on her legs  and thighs, eight of which had
 been used when I saw her, and then her mouth had become extremely
 sore.
   These circumstances, came to the ears of the family, and an alarm
 took place.  The husband went from surgeon  to surgeon, and from
 physician to physician, to learn if it were possible for him to have the
 disease for fourteen years, and never to have perceived a single symp-
 tom of it in all that  time; or if it was possible he could get children
 with the disease now, when the two first were  healthy.  He also wanted
 to know if it was possible for his wife  to have caught the disease from
 him under  such  circumstances, and also,  if she could  breed children
 with this disease, although she herself never had a single symptom of
 it.  If we  take  all the above-mentioned  circumstances as facts, the
 conclusion  is, that  it was impossible there could be anything venereal
 in the case; but as they  could not be absolutely  proved to be  facts,
 there must remain a doubt in the mind, a  something still to be proved.
  Now let  us consider the result of the case.  The nurse's mouth was
 become extremely  sore from the mercury when I  first saw her.   I de-
 sired that  Mr. Pott  might see her along with me; and  it was the
 opinion of  us both that the sores  on the  nipple and  around it were
 not venereal; but it was  alleged that, as she had taken mercury, their
 not having a venereal appearance now was owing to that cause.   The
 bark was given, as also the sarsaparilla, but the sores did not heal, nor
 did they become worse; nor was the mouth better by leaving off the
 mercury.   I ordered the  hemlock, but that appeared to have no effect.
 In the mean time, eruptions broke out on the skin.  The skin of the
 hands and fingers  peeled off;  the  nails of both  fingers and toes sepa-
 rated, and  sores formed about their roots, which were  all supposed
 (by many)  to be venereal. But some of them appearing  while the
 constitution was full  of mercury, and others disappearing without any
 farther use of that medicine, I judged that  they were  not venereal.
 We suspected that her mode of living was such  as contributed greatly
 to the continuance of her first complaint,' and gave rise to the new
 ones;  for she looked dejected and sallow.  She was desired to go into
a hospital, which she did. As soon as she got into  a  warm bed, and
had good wholesome food, she began to mend, and in about five or six
weeks she had become fat and almost  well; the sore only  about the
1 She had but one breast that gave milk. 
CONSTITUTIONAL  SYPHILIS.
405
 root of the nail of the great toe had not healed; but that appeared
 now to be owing to the root of the nail being detached, therefore act-
 ing as an extraneous body.   She came out of the hospital before this
 toe had got well, and returning to her old poor mode of living, she had
 a return of the soreness  in the mouth; however, she mended at last
 without the use of more mercury.
   This case I shall farther consider when on diseases resembling the
 venereal.
   The following case will farther  prove that we often suspect  com-
 plaints to be venereal when they really are not.
   A gentleman had for  some time blotches  on his skin.  The face,
 arms, legs, and thighs were in many places  covered with  them, and
 thejr were in their different stages'of violence.  In this situation he
 applied to me, and I must own they had a very suspicious appearance.
 I asked him what he supposed these blotches were; he said he sup-
 posed them to be venereal.  I asked him when he had a  recent venereal
 complaint; he told me for above twelve months. I then  asked him how
 long he had had the blotches; and the answer was, above six months.
 As this was a sufficient time  for  making observations upon them that
 might  ascertain better than  the mere appearance what they were, I
 asked him if any of the  blotches that came first had  disappeared in
 that time, and he said many;  I desired to see where those  had been,
 and on examination  I found only a discolored skin, common to the
 healing of superficial sores.  I then declared  to him that  they were
 not venereal, for if they  had arisen  from that source  none  of  them
 would have  disappeared.  He now  informed me that he  had  been
 taking mercury; and this information obliged me to have recourse to
 farther inquiries; and I  therefore  asked him whether, while he was
 taking mercury, many of the first got well ?   The  answer was, yes.
 And was the cure of those  imputed to mercury ?  The answer was
 again in the affirmative.  I then asked him if, while he was  taking the
 mercury, which appeared to have cured some, those that now remained
 arose ?   Yes.   My next  question was, how long had he taken  mer-
 cury ?   He said for six months.  I then declared that  they were not,
 nor ever had been, venereal.   I asked him, what was now the opinion
 of his surgeon ?  He said, that his opinion still was that they  were
 venereal, and that he should go on with the mercury.   I advised him
 to take no medicines  whatever;  to live well,  avoiding  excess, and to
 come to me in three weeks;  which he did, and then he was perfectly
 well, only the skin was stained where the blotches had been.  He now
 asked me what he was next to do?  I told him he  might  go to the
 sea and bathe for a month. This he did, and returned well and healthy,
 and has continued so.1
   [Ricord.—My numerous experiments have  confirmed those of Hun-
 ter, as  may be seen from the preceding notes.  The pus of  secondary

  1 Added : " The impropriety of giving mercury where the case is not venereal, to
indulge the wishes of the patient, is obvious, since it is  confirming his suspicions, in-
juring his constitution, and, when the medicine fails, making him believe himself
incurable, since the symptoms have not  yielded to the only medicine capable, in his
opinion, of removing them."—Home. 
406
CONSTITUTIONAL  SYPHILIS.
symptoms is not inoculable.  I have often met with persons, having at
the same time secondary ulcers, a gonorrhcea without a urethral chan-
cre, and a progressing chancre on some other region;  and whilst the
secondary ulcers and the gonorrhcea gave negative results on inocula-
tion, pus from the chancre produced the characteristic pustule which
Hunter so well observed.
  Under the influence  of  the  general  state of the system,  indolent
glandular swellings are sometimes  met with at the same time as early
secondary symptoms; but whilst we always see a ganglionic engorge-
ment succeed an indurated  chancre, here, on  the contrary, it may ap-
pear before, and never in any case  occurs with the late symptoms.
  When we  are  aWare of the facility with which  primary ulcers are
reproduced at various points, from  the virulent pus flowing over%the
surface, or being conveyed by the nails in scratching the parts, we can
easily account for a large  number of reputed secondary symptoms,
which, arising in this way, of course furnish inoculable pus.  This takes
place especially in children, and more commonly than is supposed, and
it explains certain cases in which  they communicate syphilis to their
nurses.  Recollect, also, that in young children, primary symptoms are
more rapidly followed by secondary than in adults, and that they soon
undergo a transformation in situ, which gives them the appearance of
mucous tubercles; chancres of the breasts in nurses also rapidly assume
this appearance.  Thus, we  have a rational explanation of very many
cases which are inexplicable if we do not understand how to analyze
them, and allow ourselves to be imposed upon by diseases in children,
entirely foreign to syphilis, or irritated  fissures of the breast in nurses,
which may even excite swelling of the axillary ganglia; not to mention
cases where both nurse and  child have been previously infected  and
afterwards accuse each other.—Ricord.]

   § 3. Of the Local Effects arising from the Constitution considered as
                    crit ica I.—Symptoma tic Fever.

  How far the eruptions or local effects of this disease, arising from the
constitution, are an effort of nature to clear herself of this disease is not
certain.  I observed that a gonorrhcea might be produced  by a general
law in the animal economy, by which it endeavors to relieve itself of
the irritation by producing a discharge; and that in chancres  a breach
is made in the solids for the same purpose, although this purpose is not
answered in either, nature not having a provision  against this poison.
But how far a similar attempt takes place in a lues venerea,  I do not
know; and if it was upon the same principle, the same reason might be
expected to be given why the constitution is not capable of relieving
itself in the present instance that I gave when treating of the primary
affections, because in this, as it was in  the other, the matter formed
might  be supposed to be venereal; and therefore by being absorbed by
the very surface which produced it as in a chancre, it might  keep up
the constitutional disease.  If this were really the case, it would be very
different from many other specific diseases; for the reason why many
specific diseases cure themselves is that  the irritation cannot last be- 
CONSTITUTIONAL syphilis.
407
yond a stated time;  and also that in many the patient is never suscep-
tible of the same disease  a second time, as  in  the smallpox.  If this
was not the case, a  person  once  having the smallpox would always
have them; for according to one supposition, that absorption of its own
pus keeps up the disease; and according to another, that the irritation
never  wears itself out, the patient would either never be free, or have
them repeated forever; for his own matter would give  the disease a
second time, a third time,  and so on.1  But the venereal matter, when
taken  into the constitution, produces an irritation which  is capable of
being  continued  independent of a continuance of absorption;  and the
constitution has no power of relief, therefore a lues venerea continues
to increase.  This circumstance is perhaps one ofthe best distinguish-
ing#marks of the lues venerea, for in its ulcers and blotches it is often
imitated by other diseases, which not having this property will there-
fore heal and break out again  in some  other part.  Diseases in which
this happens show themselves  not to be venereal.  However, we are
not to conclude, because they do not heal of themselves and give way
only to mercury, that therefore they are not venereal, although this
circumstance joined to others gives a  strong suspicion of their being
such.2
   When  the parts are contaminated by the venereal poison, we com-
monly find fever, restlessness,  or  want  of sleep, and  often headache;
but I  believe  that these symptoms are rather peculiar to the disease,
when the second order of parts, the periosteum and bones, are affected,
although they are sometimes found from the first.  Do these symptoms
arise from  the local  irritations affecting the constitution ?  And are
they merely sympathetic?   Whatever the immediate cause may be,
they never go off till the local irritations are removed.   This fever at
first has much the appearance  of the rheumatic fever; and after a time
it partakes a good deal of the  nature of the hectic.
   The symptoms often take place independent of, or unattended by,
any local action;  and when that is the  case it becomes very uncertain
what the  disease  is;  for, in cases not admitting of clear proof, we must
rest on the concurrence of circumstances.  Many of  these symptoms
give way to mercury.  This is probably the only concurring circum-
stance attending  this complaint that is any proof of its being venereal.3
It rather, however, appears  to militate against this idea that, for the
most part, a much smaller quantity is  sufficient for the cure of such
symptoms than what is  necessary for the cure of local complaints.
But if mercury always cured them, it would not be very material what
they are  called.   It is worthy of consideration, however, how far the

  1 This circumstance alone is a strong proof that people cannot  have the smallpox
twice, at least at any distance of time between, if they had fair eruptions the first time ;
for if the constitution was not so altered as not to be susceptible of this irritation a
second time, a person would have them immediately upon the going off of the first.
  z It is an established fact that secondary symptoms can not only be cured by other
means than mercury, but that they often disappear of themselves in one part of the
body to reappear in another; and that, too, repeatedly and for an  indefinite period.—
Ricord.
  3 Here it is to be understood that the circumstance of a previous gonorrhoea or chan-
cre is not to be considered as strong evidence. 
408
CONSTITUTIONAL syphilis.
venereal poison, when in the constitution, does or does not always pro-
duce local effects.  That it in general does we are certain; but whether
it  is ever a cause of constitutional symptoms simply, such as loss of
appetite, wasting, debility, want of sleep, and fever, at last  becoming
hectic, is uncertain; and it is also  uncertain whether it is ever capable
of producing  local actions from irritation only, without an alteration
of the structure of the parts irritated, as  cough, secretion from the
lungs,  purging, headache, sickness, pain in different parts of the body,
like rheumatic pains, but not from an alteration of the structure of the
part taking place, as beginning nodes.   If  such effects take place, we
must, in such a case rely entirely on the history of  the  disease, and
pronounce according to probability.   Such complaints come oftener
under the management of the physician than the surgeon, to whom  I
would recommend a particular attention to  this.
  The fever in consequence of the venereal irritation, like most other
fevers, deranges the constitution, which thereupon suffers agreeably to
its natural tendency.   It is capable of producing glandular swellings
in many parts of the body, and probably many of the nodes that arise
in the time of this fever may proceed from the fever; and similar to
every such effect, from whatever cause, it does not partake of the dis-
ease which produced  it, for it is not venereal; it only takes place in
constitutions very susceptible of such  action where the  predisposing
cause is strong, and probably at seasons most fitted to produce it, only
waiting the immediate cause to put them into action.   Such will and
do go away of themselves, when the predisposing cause ceases, such as
season.1

§ 4. Of the Local and Constitutional Forms of the Disease never interfering
                          with one another.

  I observed, when treating of the gonorrhoea and chancre, that when
occurring in the same person, that one  neither increases the symptoms
nor retards the cure of the other.   And it may also be observed that
the chancre or gonorrhcea, and the constitutional form of the disease,
meeting in the same person, do not interfere with each other, either in
their symptoms or cure.
  To explain these effects more  fully, let  me observe that, if a man
has a gonorrhcea, and a chancre appears some days after, the chancre
does not either increase or diminish the gonorrhcea.   Again, if a man
has either a gonorrhcea, a chancre, or both, and a lues venerea ensue
in consequence of either of these, neither the gonorrhcea nor chancre is
affected by it.  If a man has a lues venerea,  and gets either a gonor-
rhcea or chancre, or both, neither  of  them affects the lues venerea,
nor are their symptoms the worse.   Nor is  the  cure of either, singly,
retarded by the presence  of the  other;  for a gonorrhcea is as easily
cured when there are chancres, as when there are none, even although

  1 Here, in what he  calls the  general or sympathetic symptoms, Hunter sometimes
takes the effect for the cause, as in what he says of nodes. In fact, in the regular
succession of syphilitic phenomena, nodes are more frequently developed without than
with fever.—Ricord. 
CONSTITUTIONAL  SYPHILIS.
409
the chancres are not attempted to be cured; and a chancre may be
cured locally, independent of the gonorrhcea.  Farther, a gonorrhcea,
chancre, or both, may be as easily cured when the constitution is poxed
either by them, or previous to their appearance, as when the person is
in perfect health ; but the chancre has this advantage : that the con-
stitution cannot be cured without its being likewise cured.
  The gonorrhcea and chancre, indeed, so far influence one another as
the one can be in some degree a cause of prevention of the other, as
has been already observed; but I believe that this circumstance does
not assist in the cure of either; yet I could conceive it might, each
acting as  a derivator to  the other, without increasing its own  specific
mode of action.

  § 5. Of the supposed Termination of the Lues Venerea in other  Diseases.

  This disease seldom or never interferes with other disorders,  or runs
into, or terminates in  any other,  although it has  been very much
accused of doing so; for a termination of one disease in another, as I
understand  the  expression, must always be  a cure of the one termi-
nated ; but the venereal disease never terminates till the proper  remedy
is applied, and, therefore,  never can run into any other disease.
  That venereal complaints can be the cause of others I think is very
probable.   I have seen a chancre the immediate  cause of an  erysipela-
tous inflammation, but the venereal malady did not terminate in the
erysipelatous inflammation; for if it had, the chancre would have been
cured ; nor was the erysipelatous inflammation venereal; the chancre
only acted  here as a common  irritator, independently of the  specific
quality of the disease as a cause.  I have known a venereal  bubo be-
come a scrofulous sore as soon as the venereal poison  was  destroyed
by mercury ; this was not a venereal terminating in a scrofulous affec-
tion, for in such a view the scrofula must have cured the venereal.
The venereal disease would seem only to partake of the nature of such
disorders  as the constitution  was  previously disposed to, and may
excite into action the causes of these disorders.  The same observation
and mode of reasoning hold equally good with respect to  other dis-
eases. The common symptoms, however, of the lues venerea, though
in some degree according to the constitution, are not  so much  so as
either in  the chancre or the  gonorrhcea;  for the  lues venerea is
attended with  very little inflammation, which in general partakes
much more of the nature of the constitution than any other diseased
action.

       § 6.  Of the Specific Distance of the  Venereal Inflammation.

  I have already observed that many specific diseases, as  also those
arising from poison, have their local effects confined to certain distances,
which I have called their local  specific distance;  and it would appear,
from observation, that the  venereal  irritation and inflammation, of
whatever kind it may be, is guided by this principle; for it seldom ex-
tends far beyond the surface that receives it; the neighboring part not 
410
CONSTITUTIONAL  SYPHILIS.
having a tendency to sympathize or run easily into this kind of inflam-
mation.  This is the reason  why we find a gonorrhcea for weeks con-
fined to one spot in the urethra in men, and for months to the vagina
in women, not extending farther in either.   In chancres also the in-
flammation is  confined to the seat  of  the sore without becoming so
diffused as when from common accidents.  As a farther proof of this
fact, we find it is also confined to the glands in the groin, in cases of
buboes, till matter is formed in them;  which matter acts as a common
irritator, and the specific is  in some degree lost, and then the inflam-
mation  becomes somewhat  more diffused, as it  happens in common
inflammation.   We also see that the same thing happens in venereal
ulcers when they arise from the constitution; their size is at first but
small, and they are merely local; but as the disease increases the size
increases, but they still remain circumscribed, not becoming  diffused.
Perhaps all  poisons and  specific diseases agree  in  this property of
having  their inflammation  limited and circumscribed in a manner
peculiar to themselves; for  we find that the inflammation of the small-
pox, measles, and chicken-pox, is each circumscribed in its own way.
From hence it must appear that the human body in  general is not so
susceptible of specific irritations as it is of the common, or what may
be called the natural.  But we must  also consider that the common
inflammation in very healthy constitutions has its  specific distance,
although not so determined or circumscribed as is that of the specific
in such constitutions; therefore, we may reasonably suppose that such
healthy constitutions are the farthest  in disposition from  the inflam-
matory action;  and we may also suppose  still  more so from  the
specific.  What would  appear to strengthen this idea is,  that when
the constitution  is such  as  readily goes into inflammation, the more
readily does the inflammation spread,  every part being susceptible of
such action; and we find  that in many the specific also  spreads,
although not in so great a  degree,  from which we may suppose that
the specific  is always a more  confined mode of action.  I have sus-
pected that when the body was disposed to increase the inflammation
beyond the specific d istance, it was of the erysipelatous kind, as was
mentioned before, and which is to be attended to in the cure.

§ 7. Of the Parts most susceptible of the Lues Venerea—of the Time and
   Manner in which they are affected.— What is meant  by Contamination,
   Disposition, and Action.—Summary of the Doctrine.

   When I assigned the causes for so great a difference in the effects of
the same poison upon two different surfaces, as forming the gonorrhoea
and chancre, I then said  I did not know whether similar surfaces in
every part of the body were equally susceptible of this irritation, hav-
ing but few comparative trials of the direct application of the poison to
other parts besides those of generation.  But it would appear that some
parts of  the body are much less susceptible of the lues venerea than
others ; and not only so, but many parts, so far as we know, are not
susceptible of it at all.  For we have not yet had every part of the body
affected: we have not seen the brain affected, the heart, stomach, liver, 
CONSTITUTIONAL  SYPHILIS.
411
kidneys, nor other viscera, although such cases are described in authors.1
But as there are different orders of parts respecting the times of the
disease appearing, and as the person commonly flies to relief upon the
first or second appearances, it may be supposed that the whole disease in
the parts actually affected is cured before the other parts have had time
to come into action, which will therefore be cured under the state of a
disposition only, if we can conceive that a cure can take place before the
parts have come into action.  But if the parts visibly affected are cured,
while those only disposed are not, and afterwards come into action, they
would form a second order respecting time; and  if these  again are
cured, and other parts under a disposition should come into action, such
would form a third order of parts  respecting time.  The lungs have
been believed to have been affected with the venereal disease, both from
the circumstances preceding the complaint, and from  the  complaint
itself being cured by mercury;  and  their  being affected,  when the
other viscera  are not, may arise from  their  being in some degree an
external surface, as will be explained hereafter.
   It is this  form of the disease, therefore, that gives us the compara-
tive susceptibility of parts both  for disposition  and  action.  For we
must suppose  that all parts  are  equally and at  once exposed to the
action of the poison; but though there  may be various degrees of
susceptibility, it will be sufficient for practice to divide them into two,
under the following appellations of first in order, and second in order, to
which we may add the intermediate.
   Whether the parts that  are  really first affected are naturally more
easily affected  by this kind of irritation, or  that  some  other circum-
stance which belongs to these parts is the cause,  cannot be absolutely
determined; but, the matter being attentively  considered, it would
appear to be owing to something foreign to the constitution, and also
not depending on the nature of the parts themselves; for if we take
a  view of  all the  parts that are first affected by this  disease, when
arising from the constitution, which I shall suppose are the parts most
susceptible  of it, we  shall  see that, in the recent state of the disease,
the parts are subject to  one general affection, while there are similar
parts of the body not affected by this disease, and not subject to this
general affection.  Probably the parts second in  order may naturally
be as susceptible of the irritation as those first in  order; but not being
under the influence of an irritating cause,  they  are later  in coming
into action; and there are also probably other causes in the nature of
the parts themselves,  such  as being indolent in  all their actions, and
of course indolent in this, therefore later in coming into action.  How-
ever, it is not universally the case that the parts  which  I have called
first in order are always so;  on the contrary, we find that  this order
is  inverted  in  some cases, although but rarely.  We cannot suppose
that this difference arises from any active power in the poison, nor any
particular direction of it, but from properties in the parts themselves;
for it may  be allowed  us to suppose that, when this matter has got
into the circulation, it acts  on all  parts of the body with equal force;
1 See page 37, 
412
CONSTITUTIONAL  SYPHILIS.
that is, it is not determined to any one part more than another by any
general or particular power in the animal machine; nor is the nature
of the poison such as will fall more readily on one part  of the body
than another when they are  all  in similar circumstances.   That some
parts, therefore, are more readily affected by it than others, owing to
circumstances which are no part of the animal principle, nor of the
poison; and also, that some parts of the body have a greater tendency
to be irritated by it than others, must be allowed.
   The parts that are affected by this form of the disease  when in its
early stage or appearance, which I have called first'in order, are the
skin, tonsils, nose, throat, inside of the  mouth,  and  sometimes the
tongue.1  When in its  later state, the  periosteum, fascias, and bones
come into action, and these  I call  second in order of parts.  Perhaps
the bones come into action from the membrane being affected.
   That we  may be  able to account in some measure for these similar
effects as to time in dissimilar parts, such as the skin and the tonsils,
two very different kinds of parts, let us consider in what circumstance
they agree, and why they are more susceptible of this irritation than
those parts that probably are naturally as  much so, although they do
not receive it so readily, such as the periosteum, fascias, and bones.
   The most remarkable circumstance, perhaps, to which the external
surface is exposed,  and to which the internal is not, is  cold, or a suc-
cession of  different degrees of cold.   For we observe, in general, that
the atmosphere  in which we live is colder than the  human body2 in its
usual temperature;  therefore the skin, &c, is  continually exposed to
a cold greater than what the  internal parts are; and we find that  all
those parts which are most exposed to this admit of being much more
easily affected, or come  more readily into action  in this disease than
the others.
   It is certain that cold has very powerful effects on the animal eco-
nomy.  It would at least appear to have great powers of disposing the
body for receiving the venereal irritation, and going readily on with it.
   From this idea we may account for several circumstances respecting
this disease, as  the  mouth, nose, and skin, being the most frequently
affected, since they are rendered most susceptible of it from the causes
before mentioned, and for the  same reason come very readily into
action.  If this be a true solution, it also accounts for those second in
order being affected; for if the  poison has contaminated parts which
are both first in order of susceptibility and time of coming into action,
it  is natural to suppose that those parts which are most  predisposed,
as the external surfaces, shall come first into action; the parts exposed
to cold, in  the  next degree, forming the second in order, come next

  1 The tongue is very subject to have ulcers formed on it, especially on its edges.
They are seldom very large, nor are they often either very foul or have a hard basis;
these are commonly supposed to be venereal; but I believe they seldom are.  I do
not know whether I am or not acquainted with the distinguishing marks. I never
saw but one that I suspected to be either venereal or cancerous from its foul look and
its hard basis. It gave way readily to mercury, therefore I supposed it to be venereal.
  * It is to be understood that this cannot hold good as a universal principle ; it can
only take place in the temperate and frigid zone; for in the torrid, the heat of the sur-
rounding atmosphere is sometimes greater than that of the human body. 
CONSTITUTIONAL  SYPHILIS.
413
into action, such as bones, periosteum, &c, but even in them it is not
in every bone alike, or every part alike of any one bone, for it appears
first in those that are in some measure within the power of being
affected by sympathy from application of cold to  the skin; we find
that when the deeper-seated parts, or the  parts second in order, come
into action, such as the periosteum or bones, it is first in these that are
nearest the external surface of the body, such as the periosteum  or
bones of the  head, the tibia, ulna, bones of the nose, &c, nor does it
affect these bones  on all sides equally, but first on that side next the
external surface. •  However, it would appear that  in the bones there
is another cause, besides the vicissitudes of weather, why this disease
should attack them; for the periosteum of bones, or bones themselves,
are not liable to be diseased on all parts in proportion to the distance
from the skin, the  periosteum which covers the ankles, or many of the
joints,  being  as near the external surface as many other parts of the
periosteum or bones that are affected.  The nature of the bones them-
selves, which are covered by that periosteum, is somewhat different;
they are softer in  their texture, therefore they  would  seem to  be
affected in proportion to their nearness to the skin and hardness of the
bones jointly, which would incline  us to  believe that the bones are
more easily affected, and rather have some influence upon  the perios-
teum in this disease than the periosteum upon them; and this suscep-
tibility in the hard bones would appear to be in proportion to their
quantity of earth and exposure to cold combined.
 •  It may be objected to this theory, that the fore part of the tibia, &c,
cannot be really colder than  the back part; but, then, it may be sup-
posed that it is not necessary that the part should be actually cold, but
only within the power of sympathy.   For a part  that is not actually
cold is capable of being affected, from its sympathizing with a cold part
in the  same manner as if  actually cold, although, perhaps, not  in  so
great a degree, and therefore requires a longer time to come into action
than if it were  actually cold.  We find, for example, that when the
skin is  actually cold, the muscles underneath are thrown  into alternate
action, so that we tremble,  or our teeth chatter with cold, and yet it is
possible that these muscles may not  be colder  at this  time than any
other;  although it is most probable  that they are really colder,1 which
will assist the power of sympathy.  So far as cold can affect the actions
of parts, so far, also, will the sympathizing part be affected in propor-
tion as it is nearer to the  parts  actually cold; therefore, the deeper-
seated  parts in the venereal disease are later in coming into action.
   The actual cold parts come first into action, then those that are less
so, and next, those that are nearest in sympathy, and so on, except the
parts first in order of susceptibility have been only partially cured, and
then their recurrence may correspond with the action of those that are
second in order of susceptibility, and all the parts will come into action
together.  What would seem to strengthen this opinion, is the different
effects  that arise from different climates—in warm climates, the disease
seldom or never arises to such a height as in cold climates; it is more

           1 See Philosophical Transactions, vol. 68, part i. page 7. 
414
CONSTITUTIONAL  SYPHILIS.
slow in its progress, and much more easy to cure, at least if we may
give credit  to  the  accounts we have received  of the disease in such
climates.
   Whether the difference in the time of appearance between the super-
ficial and deeper-seated parts in warm climates is the same as in cold
ones, I do not know; but, from the above theory, it should not be so
great in the warm as in the cold climates.
   Besides the causes already mentioned, it would appear that there are
others  by which the lues venerea may be  brought sooner into action
than it otherwise would be, if left entirely  to the nature of the consti-
tution; for I think I have seen cases where fever has  brought it into
action, when the disposition had been previously formed.  Like most
other diseases to which there is a susceptibility or disposition, we find
that any disturbance in the constitution  shall  call it forth—scrofula,
gout, and rheumatism are often called forth in this way.
   Having said, that the deeper-seated parts of the body come into ac-
tion later than those that are superficial, I shall now observe, that when
the lues venerea has been cured so far as only to remove  the first ac-
tions, but not to eradicate the disposition in the deeper-seated parts, as
has been explained, under such circumstances  of the disease it never
attacks again the external, or the parts that were first affected, but only
the deeper-seated parts, which are second in order of time.  The reason
is, that the deeper-seated parts had not been affected at the time of the
cure of the first.  The following cases, selected from a great number of
similar ones, will illustrate the doctrines we have laid down.
   In January, 1781, A. B. had connection with a woman, and two days
after perceived an.itching in the glans; at the  end of four days he
found  chancres upon  the prepuce.   He  took about twenty grains of
calomel, and then applied to a surgeon, under whose care he remained
three months, that is, till April.   He thought himself nearly well, and
went into the country, taking  a few pills with him, and at the end of
another month believed himself perfectly cured.  Three months after,
that is, in August, he caught cold, and had considerable fever, for which
James's powders were given.  Soon after this, spots of a copper-color
appeared upon his legs, and he had violent pains in his shin bones. By
the order of a country surgeon, he rubbed in about an ounce of mercu-
rial ointment, and had a slight spitting; the pain ceased, the spots dis-
appeared, and in a month he again conceived  himself to be well. This
was in October,  1781.   In June, 1782, he had the influenza; about a
fortnight  afterwards his left eye inflamed, and he had a pain in the
head, and a  noise in his ears.  Five days afterwards his throat became
sore.   Three weeks after the inflammation  of his eye, several pustules
made their appearance near the anus.   These symptoms remained till
the 21st of  August, when  he came into St. George's Hospital.  He
rubbed in strong mercurial ointment till his mouth became sore; he
sweated very much; the pain in his head remained; but the complaint
in his eye, and about the anus, together with the sore throat, were to-
tally removed.
  It appears that in this case some additional  power was required to
dispose the  body more  readily to exhibit venereal symptoms.  That 
CONSTITUTIONAL
SYPHILIS.
415
cold has a strong power of this kind we have allowed, which appears
in this case to have been the first immediate cause; but a fever seems
to have been equally effectual  in producing the  second return of the
symptoms.
   Here was the venereal  disposition in the constitution from April,
1781, the time he was cured of the local complaint, till June, 1782,
fourteen months after; and then it reappeared eleven months after that,
which periods might have been longer, if it had not been called forth
by the two circumstances of cold and fever.
   Let us consider how far this  case corresponds with the opinion of the
action being easier of cure than the disposition.   The first action, that
is, the chancres, were perfectly cured by the quantity of mercury he
took at first, for they never recurred; but the venereal matter had pro-
duced the disposition in the constitution, which was not cured by the
same quantity of mercury, for blotches appeared three months after;
but all the parts that had taken on  the disposition at that time had not
then come into  action, therefore only the parts which had come into
action were cured by the second course of mercury, and the other parts
which had not yet taken on the action went on with the disposition till
the influenza (which happened eleven months after) brought them into
action.  The first class of pocky appearances were  perfectly cured by
the second course of mercury, as the local had been cured by the first,
for they never reappeared, not even with the second.   The second set
of pocky symptoms, we have observed, appeared  to be perfectly cured
by the third course of mercury.  How far  there may be a third set of
pocky symptoms to come forth, time can only tell.
   This case farther proves, that sometimes the second set of symptoms
appear first, and the first second; and also shows the difference in times
between the first pocky appearances after the healing of the  local, and
between the  second appearance  of the symptoms after the healing of
the first.
   A gentleman  had a chancre in May, 1781;  in the  same month of
the next year, 1782, he had a  gonorrhoea; and in May, 1783, he had
a sore throat.  He had no connection with any woman from Septem-
ber,  1782, till May, 1783, which was about a fortnight before his throat
became sore, and had had  no immediate local complaints.
   When I saw the throat first,  I said it was not venereal; and he being
rather of a hectic habit, was desired to go to Bristol.  When at Bristol
an ulcer appeared at the root of the  uvula, which made  him immedi-
ately come back to London.   When I saw this  ulcer, I  said it was
venereal.  He now went through  what I supposed was a sufficient
course of mercury, and all the venereal symptoms  appeared to be
cured.1  He went into the country about the month of August, and
about the beginning of January, 1784, viz., four months after the sup-
posed cure, he felt a pain, together  with a swelling, in  his shin bones,
for which he went through a course of mercury,  which removed both
the pain and the swelling.

  1 I may remark here, that only the  venereal ulcer got well by the mercury; for the
former excoriation of the throat continued, but was afterwards cured by bark and
sarsaparilla. 
416              CONSTITUTIONAL SYPHILIS.
  In this case, we have  every reason  to suppose that the disposition
had taken place in the bones or their coverings, from the same cause
that affected the uvula; but the uvula suffered first, being of the first
order of parts.   Whether this was really the case or not, we must allow
that in the parts second in order, the disposition, and not the action,
did exist at the  time when the disease in the uvula came into action,
as also at the time when he went through a course of mercury sufficient
to cure the uvula; we must  also allow that the disposition was  not
removed by the quantity of mercury which was capable of removing
the disease in the uvula.  From all which I would draw the following
inferences in confirmation of the preceding doctrine; first, that  the
parts  about the throat are capable of assuming the action sooner than
the bones; secondly, it is probable that mercury can cure the action
only,  and not  the disposition; and  thirdly, that the venereal pus is
not present in the circulation  while the secondary actions take place:
for if it were, the parts  first in order would  stand an equal chance of
being again contaminated, and of coming into action a second time.
Supposing the venereal matter still  to exist in  the constitution after
the parts first thrown into  action are absolutely cured, so as to conta-
minate the parts that are second in order of action, we should certainly
have the parts first in order to take on the disease a  second  and even
a third time, and so on, while the second or third in order would be
going on and only coming into their  first  action; and therefore  we
might have those that are first in order, and those that are second  in
order, in action  at the same time.  This might  be carried still farther,
for as it is possible for the parts first in order of susceptibility to have
the disease a second time, while the  parts second  in order  are under
the influence of the first infection, those first in order may  be conta-
minated a second time from a new or fresh infection, which would be
a lues venerea upon a lues venerea,  a  case which  certainly may hap-
pen.  If the matter does really continue  in the constitution, it would
be natural to  suppose that the parts most easily affected by it would
remain so long  as the poison remained.  It may  indeed be alleged,
that parts which have already been  accustomed to this irritation, and
cured, are rendered by that means less susceptible of it.
   If the poison were still capable of circulating after its visible effects
were cured, then mercury given  in  the time of a  chancre  can be of
little service, as  it can only assist in the cure of the chancre, but cannot.
preserve the constitution  from infection,  which does not agree with
experience; for practice informs  us  that not one in fifty would escape
the lues venerea if the chancre were only cured locally;  so that mer-
cury  has the  power  of preventing a disposition  from forming, and
therefore is necessary to be given while we' suppose  absorption going
on, or while there is matter that may be absorbed.
   Mercury, prior to the action, will not remove the disposition, and of
course will not hinder the action coming on afterwards; however, it is
possible, and most probable,  that the medicine  while it is present will
hinder  the action  taking  place; so  that  no venereal complaints will
take place under the course  of mercury, although the parts may  be
contaminated. 
CONSTITUTIONAL SYPHILIS.
417
  This is not peculiar to the venereal disease, but  common to many
others;  and in some it may be reversed, for there are diseases whose
disposition can be cured, and therefore the  action prevented by such
medicines as would rather increase the action if given in the time of it.
  The parts first affected are more easily cured, according to our  pre-
sent method, than the parts second in order.  A part once perfectly
cured is never irritated again by the same  stock of infection, though
probably some other parts in the constitution are still under the vene-
real irritation.  If the facts stated  be just, the  circumstance of the
disease  appearing to leave the parts first attacked,  and attacking  the
secondary parts, is easily accounted for.  It is no more than the first
parts being cured while the secondary are not, and  of course going on
with the disease, the first remaining well.
  If this mode of accounting for these circumstances be just, it proves
two things; first, a former  assertion, that this disease, in the  form of
lues venerea, has not the power of contaminating parts not  already
under its influence, even in the same constitution;  secondly, that  the
venereal poison is not circulating in the blood all the time the disease
is going on in the constitution; so that, most probably, the poison only
irritates when just absorbed, and is  soon  expelled  or thrown  out in
some of the secretions.
  The above  account of the lues venerea may be reduced to the fol-
lowing  heads:—
  First, that most parts, if not all, that are affected in the lues venerea,
are affected with the venereal irritation at the same time.
  Secondly, the parts exposed to cold are the first that admit the vene-
real action; then the deeper seated parts, according to their suscepti-
bility for such action.
  Thirdly, the venereal disposition, when once formed in a part, must
necessarily go on to form the venereal action.
  Fourthly, that all parts of the body, under such disposition, do not
run into action equally fast, some requiring six or eight weeks, others
as many months.
  Fifthly, in the parts that come first into action, the disease goes  on
increasing  without wearing itself out, while those  that are second in
time follow the same course.
  Sixthly, mercury  hinders  a disposition from forming, or, in other
words, prevents contamination.
  Seventhly, mercury does not destroy a disposition already formed.
  Eighthly, mercury hinders the action from taking place, although
the disposition be formed.
  Ninthly, mercury cures the action.
  These principles being established, the facts respecting the cure are
easily accounted for.
27 
418
CONSTITUTIONAL SYPHILIS.
                      CHAPTER  II.

         OF THE SYMPTOMS  OF THE LUES VENEREA.

   When the venereal matter has affected the constitution in any of
the ways before  mentioned, it has the whole body to work upon, and
shows itself in a variety of shapes; many  of which putting on the
appearance  of a different disease, we are often obliged to have recourse
to the preceding  history of the case before we can form any judgment
of it.  Probably, the varieties in  the appearances  may be  referred to
the three following circumstance:  the different kinds of constitutions,
the different kinds  of solids affected,  and  the different dispositions
which the solids  are in at the time; for I can easily conceive that a
peculiarity of constitution may make a very material difference in the
appearance  of the same specific complaint; and I am certain that the
solids, according to their  different natures, produce a very different
appearance when attacked with this disease; and I can also easily con-
ceive that a different disposition from the common in the solids at the
time may make a considerable difference in the appearances.
   The difference  of constitution,  and of the same parts  at different
times, may have  considerable effects in the disease with respect to its
appearing sooner or later.   This  I  am certain of, that  the different
parts of  the body produce a  very considerable difference  in the times
of appearance  of this disease.  That it appears much sooner in some
parts than in others, is best seen where different parts are affected in
the same person; for I have already endeavored to show that it is most
probable that all the parts affected  are contaminated nearly at the same
time.  This  difference in the times is  either owing to some parts being
naturally put into action more easily by the poison than others, or they
are naturally more active in themselves, and therefore, probably, will
admit more  quickly the action of every disease that is capable of affect-
ing them.
   When on the general history of the lues  venerea, I divided the parts
into two orders,  according to the time of their appearance.  I also
observed that the first were commonly the external parts, as the skin,
nose, tonsils; and that the second were more  internal, as the bones,
periosteum,  fascias, and tendons.
  The time necessary for its appearance, or for producing its local
effects in the several parts of the body most readily affected, after it
has got into the constitution, is uncertain, but in general it is about six
weeks; in many cases, however, it is much later, and in others much
sooner.  In  some cases, it appears to  produce its local effects within a
fortnight after the possibility of  the absorption of the matter. In one
case a gentleman had a chancre, and a swelling in the groin came on, 
SYMPTOMS.
419
and within the before-mentioned  time he had venereal eruptions all
over the body.  He could not impute this  to any former complaint,
yet there is  a possibility of its having  arisen from the first mode of
catching the disease, by simple contact, at the time he got the local
infection or chancre, which might extend the time to a week or more,
although this is not  probable.  In another case, three weeks after the
healing of a chancre, eruptions broke out all over the body, and this
happened only a fortnight after leaving off the course of mercury that
cured the  chancre.  The  effects on other parts of the body,  that are
less  susceptible of this irritation, or are  slower in their action, are of
course much later in appearing; and, in those cases where  both orders
of parts are contaminated, it is in general not till after the  first has
made its  appearance for a considerable time, and even, perhaps, after
it has been, cured; for while the parts first in order of action were con-
taminated  and under cure, the second in order are only in a state of
contamination, and go on with the disease afterwards, although it may
never again appear in the first.
  From this circumstance of the parts second in order coming later
into action we can plainly see the reason why it shall appear  in them,
although the first in order may have been cured; for if the  external
parts, or first in order, have been cured, and the internal, or second,
such as the tendons, bones, periosteum, &c, have not been cured, then
it becomes confined solely  to  these parts.  The order of parts may
sometimes be inverted; for I have seen cases where the periosteum, or
bone, was affected prior to any other part.  Whether in the same case
it might in the end have affected the skin or throat I will  not pretend
to say, as it was not allowed to go on; but it is possible that the second
order of parts may be affected without the first having ever been con-
taminated.
  Its effects  on the deeper-seated parts are not like those  produced in
the external, and the difference is so remarkable as to give the appear-
ance of another disease;  and a person accustomed to see it in the first
parts only would be entirely at a loss about the second.
  The parts  which come first into action go on with  it, probably on
the same principle, much quicker than the others; and this arises from
the nature of the parts, as has already been observed.
  Each succeeding part that becomes affected is slower and slower in
its  progress, and more fixed  in  its symptoms when  produced; this
arises also from the natural disposition of such parts, all their actions
being slow, which indolent action may be assisted by the absence of
the  great  disposing cause,  that is, cold.  I should, however, suspect
that warmth does not  contribute much to their  indolence of action;
for if it  did it would assist in  the cure, which it appears not to do,
these parts being as slow in their operations of restoration as they are
in their actions of disease.   We may also observe that similar parts
come sooner  into action, and appear to go on more rapidly with it, as
they are nearer the source of the circulation.  It appears earlier on
the face, head, shoulders, and breast than on the legs, and the erup-
tions come sooner to suppuration in the before-mentioned  parts.1
1 See Introduction. 
420
CONSTITUTIONAL  SYPHILIS.
  The circumstance of its being very late in appearing in some parts,
when it had been only cured in its first appearances, as mentioned, has
made many suppose that the poison lurked somewhere in the solids;
and others that it kept circulating in the blood for years.
  It is not, however, easy to determine this point; but there can be no
good reason for the first hypothesis, as the lurking disposition never
takes place prior to its  first appearance; for instance, we never find
that a man had  a chancre a twelvemonth  ago, and that it broke  out
after a year in venereal scurfs upon the skin, or ulcers in the throat.
The slowness of its progress is only when the parts less susceptible of
its irritation have been affected by it.
  [Ricord.—It has already been apparent, from the divisions which
I admit of syphilitic symptoms into primary, successive, secondary, and
tertiary, that my views coincide almost entirely with Hunter's.  Yet
there are some points  of difference which I consider important, and to
which I would for a moment call the reader's attention.  Thus, it ap-
pears to me that the  order of succession, and the almost undeviating
time of appearance of the different groups of syphilitic symptoms, are
subject  to less variable laws than Hunter  seems to think.  For exam-
ple, a primary ulcer is  never preceded by secondary symptoms, and
still less by tertiary.  Yet some apparently contradictory cases seem
to militate in favor of Hunter's opinion in opposition to the doctriue
which I  lay down as  absolute.   But these cases, if well analyzed, are
not contradictory in fact; they are so only in appearance, and simply
in consequence of the mode in which they are explained.
  When a person contracts a chancre for the first time, which becomes
indurated, if no treatment be employed, this chancre may, from its first
appearance, give rise to successive symptoms, that is, to other chancres
in the neighborhood by direct inoculation, and to primary infection of
the lymphatics connected with it, by absorption; it may also  be fol-
lowed by secondary symptoms as early as the third week of its dura-
tion, rarely earlier, and more frequently after the sixth week; and,
finally, always supposing that  the disease be left  to itself,  tertiary
symptoms will be developed generally by  the end of six months, sel-
dom earlier and commonly later.  Each of these  phases which we
have described  may  last a longer or shorter time.  The preceding
series of symptoms may have disappeared  before the succeeding series
is developed; or, on  the contrary, the primary symptoms may still
remain  on the appearance of secondary symptoms, or tertiary symp-
toms supervene during the  course of the latter.
  It is  rare, however, for the primary ulcer to last long  enough for
tertiary symptoms to  be developed.
  In the order of cessation, the primary symptoms will generally dis-
appear first; next, the secondary symptoms, and, finally, the tertiary.
Yet, as a cure rarely takes  place spontaneously, frequent inversions in
the above order will occur,  depending on the efficacy of treatment,
and its seasonable application to one order of symptoms rather than
another; thus, secondary symptoms may disappear while the primary
ulcer still  remains, and  tertiary symptoms may yield to treatment
which the secondary have resisted.   Again, each  series of symptoms 
SYMPTOMS.
421
may be repeated an indefinite number of times, independently of the
preceding or subsequent series.  So  that one  patient will contract  a
new chancre  while  he has symptoms of constitutional syphilis, and
another repeatedly have secondary symptoms during the continuance
or after the disappearance of tertiary; to careless observers, there may
thus be an apparent inversion.
  But the most fruitful source of error is the effect produced by treat-
ment.  Thus, treatment directed against the primary ulcer may en-
tirely  anticipate secondary symptoms,  or  diminish  their intensity,
modify their form, or retard the time of  their appearance.
  The same  treatment also which modifies the  secondary symptoms
and keeps them under its influence so long as its action lasts, may not
have the least prophylactic effect on  the tertiary  symptoms, which are
then developed during  its administration, and may still be followed by
secondary symptoms  in case the treatment  which prevented their
appearance  be suspended  too soon.  And, finally, though treatment
produces this result more frequently than  any other cause, and  its
influence is more evident and easily recognized, yet if we  take the
trouble to analyze facts, we shall find that certain casual hygienic cir-
cumstances and preceding or  concomitant pathological conditions may
also have the same effect.
  In conclusion, if, to the above, we  add those cases in which patients
deceive themselves, or intentionally deceive their physicians, and if we
lay aside, as  should be done  at  the present day, the apocryphal cases
of non-consecutive  constitutional syphilis, then  the order which we
have established in the succession of symptoms  and the time of their
appearance will remain as a general rule, to which there is, perhaps, no
exception that cannot  be explained.—Ricord.]


       § 1. Of the Symptoms of the first stage of the Lues Venerea.

   The first symptoms of the  disease, after absorption, appear either on
the  skin, throat, or mouth.   These differ from one another according
to  the nature of the  parts affected.  I shall, therefore,  divide them
into two kinds, although there appears to be no difference in the nature
of the disease itself.
   The appearance on  the skin I shall call the first, although it is not
always the first appearance;  for that in the throat is often as  early a
symptom as any.  The appearances upon the skin generally show them-
selves in every part of the body, no part being more susceptible than
another, first in discolorations, making the skin appear mottled, many
of them disappearing, while  others  continue and  increase with the
disease.1
   In others,  it will come on in distinct blotches, often not observed till
scurfs are forming;  at other times, they appear in small distinct inflam-
mations, containing matter, and resembling  pimples, but not so pyra-
midal, nor so red at the base.
   Venereal blotches at their  first coming out, are often attended with

     1 This is not peculiar to this disease ; it often takes place in the smallpox. 
422              constitutional syphilis.
inflammation,  which gives them a  degree of transparency, which I
think is generally greater in the summer than in the winter, especially
if the patient be kept warm.   In a little time this inflammation disap-
pears, and the cuticle peels off in the form of a scurf.  This sometimes
misleads the patient and the surgeon, who look upon this dying away
of the inflammation as a decay of the disease, till a succession of scurfs
undeceive them.
  These discolorations of the cuticle arise from the venereal irritation,
and are seldom to be reckoned a true  inflammation, for they seldom
have any of its characteristics, such as  tumefaction and pain; but this
is true only on those parts most exposed, for in parts well covered, and
in parts constantly in contact with other parts, there is more of the
true inflammatory appearance, especially about the anus.
  The appearance of the parts themselves next begins to alter, forming
a copper-colored  dry inelastic cuticle,  called  a scurf;  this is thrown
off, and new ones are formed.   These appearances spread to the breadth
of a sixpence or shilling, but seldom broader, at least for a considerable
time, every succeeding scurf becoming thicker and thicker, till at last
it becomes a common scab, and the disposition for the  formation of
matter takes place in the  cutis under the scab, so that at last it turns
out a true ulcer, in  which state it commonly spreads, although but
slowly.
  These appearances arise first from the gradual loss of the true sound
cuticle, the diseased cutis  having lost the disposition to form one; and,
as a kind of substitute for  this want of cuticle, an exudation takes place,
forming a scale, and afterwards  becoming thicker, and  the matter ac-
quiring more consistence, it at last forms a scab; but  before it has
arrived at this stage the cutis has given way, and ulcerated,  after which
the discharge becomes  more of a true pus.  When it attacks the palms
of the hands and the soles of the feet,  where the cuticle is thick, a
separation of the  cuticle takes place, and it peels off; a new one is im-
mediately formed, which also separates, so that a series of new cuticles
takes place, from its not  so readily forming scurfs as on the common
skin.  If the disease is confined to those parts it becomes more difficult
to determine whether or  not it be venereal, for most  diseases of the
cutis of these parts produce a separation of the cuticle attended with
the same appearances in all, and having nothing characteristic of the
venereal disease.
   Such appearances are peculiar to that part of the common skin of
the body which is usually exposed ; but when the skin is opposed by
another skin which keeps it in some degree more moist, as between the
nates, about the anus, or between the scrotum and the thigh,  or in the
angle  between the two thighs, or upon the  prolabium of  the mouth,
and in the armpits,  the eruptions never acquire the above-described
appearances, and  instead of scurfs and  scabs we have the skin  elevated,
or, as it were, tumefied by the extravasated  lymph into a  white, soft,
moist, flat surface, which discharges a white matter.  This may perhaps
arise from  there being  more warmth, more perspiration, and  less eva-
poration, as well  as from the skin being thinner in such places.  What
strengthens this  idea still more is, that in many venereal patients I 
SYMPTOMS.
423
have seen an approach towards such appearances on the common skin
of the body ; but this has been on such parts as were covered with the
clothes, for  on those parts of the skin that were  not covered  there
was only the flat scurf; these, however, were redder than  the above-
described appearances, but hardly so high.
   How far this is peculiar to the venereal disease, I know not.  It may
take place in most  scurfy eruptions of the skin.  From a supposition
of this not being venereal, I have destroyed them at  the side of the
anus with a caustic, and the patient has got well; however, from my
idea of the disease,  that every effect from the constitution is truly local,
and therefore may  be cured locally,  a cure effected by this  treatment
does not determine the question.
   This disease, on  its first appearance, often attacks that part of the
fingers upon which the  nail is formed, making that surface red which
is seen shining through the nail, and, if  allowed to continue, a sepa-
ration  of the nail  takes place, similar to the  cuticle in the before-
described symptoms; but here there cannot be that regular succes-
sion of nails as there is of cuticle.
   It also attacks the superficies  of the  body which is covered with
hair, producing a separation of the hair.   A prevention of the growth
of young hair is also the consequence while the disease lasts.
   [G. G. B.—The variety of venereal eruptions is so great as almost to
baffle description.  Hence, pathologists have usually contented them-
selves with fixing on some one characteristic which was generally appli-
cable, and have neglected any attempt at distinct  classification, or more
accurate and detailed delineation.  Thus, the copper color has been
assigned by some, and the circular form by others, as the distinguish-
ing character.  Yet these general tests tend only to mislead, since the
first is wanting in many species of venereal eruption, and the second is
shared also by the great majority of eruptions which are not venereal.
   It must be confessed, that in the present  state of our knowledge it
would be impossible to produce  a complete history of every form  of
venereal eruption.   There are  many sorts which are so indistinct and
uncertain in their character  that it would be difficult to  find their
proper place in any arrangement, and equally difficult to point out any
constant and invariable signs by  which they may be always identified.
Yet the  species of  eruption which are of most frequent occurrence,
and which are in practice of the greatest importance,  are sufficiently
distinct to  admit of classification ; and it is obvious that a clear his-
tory of the aspect and course of  these more common  forms of  erup-
tion must greatly elucidate the whole subject, and ultimately facilitate
the knowledge of those other varieties which are not included in the
list.
   The mottled  state of the  skin, to which allusion is made by the
author, is certainly  found in venereal cases.  Yet a similar appearance
is often seen in cases where no venereal  cause can be assigned; nor
does there seem to  be any peculiarity by which the one case can be
distinguished from the other.  It may be doubted whether this mottled
color denotes more than an irritability of the skin, and a general dis-
position to eruptive disorders. 
424
CONSTITUTIONAL SYPHILIS.
  The more  distinct sorts of venereal eruption may be divided into
the following classes:—
  1. Tubercles.—The original seat of the tubercle is probably in the
sebaceous glands, certainly in some  structure which is  below the sur-
face of the cutis.  This is sufficiently evident  from its aspect at the
period of its commencement.  It appears, in  the first instance, as a
small hard substance like a pea, which may be felt by the finger before
there is sufficient discoloration to attract the notice  of the eye.  At
this period, the eruption is scarcely discernible if the light falls directly
on the part, though if it is viewed  by a side-light the  prominence is
sufficient to cast a distinct shadow.   However, this stage  is of short
duration; the inflammation soon reaches the surface, and the spot then
wears the appearance of a small red elevation, evenly rounded on the
surface.  In  the next place, the cuticle  dies,  and becomes  detached
from the cutis; but it  usually remains for a  time, forming a horny
cap, which covers the  surface, and protects the formation of a new
cuticle beneath.  In this state, it frequently resembles a large vesicle;
but the appearance is deceptive.  If the dead  cuticle be removed by
a probe, not a particle of fluid will be found under it.
  The tubercle may remain in this state with little change, except that
it slightly enlarges, and  that successive layers of cuticle  desquamate
from the surface.  But it often happens  that it goes  on to ulceration.
In such cases, the ulcer always commences at a central point, which is
slightly depressed, and may be distinctly seen on the first  removal of
the cuticle, and which appears to be the orifice of the sebaceous duct.
As the ulcer proceeds, it usually destroys the  centre of the tubercle
only, and leaves an indurated and elevated portion, by  which it is en-
circled and separated from the  sound skin.  In the progress of the
ulcer, this tubercular thickening continues to precede it, so that there
is always  a  margin of red  induration, more  or less marked, as the
powers of the system are greater or  less; frequently of considerable
breadth in those who are strong and vigorous, but in the feeble often
so slight as to  be scarcely distinguishable; yet in all cases leaving, as
it subsides, the peculiar brown stain, which is the chief characteristic
of the tubercle.
  It is from this stain that the tubercle has received the appellation of
the copper blotch.  The hue varies  with the age and the  progress of
the eruption.   In the earliest stages, it differs in nothing from that of
common inflammation, and  is effaceable, or nearly so, on  pressure.
But in a short time a yellow  or copper tinge is blended  with the florid
red, and gives it a peculiar brightness, the cause of which is made evi-
dent by passing the finger over the spot.  The vessels are thus emptied
for the moment, and the florid arterial color disappears;  but the yellow
or copper stain remains unchanged, and is shown to depend  on some-
thing which  has been effused on the surface, and  which cannot be
removed by pressure.   While  the  tubercle  is stationary the color
becomes deeper, and more yellow, but retains much of  its  brightness;
but as the  disease is subdued, and as the tubercular thickening sub-
sides under treatment,  the copper tinge gradually fades  away, and
gives place to a dirty brown.  Though the hue is changed, the stain 
SYMPTOMS.
425
remains equally indelible, even at a time when all elevation has  dis-
appeared, and  the spot is on the same level  with  the  surrounding
skin.   There is still a later stage, at which this brown stain gradually
fades away, and the seat of the spot is altogether undistinguishable.
  This peculiar stain is not found in all forms of venereal eruption;
it seems to be confined to the varieties of the tubercle;  and  there is
reason to think that its exact nature and cause might be ascertained
if we had a fuller  acquaintance with the causes of the general color
of the skin, and with the functions of the sebaceous glands.
  2. Lichens.—This eruption consists of small acuminated pimples, of
a red color, which are sometimes evenly scattered over the surface, at
other times arranged in patches.  It is not correct to characterize this
eruption, as has been sometimes done, by the absence of  suppuration.
Many of the papulae imperfectly suppurate; that is,  a small quantity
of opaque serum is effused under the cuticle at the apex, and this serum
soon becomes purulent; but the pus never accumulates; in a few days,
the greater part is absorbed; the rest dies into a small scab; and when
this scab falls off, no ulcer, or  depression, or  cicatrix, is left behind.
The pus is effused from the surface of the cutis, and  is altogether un-
attended by ulceration.
  Lichens  differ much  in the size of the papula and  the  depth of the
color; but they have one character which is very generally  present,
and which is shared by no other venereal eruption.  They  tend to
pass spontaneously through their successive stages, and  then sponta-
neously  to subside.  In  other venereal eruptions, the course of the
disease in the skin is a test of the course of the disease in the general
system.  A diminution in the eruption argues an improvement in the
affection of the  constitution.  In lichen, on the contrary, the color may
fade, and the elevation diminish, at a time when other symptoms  are
continuing to increase, and even when a fresh crop of lichen is appear-
ing.  Hence, the same case  frequently presents specimens  of every
stage of  this eruption,  from the first rise of the small papula, before
maturation has taken place, to  the period when all elevation has sub-
sided,  and  the  seat of the spot is marked only by a pale or purple
discoloration of the skin,  which is  effaceable  by the pressure of the
finger.  This progress towards recovery, which often occurs sponta-
neously, may be very  readily produced by remedies which are alto-
gether inadequate  to cure the disease, especially if they are exhibited
when  the  eruption has run  through its  natural periods, or  about a
fortnight or three weeks from the date of  its appearance.
  Yet this natural tendency to pass off is subject to exceptions.  It
sometimes  happens that the small papula continues slowly but steadily
to enlarge, and  at length attains the size, and assumes the  copper stain,
and all the other characters of the tubercle.  A close  examination
shows the  mode in  which this change takes  place. The lichenous
papula is situated on  one of those small elevations  on the surface of
the  cutis which mark the orifices of the ducts that perforate the cutis,
and-proceed to  the glands  which are situated beneath it.   The inflam-
mation, which began on the surface, gradually extends down the duct,
and involves the sebaceous gland which is at the bottom.   This tuber- 
426
CONSTITUTIONAL SYPHILIS.
cular lichen is not so much a peculiar form of lichen as an eruption
of lichen passing into an eruption of tubercles, by a process which is
very easily understood.  In such cases, the subsequent course and the
treatment are exactly those of the tubercle.
  Most forms  of lichen present no indelible stain.  But  where the
eruption has been unusually  lasting there will be seen, after the sub-
sidence of the papula, a brown stigma, occupying a central point, and
commonly presenting  an appearance  of depression or pitting.   This
appearance  is, however, in almost  all cases, delusive.  It arises from
the stain being situated deep in the substance of the cutis, and shining
through the more superficial  parts, which are transparent.   These stig-
mata seem to  characterize an earlier and more imperfect form of the
preceding variety.  There has been an attempt  to form a tubercle;
but the complaint has been arrested before the sebaceous gland has
been fully involved.
  3. Psoriasis and Lepra.—Scaly eruptions are very common in vene-
real cases;  but they differ little from those which occur from other
causes.   They appear generally in  small circular spots, but they vary
much in the degree of elevation, the size of the spot, and the depth of
the color; yet they never assume  the copper tinge of the tubercle.
The color is rather sandy, and  is in almost all instances nearly efface-
able by pressure.  The difference  of color, the superficial origin of
these eruptions, and the total absence of  ulceration, in all  forms and
stages, sufficiently distinguish them from tubercles.
  4. Rupia.—This eruption  shows itself at first  by a slight blush on
the surface.   Generally in a few hours, sometimes at a longer period,
the cuticle at  this part is elevated  into a  small blister, by the effusion
of opaque serum, which soon becomes purulent, and shortly afterwards
concretes into a scab.   The disease spreads by a process in all respects
similar.  Effusion takes place under the cuticle at the edge, and the
concretion of this effusion enlarges the diameter of the scab, and ele-
vates it from  the surface of  the cutis.  Hence the scab, as it  grows,
consists of a series of concentric layers, those towards the apex having
been formed at the commencement of the disease, and being conse-
quently small in size; those at the base, which have been formed by
the latest effusion, being commensurate with the present size of the
sore.   The accumulation of  the  whole forms a  cone, which projects
like a horn  when the extension of  the ulcer has been slow; but has a
wide base, and comparatively a slight projection, where the ulcer has
rapidly enlarged.
   That rupia begins on the surface of the cutis  is manifest, not only
from the course of the ulcer, but also from the aspect of the cicatrix
which it leaves.  The sore most frequently heals first at the centre, an
island of skin forming there while the edges are still stationary, or even
spreading;  and this is an occurrence which is known to be extremely
rare in ulcers  which have destroyed  the whole substance of the cutis.
Again, after the sore has healed,  the surface of the cicatrix, especially
near the edges, often presents distinctly to the eye the minute points
that mark the  ducts which  perforate the cutis, and which  must have
been destroyed  if the whole thickness of the cutis had been involved. 
SYMPTOMS.                       427
  Some cases of ulcerating tubercles closely resemble rupia; but in
rupia there is neither tubercular thickening nor copper stain.  When
these exist at the edges of the sore,  the  eruption is not rupia, but
tubercle, passing rapidly into  ulceration.  In such cases, the spots
which resemble rupia will generally be found intermixed with distinct
tubercles, and the treatment required will be that which is adapted to
the tubercle.
  All pustular venereal eruptions  seem to partake of the characters
which belong to rupia, as far as the superficial origin, the mode of ex-
tension, and  the accumulation  of the crust, are concerned;  but they
differ much in the degree of inflammation which precedes the formation
of matter, and the size of the original pustule.  In genuine rupia, the
vesicle is preceded only by a slight blush of inflammation, and at its
first appearance  is nearly of the size of a silver penny.  But it often
happens that the inflamed spot is smaller, and somewhat more elevated,
and that the  fluid effused  is purulent from the first, and forms imme-
diately a small scab at the top of the eminence.  Such a spot resembles
a common pustule, and the small size of the scab, and the slowness of
its progress, give it  an appearance which is not readily recognized as
that of  rupia. Yet it is difficult to point out any essential difference;
and if the ulcer be allowed to increase, the aspect in the more advanced
stages will be precisely similar.  The description, therefore, which has
been given may  be taken as applicable to pustular venereal eruptions
in general, if not in all the minuter details, at least in the prominent
and essential characters.
  It must not be forgotten that this classification of venereal eruptions
is intended to include the principal varieties only, and that other forms
of eruption occur which are less frequent  and less distinctly marked,
but  which yet, from the history of the case, and the accompanying
symptoms, must be referred to a venereal origin.—G. G. B.]
  The second part  in which it appears is  most commonly the throat,
sometimes the mouth and tongue.   In the  throat, tonsils, and inside of
the mouth, the disease generally shows itself  at once, in  the form of
an ulcer, without much previous tumefaction, so that the tonsils are
not much enlarged; for, when the venereal inflammation attacks these
parts, it appears  to be always upon the surface, and it very soon ter-
minates in an ulcer.
  These ulcers in the throat are to be carefully distinguished from all
others of the same parts.  It is to be remarked that this disease, when
it attacks the throat, always, I believe, produces an ulcer, although this
is not commonly understood; for, I have seen cases where no ulcera-
tion had taken place called, by mistake, venereal.  It is, therefore, only
this  ulper that is to be distinguished from other ulcers of  these parts.
This species of ulcer is generally tolerably  well marked; yet it is, per-
haps, in all cases not to be distinguished from others that attack  this
part, for some have the appearance of being venereal, and  what are
really venereal resemble those that are not.  We have several diseases
of this part which do not  produce ulceration  on  the  surface, one of
which is common inflammation of the  tonsils,  which often suppurates
in the centre, forming an abscess, which bursts by a small opening, but 
428
CONSTITUTIONAL  SYPHILIS.
never looks like an ulcer begun upon the surface, as in the true vene-
real; this case is always attended with too much inflammation, pain,
and tumefaction of the parts to be venereal;  and if it suppurates  and
bursts it subsides directly, and it is generally attended with other in-
flammatory symptoms in the constitution.
  There is another disease of  these parts, which is an indolent tume-
faction of the tonsils, and is peculiar to many people whose constitu-
tions have  something of the scrofula in them, producing  a thickness
in the speech.  Sometimes the coagulable lymph  is thrown out on the
surface, and called by some ulcers, by others sloughs, and such are
often called putrid sore throats.  Those commonly swell to too large a
size for the venereal; and this appearance is easily distinguished from
an ulcer or loss of substance;  however, where it is  not plain at first
sight it will be right to endeavor to remove some of it; and if the sur-
face of  the tonsil is not ulcerated, then we may be sure it is not vene-
real.  I have seen a chink filled with this, appearing very much like
an ulcer, but upon removing the coagulable lymph  the tonsil  has ap-
peared perfectly sound.   I have seen cases of a swelled tonsil where a
slough formed in its centre,  and that slough has opened a passage out
for itself, and when it has been, as it were, sticking in this passage, it
has appeared like a foul ulcer.
  The most puzzling stage of the complaint is when the slough is come
out, for then it has most of the characters of the  venereal ulcer;  but
when I have seen the disease in its first stages I have always  treated
it as of the erysipelatous kind, or as something of the nature of a car-
buncle.
  When I have seen them in their second stage only I have been apt
to suppose them venereal; however, no man  will be so rash as to pro-
nounce what a disease is from the eye only, but  will make inquiries
into all the circumstances before he forms a judgment.  If there have
been no preceding local symptoms within the proper date, he will sus-
pend his judgment, and wait a little to see how far Nature is able to
relieve herself.   If there has been any preceding fever, it will  be still
less probable  that  it is venereal.  However, I will not say of what
nature such cases are, but only that they are  not venereal  as they are
often believed to be.  I have seen a sore throat of this kind mistaken
for venereal, and mercury given till it affected the mouth, which, when
it did, it brought on a mortification on all the parts concerned in the
first disease.  It would therefore appear that this species of the sore
throat is aggravated by mercury.
  There is another complaint of those parts  which  is often taken for
venereal, which is an ulcerous excoriation, where the ulceration or ex-
coriations run along the surface of the parts, becoming very broad, and
sometimes foul, having a regular  termination, but never going deep into
the substance of the parts, as the venereal ulcer does.   There is  no part
of the inside of the mouth exempted from this ulcerous excoriation,
but I think it is most frequent  about the root  of the uvula, and spreads
forwards along the palatum  molle.  That such are not venereal is evi-
dent, from their not giving way in general to mercury; and I have seen 
SYMPTOMS.                       429
them  continue for weeks without altering, and a true venereal ulcer
appear upon the centre of the excoriated part.
  The difference between the  two is  so strong that there can be no
mistake; patients have gone through a course of mercury which has
perfectly cured the venereal ulcers,  but has had no effect upon the
others, which have afterwards been cured by bark.
  The true venereal ulcer in the throat is perhaps the least liable to
be mistaken of any of the forms of  the disease.  It  is  a fair loss of
substance, part being dug out, as it were, from the body of  the tonsil,
with a determined edge, and is commonly very foul, having thick white
matter adhering to it like a slough, which cannot be washed away.
  Ulcers in such situations are always kept moist, the matter not being
allowed to dry and form  scabs, as in those upon the  skin; the matter
is carried off the ulcers by deglutition or the motion of the parts, so
that no succession of scurfs or scabs can take place, as on the  skin.
  Their progress is also much more  rapid than on the common skin,
ulceration taking place very fast.
  Like most other spreading ulcers, they are generally very foul, and,
for  the most part, have  thickened or  bordered edges, which  is very
common to venereal  or  cancerous sores; and, indeed, to most sores
which have no disposition to heal, whatever the specific disease may be.
  [G. G. B.—There is as great a variety in venereal sore throats as in
venereal eruptions, and, from the situation of the part, the distinguish-
ing characters are, on the whole, less easily observed.   Yet some of the
principal species  are sufficiently distinct to be noticed.
  1. The most genuine form of venereal sore throat  appears to begin
in the centre of the tonsil.  In the early stages it is attended with very
little  pain or swelling, and is seldom observed until it has formed a
distinct ulcer. But if attention  is from  any cause directed to the throat,
an earlier appearance may sometimes be discovered.   The tonsil may
be found slightly swelled, and a yellow appearance may be seen occu-
pying the substance of that part, and shining through the membrane
on the surface which is yet entire.  In  a  day or two ulceration takes
place, and discloses a yellow or whitish slough, penetrating deep  into
the centre of the tonsil.  There is little  enlargement, and the surround-
ing parts are not violently inflamed.  There  is some sense of pricking,
especially at  the  time of swallowing;  but there is  on the whole less
difficulty of deglutition,  and less uneasiness than might be expected
from the magnitude and appearance of the ulcer.  As it  spreads, how-
ever,  the surrounding parts become involved, and  then it occasions
more  distress.  The voice is altered, the hearing is rendered dull, and
the inflammation of the soft palate impedes  deglutition.  Yet on the
whole the progress is slow, and there is little accompanying  disorder
of the general system.
  This species of sore throat often attends tubercular eruptions on the
skin.   There is  reason  to suppose that the  secretion of the tonsils  is
analogous to that of the sebaceous  glands of the skin, and hence  it
naturally happens that both parts are attacked simultaneously.
  2. Venereal sores often commence  on the surface of the mucous
membrane, by a small foul ulceration, which passes at an early period 
430
CONSTITUTIONAL  SYPHILIS.
into rapid and extensive sloughing.   These ulcers are not limited to
the membrane covering the tonsils, but may arise on the soft palate
or any part of the pharynx, and are most frequently found immediately
behind one of the posterior arches, or at the upper and back part of
the pharynx, where the early appearance  is concealed by the velum
pendulum and  uvula.   They *are sometimes  preceded and  always
accompanied by much  pain and  inflammation.   The soft palate is
swelled and very pendulous, and the attempt to raise it in swallowing
is attended with excruciating pain.  In speaking,  it seems to be abso-
lutely quiescent.   The irritation of the tumid velum  and the slough
excites a profuse secretion of saliva, and frequently much cough.  The
great distress which is thus occasioned produces a  remarkable  anxiety
of countenance, which, conjoined with rapid emaciation, an accelerated
pulse, and expectoration  of a  puriform character, gives  the  patient
the aspect of considerable danger, and often suggests the idea that he
is laboring  under phthisis.  The  ravages  committed  by these ulcers
are very extensive.  The bone  at the  back part  of the nares is fre-
quently laid bare, and the disease proceeds to the destruction of the
nose; and it occasionally occurs that the bodies of the vertebras are
exposed, and affected with fatal caries.
 ■  At other times, especially in cases of long standing, these sores shall
extend, not by sloughing, but by rapid ulceration.  The aspect is less
formidable, but the progress is scarcely less destructive.  This variety
is most commonly seen on the soft palate.  The surface is foul, but the
slough which occupies it is of little depth.  The  sore is edged by a
very narrow fringe of yellow slough, and beyond this, for the extent
of a quarter of an  inch, there is an inflamed margin of a deep crimson
color;  but there is  not much general swelling of the surrounding parts.
Yet the  sore, extends daily with extraordinary  rapidity.   The  sub-
stance  of  the part seems to melt away under the ulceration, and  the
greater part or the whole of the soft palate is often destroyed before it
can  be arrested, though no distinct  slough can be seen  to separate
through the whole of its course.
   These ulcers frequently accompany rupia.
   3. A third appearance, which is shortly described by John Hunter,
under the name of an ulcerous excoriation, is of very common occur-
rence.   It is distinguished by the opaque white color of the  surface.
This appearance sometimes  supervenes at the edges of an ulcer on the
tonsil.  More frequently there is no ulceration, but simply this change
of the surface, accompanied by more or less of redness, and, as  it were,
of excoriation of the neighborhood, more or less swelling of the mem-
brane,  much soreness, but very little pain.   This  superficial affection
may attack any part of the tonsils, arches of the palate, velum pendu-
lum, and  uvula, and even the tongue or the inside of the cheeks.  It
is very frequently  to  be  seen  at the  angles of the mouth.   It often
occupies the soft palate, spreading  upwards in a semicircular form
towards the roof of the mouth. The white appearance may be removed
by slightly touching it with caustic, and then the surface beneath looks
as if excoriated.
   This complaint very often accompanies psoriasis of the skin, and it 
SYMPTOMS.
431
is reasonable to suppose that the white color which peculiarly charac-
terizes it implies a change analogous to that which shows itself on the
surface of the body in thickening of the cuticle, and scaliness.
   The author seems to be of opinion that this affection is never vene-
real ; but cases occur where it exists in union with other venereal symp-
toms, and where it  is only ultimately, cured by the use of mercury.
Yet it cannot be denied that, in the  majority of cases, it is not vene-
real ;  that very often mercury aggravates instead of removing it; that
it may take  place where there is no suspicion of syphilis in patients
laboring under psoriasis or lepra; and that, in general, the presumption
is so far against its venereal origin that the treatment should be rather
directed  to  the regulation of the diet, and to the prevention of acid
secretions in the stomach, than to the extirpation of the venereal virus.
The complaint is in this respect also analogous to scaly diseases of the
skin.  Both  affections depend most  usually on causes which are not
syphilitic; nor do there appear to be any signs in the aspect of either
by which the syphilitic can  be distinguished from  the non-syphilitic
cases.
   There are other forms of sore throat which are less important, and
of which it is less easy to convey an idea by description.—G. G. B.]
   When it attacks the tongue it sometimes produces a thickening and
hardness in the part; but this is not  always the case, for it very often
ulcerates, as in the other parts of the mouth.
   They are generally more painful than  those of the skin, although
not so much so as common sore throats arising from inflamed tonsils.
   They oblige the person to speak thick, or as if his tongue  was  too
large for his mouth,  with a large degree of snuffling.
   These are the most common symptoms of this stage of the disease,
but it is perhaps impossible to know all the symptoms this poison pro-
duces when in the constitution. I knew a gentleman who had a teasing
cough which he imputed to  it; for it came on with the symptomatic
fever, and continued with it,  and by  using  mercury both disappeared.
   There are inflammations of the eyes which are supposed to be vene-
real ; for after the usual remedies against inflammation have  been tried
in vain, mercury has been given, on the supposition of the case being
venereal, and sometimes with success, which has  tended  to  establish
this opinion.  But if such cases are venereal, the disease is very dif-
ferent from what it is when attacking other parts from the constitution,
for the inflammation is more painful  than in venereal  inflammation
proceeding from the constitution; and I have never seen such cases
attended with ulceration, as  in the mouth, throat, and tongue, which
makes me doubt much of their being venereal.
   [G. G. B.—The author has here been misled, either by the general
principle which he imagined he had  discovered, and which may be
shown to be  in many instances erroneous, or by the want  of oppor-
tunity for a  more extended observation of diseases of the eye.  It is
established beyond  the possibility of doubt, that iritis is frequently a
secondary symptom of the venereal disease.  The general symptoms
of iritis are well known. The distinctive signs of syphilitic iritis have
been supposed to be  chiefly the deposit of masses of lymph, of a red- 
432               CONSTITUTIONAL SYPHILIS.
dish or brownish color, on the surface  of the iris, and the nocturnal
exacerbation of pain.  However, the accuracy of the diagnosis may
be questioned, since it is certain that in venereal cases many instances
of iritis occur where these peculiar symptoms are  wanting, and where
the appearance differs in nothing from the idiopathic forms of the dis-
order.— G. G. B.]

§ 2. Experiments made to ascertain the Progress and Effects of the Vene-
                           real Poison.

  To ascertain several facts relative to the venereal disease, the fol-
lowing experiments were made.   They were begun in May, 1767.
  Two punctures were made on the penis with a lancet dipped in vene-
real matter from  a gonorrhcea; one puncture was  on the glans, the
other on the prepuce.
  This was on a Friday; on the Sunday following there was a teasing
itching in those parts, which lasted till the Tuesday following.   In the
mean time, these  parts being often  examined, there  seemed to be a
greater redness and  moisture than  usual, which was  imputed to the
parts  being rubbed.  Upon the Tuesday morning, the parts of the pre-
puce  where  the puncture had been made were redder, thickened, and
had formed a speck; by the Tuesday following, the speck had increased,
and discharged some matter, and there seemed to be a little pouting of
the lips of the urethra, also a sensation in it in making water, so that
a discharge was expected from it.  The speck was now touched with
lunar caustic, and afterwards dressed with calomel ointment.  On
Saturday morning the slough came off, and it was again touched, and
another slough came  off on the  Monday following.  The  preceding
night, the glans had itched a good deal, and on Tuesday a white speck
was observed where the puncture had  been  made;  this  speck, when
examined, was found  to be a pimple full  of yellowish matter.  This
was now touched with the caustic, and dressed as the former.  On Wed-
nesday, the  sore on  the prepuce  was yellow, and therefore was again
touched with caustic.  On Friday, both sloughs came off,  and the sore
on the prepuce looked red, and its basis not so hard ; but on the Satur-
day, it did not look quite so well, and was touched  again, and when
that went off, it was allowed to heal, as also the other,  which left a
dent  in  the  glans.  This dent on  the glans was filled  up in some
months, but for a considerable time it had a bluish cast.
  Four months afterwards, the chancre on the prepuce broke out again,
and very stimulating applications were tried; but these seemed not to
agree with it, and nothing  being applied, it healed up.   This it did
several times afterwards, but always healed up without any application
to it.  That on the glans never did break out, and herein, also, it dif-
fered from the other.
  While the sores remained on the prepuce and glans, a swelling took
place in  one of the glands of  the  right groin.  I had for some time
conceived an idea that the most effectual way to put back a bubo was
to rub in  mercury on that leg and thigh;  and thus a current  of mer-
cury would pass through the inflamed gland.  Here was a  good oppor- 
SYMPTOMS.
433
 tunity of making the experiment.  T had often succeeded in this way,
 but now wanted to put it more critically to the test.1   The sores upon
 the penis were healed before the reduction of the bubo was attempted.
 A few days after beginning the mercury in this method, the gland sub-
 sided considerably.  It was then left off, for the intention, was not to
 cure it completely at present.   The  gland, some time after, began to
 swell again, and as much mercury was  rubbed in as appeared  to be
 sufficient for the  entire reduction of the gland; but it was meant to do
 no more than to  cure the gland locally, without giving enough to pre-
 vent the constitution from being contaminated.
   About two  months after the  last  attack of the bubo, a little sharp
 pricking pain was felt in one of the  tonsils  in swallowing anything,
 and on inspection a small ulcer was found, which was allowed to  go on
 till the nature of it was ascertained, and then recourse was had to mer-
 cury.  The  mercury was thrown  in by the same  leg  and thigh as
 before, to secure the gland more effectually, although that was not now
 probably necessary.
   As soon as the ulcer was skinned over, the mercury was left off', it
 not being intended to destroy the poison, but to observe what parts it
 would next affect.   About three months after, copper-colored blotches
 broke out on the skin,  and the former ulcer returned in the tonsil.
 Mercury was now applied the second time for those effects of the poison
 upon the constitution, but still only with a view to palliate.
   It was left  off a second time, and the attention was given to mark
 where it would break out next; but it returned  again in the same
 parts.  It not appearing that any  farther knowledge was to be pro-
 cured by only palliating the disease a fourth time in the tonsil, and a
 third time in the skin, mercury was now taken in a sufficient quantity,
 and for a proper time, to complete  the cure.
   The time the experiments  took up, from the first  insertion to the
 complete cure, was about three years.
   The above  case is only uncommon in the mode of contracting the
 disease, and the particular views with which some parts of the  treat-
 ment were directed; but  as it was meant to prove many things which
 though not uncommon, are yet not attended to, attention was paid to
 all the circumstances.  It proves many things, and opens a field for
 farther conjecture.
   It proves, first, that matter from  a gonorrhcea will produce chancres.
   It makes  it probable that the glans does not admit  the  venereal
 irritation so quickly as  the prepuce.  The chancre on the prepuce
 inflamed and suppurated in somewhat more than three days, and that
 on the glans in about ten. This is probably the reason why the  glans
 did not throw  off its sloughs so soon.
  It renders it highly probable that to apply mercury to the  legs and
 thighs is the best method of resolving a bubo;  and, therefore, also the
 best method of applying mercury to assist in the cure, even when the
 bubo suppurates.

  1 The practice, in 1767, was  to apply a  mercurial plaster on the part, or to rub in
mercurial ointment on the part, which could hardly act by any other power than sym-
pathy.
       28 
434
CONSTITUTIONAL SYPHILIS.
  It also shows that buboes may be resolved in this way, and yet the
constitution not be safe; and therefore that  more mercury sliould be
thrown in, especially in cases of easy resolution, than what simply
resolves the bubo.
  It shows that parts may be contaminated,  and may have the poison
kept dormant in them while under a course of mercury for other symp-
toms, but break out afterwards.
  It also shows, that the poison having originally only contaminated
certain parts, when not completely cured, can break out again only
in these parts.1


     § 3.  Of the Symptoms of the Second Stage of the Lues Venerea.

  This stage of the disease is not so well marked as the former; and,
as it is of more importance, it requires all our discernment to determine
what the disease is.
  The parts less susceptible of this irritation are such as are more out
of the way of the great exciting cause, which is the external air, as has
been before related.  And they begin to  take on the venereal action,
whether it may or it may not have produced its local effects upon the
external or exposed surfaces;  and they even go on with the action, in
many cases, after these surfaces first affected have taken on the action
and have  been cured, as has  been already observed.  These deeper-
seated parts are the periosteum, tendons,  fascias, and ligaments; how-
ever, what the parts affected may be when the disease is in this stage
is not  always certain;  I have  known  it produce total deafness,  and
some of those cases to end in suppuration, attended  with great pain in
the ear and  side of the head.  Such cases are  generally supposed to
arise from some other cause; and nothing but some  particular circum-
stance in  the  history of the case, or some symptom attending it,  can
lead the surgeon to the  nature of the complaint.
  When these deeper-seated parts become irritated  by this poison, the
progress is more gradual than  in the first; they have very much  the
character  of scrofulous swellings or chronic rheumatism, only in this
disease the joints are not so subject to it as they are in the rheumatism.
We shall  find a swelling come upon a bone when  there has been no
possible means of catching the infection for many months, and it will
be of some size before it is taken notice of, from having given  but
little pain.  On the other hand, there shall be great pain, and probably
no swelling to be observed till some time after.  The  same observations
are applicable to the swelling of tendons and fascias.
  As these swellings increase  by slow degrees, they show  but little
signs of inflammation.  When they attack the periosteum, the swelling
has all the appearance of a swelling of the  bone, by being firm  and
closely connected with it.

  1 See the addition at p. 51.  If the experiment had been made by one less practised
and less accurate than John Hunter, the history of the case would lead to the suspicion
that the venereal virus had been conveyed to the punctures by means of the caustic
with which they were repeatedly touched.   Certainly  the course which they held was
very different from that which is usually observed in common chancre.—G. G. B. 
SYMPTOMS.
435
  The inflammation produced in these latter stages of the disease can
hardly get beyond the adhesive, in which state it continues growing
worse and worse, and when matter is formed it is not true pus, but a
slimy matter.  This may arise in some degree from the nature of the
parts not being  in themselves easily made to suppurate; and when
they do suppurate, the same languidness still continues, insomuch that
this matter is not capable of giving the extraneous stimulus, so as to
excite true suppuration or ulceration, even  after the constitution  is
cleared of the original cause, and then  the disease is probably scro-
fulous.  Some nodes, either in the tendons  or  bones, last for years
before they form any matter at  all; and in this case, it is doubtful
whether they are venereal or not, although commonly supposed to be so.
  I have already observed that the pain in the first stages of this dis-
ease is much less than might be expected, considering the effects pro-
duced by the poison.  The disease being very slow and gradual in its
progress, its giving little pain may be accounted for.  An ulcer in the
throat causes no great pain; and the same may be said of blotches on
the skin, even when they become large sores.
  When the periosteum and bones become affected, the pain is some-
times very considerable, and at other times there is hardly any.  It is
not,  perhaps, easy to account for this.  We know, also, that the tendi-
nous parts, when inflamed,  give in  some cases very considerable pain,
and  that of the heavy kind, while in others they will swell considerably
without giving any pain.
  These pains are commonly periodical, or have their exacerbations,
being commonly worst  in the night. This is common to  other aches
or pains, especially of the  rheumatic kind, which the venereal  pains
resemble very much.
  When the pain is the first symptom, it affords no distinguishing
mark of the disease; it is therefore often taken for the rheumatism.
   [G. G. B.—Venereal  affections of the bones are of different kinds.
  1.  Simple inflammation of the periosteum, which is marked by thick-
ening of the periosteum, with much pain and tenderness, and usually
terminates in the deposit of osseous matter beneath it, and the perma-
nent enlargement of the bone.  Sometimes, though  more rarely, the
periosteum suppurates,  and then it often happens  that a portion of the
bone beneath it  dies and exfoliates. This constitutes the most com-
mon venereal node, and is frequent on the tibia, the  ulna, and  the
cranium.
  2.  Caries of the bone, which commences in the cancellous structure
and gradually perforates the external plate, and then  appears as a soft
tumor, which may be seen  and felt externally.  If this tumor is laid
open, a glairy fluid is evacuated; the periosteum is found to be some-
what thickened, and the bone beneath is denuded, and in  the centre of
the denuded part  is found  a small hole, which perforates the cortical
plate, and communicates with the interior of the bone.  This affection
is very common in  the skull, and may be occasionally seen in the
tibia, the jaw, and the  ulna.  It constitutes, in its aggravated forms,
the worm-eaten  caries, which is sometimes seen to pervade extensively
the bones of the cranium. 
436
CONSTITUTIONAL SYPHILIS.
  3. There is, less frequently, a third form of disease, which seems to
be  originally simple inflammation  of  the bone, and which  is  most
commonly seen in the skull.  The thickness of the bone is  greatly
increased, and the structure becomes dense and ponderous.  The peri-
osteum is for the most part unaltered;  but, during the course of the
disease, it is  often attacked by inflammation at particular points, and
then it rises into small nodes.   These nodes generally subside again
in a week or two, when similar enlargements occur  elsewhere, and
usually in like manner disappear in their turn.   Sometimes, however,
instead of subsiding,  they  suppurate,  and the  surface of the  bone
becomes carious.  Yet no considerable  portion  dies and  separates—
the ulcer does not spread; but after a certain lapse of time heals again,
leaving the  surface of  the bone uneven, and  the cicatrix  closely
adhering to it.   The enlargement of the bone subsides on the cure of
the disease, except  in  cases where the disease  has been of very long
continuance.—G. G. B.]


          § 4. Of the Effects of the Poison on the Constitution.

  The poisonous matter, simply  as extraneous matter, produces no
change whatever on the constitution; and whatever effects it has, de-
pend wholly  upon its specific quality as a poison.   The general effects
of this poison on the constitution are similar to other irritations, either
local or constitutional.  It produces fever, which  is of  the slow kind;
and when it continues a considerable time, it produces what is called
a hectic disposition, which  is no more than an  habitual slow fever,
arising from  a cause which  the constitution cannot overcome.  While
this exists, it is impossible that anything salutary can go on in such a
constitution.   The patient loses his appetite, or, even if his appetite is
good, loses his flesh, becomes restless, loses his sleep, and looks  sallow.1
   In the first stage of  this disease, before  it begins to  show itself ex-
ternally, the  patient has  generally rigors, hot  fits, headaches,  and all
the symptoms of an approaching fever.
   These symptoms, continuing for some  days, and often for weeks,
show that there is some irritating cause, which works slowly upon the
constitution.  It is then supposed  to  be whatever the invention or
ingenuity of the practitioner shall call it; but  the venereal eruptions,
or  nodes, upon  either the periosteum, bones, tendons, or  other parts,
appearing, show the cause, and in some degree  carry off the symptoms
of fever, and relieve the constitution for a little time, but they soon
recur.
   These constitutional complaints, however,  are not always to be
found, the poison stimulating so slowly as hardly to affect the consti-
tution, unless it be allowed to remain in it'a long time.
   There are a  number of local appearances mentioned by  authors
which I never saw, such as  the fissures about the anus, &c.  There are,

  1 This kind of look, although arising entirely from a harassed constitution, i9
always supposed to be peculiar to a venereal one.  This idea, however, does not arise
from the look only, but from the leading symptoms. 
SYMPTOMS.
437
also, a number of diseases, described by authors as venereal, especially
b\ Astruc and his  followers, which are almost endless.  The cancer,
scrofula, rheumatism, and gout, have been considered as arising from
it, which may be in some measure true, but they are, with them, the
disease itself, and all their consequences; as consumption, wasting from
want of  nourishment, jaundice, and a  thousand other diseases, which
happened many years before the existence of the lues venerea, are all
attributed to it.
   There  is, even at this  day, hardly  any disease the practitioner is
puzzled  about  but  the venereal comes immediately into his  mind;
and, if this became  the cause of careful investigation, it would be pro-
ductive of good;  but with many, the idea alone satisfies the mind.
   [Ricord. — Secondary  symptoms,  wherever situated,  and  under
whatever form  developed,  commonly appear  without premonitory
symptoms, and then their only antecedent is the preceding chancre.
   But it is not uncommon to observe a profound change in the aspect
of the patient; the eyes lose their brilliancy; the complexion becomes
yellowish and cadaverous; the muscular power diminishes, and it is
evident  that  there  is some defect in the arterialization of the blood.
In fact, I have been able to  establish, by numerous experiments, that,
in this state, the blood  is  affected and  impoverished; that the propor-
tion  of  globules is  diminished, sometimes  to a considerable extent;
and that a more or less decided chloro-anasmic state is consequently
produced.1   Often, at this time, the hair begins to fall off;  the cervical
ganglia  become engorged, and vague pains are felt, generally nocturnal,
and bearing  a great resemblance to the pains of rheumatism.  These
pains are not unfrequently situated in the sternal region, the neighbor-
hood of the  articulations of the extremities, or on  the  scalp, where
they often simulate sick-headache  or  neuralgia.  They differ, as  we
shall see hereafter, from the osteocopic pains, which precede or accom-
pany the development  of periostosis,  and also from the  deeper and
later affections of the osseous system, belonging to tertiary symptoms.
Finally, in certain cases, some or all of the premonitory symptoms of
an acute affection  are observed, and  especially of  an exanthema or
angina,  according to the  region in which the symptoms are  about to
appear.
   In the great majority of cases, however, it  is only by  chance that
the patient observes the first constitutional symptom, though it may

   1 M. Grassi has made numerous chemical analyses of the blood of persons affected
both with simple and with indurated chancres. These analyses are the more note-
worthy as they were made at a time when the essential difference between these two
varieties  of chancre was not fully appreciated, and yet they confirm  the results of
clinical observation at the present day.
  M. Grassi's analyses show :—
  I. That the blood of persons bearing simple chancres preserves its normal character.
  H. That the blood of persons bearing indurated chancres exhibits a diminution in
the quantity of its corpuscles and an increase in the proportion of its albumen.
  Thus we have additional proof of the constitutional reaction of  the indurated
chancre.
  This deterioration of  the blood  in constitutional syphilis is confined  to its early
stages, when the virus first finds entrance  into the economy; at a later  period, the
blood resumes its normal composition.  See Lecons sur le Chancre, p. 145.—Ed. 
438
CONSTITUTIONAL  SYPHILIS.
have already existed a long time; or it may be first discovered by the
physician, who is guided by his knowledge of the nature and necessary
consequences of the primary symptom, the indurated chancre.
   Syphilitic Affections of the Skin.—Following the order adopted by
Hunter, and considering first  those secondary diseases which  appear
on the skin—although this affection may show itself at the same time
on the mucous membranes, or commence in the  latter  alone—I will
observe that  the  skin  may become covered at once  with a general
eruption,  especially when developed a short time after the primary
ulcer;  whilst at a later  period it  is more discrete, and  generally con-
fined to certain regions.
   With the same antecedent,  viz., a chancre, a person may have, at
the same time or successively, the various syphilitic eruptions, formerly
confounded under the name of venereal pustules, but  since grouped
under the title of Syphilides.
   It is entirely contrary to all observation to admit that any form of
secondary cutaneous affections is  produced by a peculiar form of the
primary ulcer.  A chancre is the common origin  of all syphilitic dis-
eases of the skin; and, in the presence of this fact, Carmichael's inge-
nious system, reconstructed in whole or in part by some more recent
writers, must fall to the ground.  As I have  elsewhere said, if any
coincidence of form and progress  between primary and secondary
symptoms be ever observed,  it is  never due  to  a difference  in the
nature of  the virus, or to any influence of the primary ulcer, but to the
idiosyncrasy of the patient, at the time of development of the primary
disease and during the course  of the constitutional phenomena.
   Moreover, there is, perhaps, not a single variety of cutaneous disease,
which may not be  produced by the syphilitic  virus; and  all diseases
of the skin, without exception, may complicate syphilis, either in its
primary form or after constitutional infection has taken place.
   Observation, independent  of any preconceived ideas, proves not
only that  there is sometimes a fusion and combination of causes in the
production of morbid affections of the  skin, but also that syphilis  may
act in one of two ways, viz., either by exciting specific effects on the
cutis, which continue dependent upon the virulent cause, or, like any
ordinary  non-specific agent, by giving  rise to simple effects, which
any other cause might  produce, and which when once excited, cease
to be under the syphilitic influence.  These clinical truths are incon-
testable, and having once recognized them, we can account for the
great variety of  syphilitic eruptions which  have been admitted, the
differences and almost  hopeless confusion in the descriptions of them
given by  authors, and the difficulty of always establishing an absolute
distinction.
   In order to escape as methodically as  possible from this labyrinth, •
and circumscribe what  is not always easily  limited, the following
divisions of syphilitic eruptions are now admitted: The exanthematous,
papular, squamous, vesicular, pustular, tubercular, and ulcerous; the last
being always a consequence of one of  the preceding forms.
   Denying, as I do absolutely, the existence of non-consecutive  con-
stitutional syphilis, except in cases of hereditary transmission, in which 
SYMPTOMS.
439
communication of the disease from mother to child is easily compre-
hended, I do not admit any primary syphilitic eruption, of any form.
Syphilitic eruptions are always consecutive to chancres.   As I have
already said, the time of their appearance after the primary ulcer may
vary, but they never occur without it.   It is  well known that they
may arise during the existence of a chancre, and disappear before  it
has healed;  but they are none the less a  consequence of it—for they
never precede it, and never occur without its previous existence.  To
divide syphilitic eruptions, therefore, into primary and consecutive,  is
an error—unjustifiable by the form of the disease, its progress, dura-
tion, termination,  and treatment.  The  title of  successive affections,
indicating the pathological conditions immediately following a chancre,
is also inadmissible, since precisely similar  symptoms  may  appear
much later.1
  No age, sex, nor temperament is secure against syphilitic eruptions.
They are most common in adults—a fact which is easily accounted
for; but they are very readily developed in  infants.  Women, lym-
phatic subjects, and those whose constitution is  already  enfeebled,  or
who  are  predisposed to diseases of the  skin, are, perhaps, most fre-
quently affected.  Certain concomitant pathological conditions, errors
in diet, the  privations of poverty, violent exercise, strong moral emo-
tions, the use of excitants  of the digestive passages, or especially  of
the skin, and a high or low degree of temperature, seem to favor their
development.
   Although, in some rare cases, an improper  administration of mer-
cury may cause the appearance of certain syphilitic eruptions, it is not
true that this mineral can produce them outright.   Syphilitic erup-
tions not only occur in patients who have taken no mercury, but they
may be predicted with certainty in those, who, having  had an indu-
rated chancre,  have undergone no treatment;  and  we may  almost
always succeed in curing those persons to whom we suitably administer
mercury.
   Syphilitic eruptions generally present a copper color; but the value
of this sign has  been exaggerated, though  it  is contrary to truth  to
deny its existence.  The fact is, that syphilitic eruptions  at their outset
sometimes have a decidedly red tint, which disappears on pressure, but
soon  returns; whilst other cutaneous affections,  entirely foreign  to
syphilis,  offer at times so marked a copper color, that a practised eye
may be deceived.  It is correct to say, that the earlier after its appear-
ance we observe an eruption, the less dark and  characteristic we find
its tint to be.
   The form of syphilitic eruptions is most commonly circular;  when
annular, the circles may be complete or incomplete, isolated or united,
and, in the  latter case, they may appear irregular.  The scales are not
always as thin, dry, or dark colored; nor the  scabs as thick, greenish,
black, hard, and furrowed, as some authors seem  to  think.  Though

  1 I have reserved the title of successive for the symptoms  belonging to the same
order as the primary, and precisely similar to them, succeeding them without inter-
ruption—as successive chancres, developing themselves from place to place, successive
buboes, etc. 
440
CONSTITUTIONAL  SYPHILIS.
these are the most common appearances, it should be known that there
are more exceptions than have been generally admitted.
   The skin of persons affected with constitutional syphilis is sometimes
of a cadaverous or pale yellow color, either universally or only in the
intervals or neighborhood of the eruption.
   Such persons have nothing peculiar in the odor of their breath, as
has recently been asserted, unless in exceptional cases.
   Syphilitic eruptions may appear  on all parts of the  skin.  The fol-
lowing is the order of frequency in which I have observed them in
different regions:  the trunk and the extremities, the neighborhood of
the genital organs and anus, the scalp, the face (the forehead, the  alio
nasi, the commissure of the lips, the chin, etc.), the spaces between the
toes, the sole of the foot  and  palm  of the hand, the roots of the nails,
the umbilical depression, and the external meatus auditorius.
   The form in which syphilitic eruptions are developed, depends on the
time of their appearance after the  primary ulcer; on their duration;
on the particular region affected; on their repetition, and on the modi-
fications which they receive from proper or improper treatment, and
from a multitude of complicating circumstances which influence their
physiognomy.
   In the most simple state, and  when observed a  short time after the
primary ulcer, the most  common form  of  syphilitic eruptions is the
exanthematous (spots, maculas, roseola, erythema, and syphilitic ephe-
lides).   These maculas are confluent or discrete, and consist of minute
points, or cover a certain extent of  surface.  They are very rarely at-
tended by sympathetic constitutional symptoms and almost never excite
itching.  They are often of a very  decided red color at first, but soon
grow pale or dark colored. The eruption may take place at once over
the whole surface, or  appear  slowly and successively in different  re-
gions.  These syphilitic maculas are sometimes transient; disappearing
in a few days and again reappearing at longer or shorter intervals, and
lasting in some cases indefinitely.   They are often observed to appear
at the commencement of treatment, before it has had time to neutralize
their cause.  In that case, patients  and  even some physicians do not
hesitate to  attribute them to the treatment.
  Rubeolar eruptions, which frequently occur in the course of a gonor-
rhcea in patients who are taking cubebs or copaiba, are often mistaken
for syphilitic maculas; hence, it  has been thought that this eruption is
often attended with gonorrhceal discharges.  Indeed, it is not impossible
that some simple exanthemata may act on the mucous membranes of
the genital organs, as they are known to act on other mucous mem-
branes, and vice versa.
   As we have  seen, maculas  are ordinarily the first manifestation of
constitutional syphilis; but, in very many cases, they are the termina-
tion of some other preceding disease of the cutis.  Sometimes, indeed,
they are the only traces left of an imperfectly subdued syphilitic erup-
tion, or one recently cured; but it often happens that these eruptions
may still be found on the neighboring parts, as they are about to be
replaced by maculas;  thus indicating the origin of the latter.
   When the maculas are consecutive to other eruptions, their form and 
SYMPTOMS.
441
extent vary according to the species of the cutaneous affection which
preceded them.  Becoming less and less protuberant above the neigh-
boring parts, they frequently subside by a kind of atrophy of the skin
in the affected points, whether  there be  previous ulceration or not.
Their color is generally darker or more coppery than that of primary
maculas; and the more so when they succeed diseases of long duration,
or which have been imperfectly  cured.  This  purplish brown tint of
consecutive maculas is still more  decided on depending parts, and par-
ticularly on the legs, where other diseases foreign to syphilis so fre-
quently present an analogous  color.   But whilst primary maculas seem
due to capillary congestion, which pressure easily removes and causes
to disappear, consecutive maculas appear to depend on a deposit of
coloring matter in a state of intimate combination with  the  part, and
are with difficulty rendered pale by compression.  Finally, these spots,
the duration of which is indefinite, and upon which treatment has in
the end no effect,  disappear, in the majority of cases, without leaving
any trace behind; but they may be  replaced,  even when not accom-
panied by ulcerations, by white tissue, like that of cicatrices, with or
without depression of the surface.
   When patients  are first observed at a little later period  after the
primary ulcer, or  when accessory causes are more active, or treatment
is wanting or badly applied, a papular or squamous affection is found
to have succeeded the exanthematous eruption.
   An early and the most common variety is the mucous papule; this
is undoubtedly the constitutional symptom which may appear soonest
after the primary ulcer.  In many cases it succeeds the latter so rapidly
and so soon after  sexual  intercourse, that  many syphilographers have
believed that it might be primary.  But I feel authorized to assert that
it has never been seen in a well characterized form before the second
week following the infecting coitus—the earliest time apparently in which
true secondary symptoms can be developed.  It is always preceded by a
chancre, either on  the spot where  the papule is developed or elsewhere.
When it succeeds a chancre in situ, it is an instance of uninterrupted
transition from a primary to a secondary symptom.  In that case, the
chancre assumes the character of a mucous papule during its repara-
tive period; and the latter affection retains the prerogative of primary
symptoms only in case this transformation is not everywhere complete.
Mucous papules originating in this manner may exist alone for a longer
or shorter  time, or even permanently, unaccompanied  by any other
symptoms of constitutional infection; or other mucous papules maybe
developed in the neighboring parts or at a distance, and it is then  no
longer possible to distinguish one from the other.   When the trans-
formation in situ is complete,  or papules occur at a distance as a con-
sequence of constitutional infection, their morbid secretion is not sus-
ceptible of inoculation, like the pus of a progressing chancre.  Without
careful observation, however,  a person may sometimes be deceived; for
it is not uncommon to find among mucous papules chancres in the pro-
gressive stage, which have either preceded them, or occurred afterwards
in consequence of a new  infection.
  A chancre itself, in consequence of cicatrization taking place irregu- 
442
CONSTITUTIONAL SYPHILIS.
larly, may present an appearance quite analogous to that of mucous
papules, owing to the granulations  and elevation of its floor, and the
subsidence and more or less complete disappearance of its edges; and
it is not always possible to distinguish these cases from  those which
result from constitutional syphilis and belong to secondary symptoms.
  Mucous papules are most frequent in lymphatic subjects, especially
among women and children.
  The regions in which they appear, in the order  of their frequency,
are: the anus; the vulva,  especially on the internal surface of the
labia majora;  the genito-crural fold; the scrotum, and more particu-
larly the angle formed by the penis  and scrotum; the umbilical de-
pression ;  the  lips; the external meatus auditorius;  the  points where
the toes touch each other, and the roots of the nails, which they often
destroy.
  Acrid secretions, the habitual moisture of certain regions, want of
cleanliness, and the contact of opposed  surfaces favor their develop-
ment in a remarkable manner.  The use of a pipe with a short stem
is one of the most frequent exciting causes of their appearance on the
mouth.
  It is not uncommon to find mucous papules the only  sign of con-
stitutional syphilis, limited to one of the regions which I have enume-
rated, or  occupying  several at once, and  situated especially in the
buccal cavity  (on the fauces, tongue, internal surface of the cheeks,
&c), as will be seen hereafter; but they are  also frequently accompa-
nied by other exanthematous, papular or squamous eruptions, of which
they are  in reality only  a modification chiefly  dependent on their
situation,  as Hunter  understood so  well.  Sometimes, at the outset,
they consist  of small papules, more or less protuberant, and soon
deprived of their  epidermis;  their surface of a grayish or brownish-
yellow color, rugous or slightly granulated, and presenting superficial
erosions or true ulcerations.  To these papules, which are sometimes
isolated and sometimes in groups, the name of mucous papules should
be confined.   At other times they consist of tubercular  prominences
due to the successive development of the papules, or to their being col-
lected into groups (mucous tubercles, mucous patches, moist flat pustules).
  Mucous patches, which differ from mucous papules only in their
larger size, are sometimes of a deep violet or red color; at other times
of a grayish tint,  their color differs  but  little from that of the sur-
rounding parts.  But the  particular hue of  mucous patches varies
according to a multitude of circumstances depending on their situa-
tion, duration, &c.  Their form is at first circular; but,  when several
patches unite  and form groups, it may be  different.  The surface of
these patches  is rugose, or rather like shagreen leather, and is formed
of small granulations, some of a reddish, others of a dark-gray color,
and covered with a peculiar muco-purulent secretion, which exhales a
strong and offensive odor when they are situated on the genital organfl,
near the anus, or especially between the toes.
  Mucous papules are not only the first of all secondary symptoms to
appear in many cases, but  they may also disappear at  a very early
period, even under the sole influence of repose, cleanliness, and isola- 
SYMPTOMS.
443
tion of the surfaces.  They are, however, very liable  to return;  and,
when left to themselves, or badly treated, may  become  the  seat of
irregular ulcerations of various depths, which, when situated near the
anus, or between  the toes, often receive the name of rhagades, which
is also  applied  to some other ulcerations. Finally, mucous papules,
or rather hypertrophied mucous patches, sometimes give rise to vege-
tations belonging to the  different  varieties which we  have elsewhere
described.
  In other regions, the papules are solid, hard, and dry; they protrude
above the level of the skin, and generally terminate by resolution or
desquamation.  They may be discrete, or arranged in groups or circles.
This form, constituting syphilitic lichen, or  scabies venerea, may be
developed very rapidly a short time after the disappearance of the
primary ulcer, or even before, and, its first stage  consisting of simple
maculas, pass without notice.   It may extend over the whole body and
face, or be confined to certain  regions.
  Sometimes lichen  affects a chronic type; its papules are then larger,
of a deeper color, flat or  protuberant, and appear most commonly on
the extremities, scalp, face, back, &c.  It not only accompanies other
syphilitic eruptions,  which are often in reality its first phases, but it
also undergoes evident transformations.  Thus,  these large, slightly
projecting and  scaly papules finally merge into true squamous syphi-
litic eruptions; and, in other  cases, the lichen is succeeded by true
tubercles, as Mr.  Babington has well remarked.  Although, generally,
when the eruption undergoes  no transformation, and terminates in a
frank lichenoid form, the  papules are solid, and do not suppurate or
ulcerate, yet it  sometimes happens that the epidermis becomes elevated
by a fluid, which, at first serous and afterwards purulent,  is absorbed
at an earlier or later period;  in other cases, also,  the papules become
ulcerated at their summit, as was observed by Bateman.
   In all cases, however,  lichenoid eruptions, which may  appear re-
peatedly during the course of constitutional syphilis, persist for some
time; and, though they sometimes rapidly yield to treatment, in other
cases they seem to elude all medication, resisting even those therapeutic
agents which have cured the other concomitant  syphilitic  symptoms.
These  eruptions,  like many others, have a tendency to  become more
serious the  later they appear after the primary  ulcer, and the more
the constitution has been impaired by  improper treatment, or other
coexisting diseases.
   The larger maculas of  exanthematous eruptions are also frequently
succeeded by small elevations, the color of which becomes darker and
darker, or more  coppery,  if you  prefer the  term,  and  covered  with
scales,  which are  generally dry.  These squamous eruptions, so called,
are classified under psoriasis or lepra.
  In the first variety (psoriasis), the patches are confined  to a single
region, or scattered  at different  points over the whole surface; they
are discrete,  approximated, or sometimes even  confluent; their  size
varies from that of  a lentil to a ten cent piece or over, and they  are
irregularly circular and  protuberant  above  the neighboring parts.
When the scales are detached, the surface beneath is generally  smooth 
444               CONSTITUTIONAL  SYPHILIS.
and  dark-colored.  M. Biett has  observed that when  this variety
simulates psoriasis guttata (the common and characteristic lenticular
syphilitic eruption), the patch is surrounded, on the fall of the scales
by a white  adherent margin, which, although quite constant, cannot
be considered as pathognomonic.
  In the second variety (lepra), which is probably the  affection often
described as lepra nigricans, and to which  the name of annular  syphi-
litic  eruption is perhaps  better  applicable, the  patches are perfectly
round, from two lines to half an inch or more in diameter, and gene-
rally of a dark-brown or violet color, or even blackish in  the centre.
Their edges, in  the  form of a more or less perfect ring, and  raised
above the level of the neighboring parts,  often  extend centrifugally,
their inner margin healing, and their outer advancing.   The color of
the edges is not so dark as the centre of the patches, in accordance
with a law which I have elsewhere established; yet, when the erup-
tion remains, and  the circles do  not  enlarge,  the skin resumes its
normal color  in the centre, while  the circles continue colored for a
longer or shorter time.  The rings are  generally due  to swelling of
the tissues, but they are sometimes formed of scales, which, becoming
detached, leave behind them a non-protuberant circle, marked only by
its color.  In other cases, the rings are evidently formed of papules,
more or less perfectly developed, in close contact with  each other, and
each one surmounted by a distinct scale, or even, in some cases, by a
crust varying in  thickness, which  gives the cuticle a  honeycomb ap-
pearance.  The rings frequently touch or overlap each other in various
ways,  so as to  form figures of eight, threes,  parts  of a circle, &c.
This form of syphilitic eruption is infinitely more common than some
writers suppose.
  The varieties which we have just described often  appear on the
palms of the hands and the soles of the feet; the only difference  which
they present in this case  is that  the scales are thicker, harder, and of
a horny consistence, in consequence of the usual state of the epidermis
on these parts.  On the contrary, where the skin is moist or in contact
with neighboring parts, or where it resembles mucous membrane in its
structure, as in  the  neighborhood of the  anus, the vulva, the genito-
crural fold,  the internal surface of  the prepuce, or the  scrotum, &c,
the  scales are soft and  pultaceous, or even entirely wanting, and the
parts beneath ulcerated.
  A vesicular syphilitic eruption is not so rare as those pathologists,
who claim to collect all diseases of the skin at the Hopital Saint-Louis,
have been pleased to assert.   Examples of it may  always be seen in
my wards at  the  Hopital des Ve'neriens.  Vesicular syphilitic erup-
tions correspond to eczema impetiginodes  more frequently than to the
other varieties.   They are always less active and more chronic than
the  ordinary forms;  when in confluent groups, they rest  on a dark
violet  or coppery base;  or, otherwise, each vesicle is surrounded by
an  areola presenting this specific  tint.   They  are not  attended by
itching.
  A variety of syphilitic eruptions very  frequently met with  at the
Hopital des Veniriens is the herpetic; it  is sometimes in more  or less 
SYMPTOMS.
445
confluent groups, and sometimes simply circular with concentric rings
or central squamous patches, which are often moist.   Its distinctive
characters are, the absence of itching, the violet or copper color of the
affected surface or of the areola surrounding the vesicles, its slow pro-
gress, its duration, and perhaps  a certain peculiarity in  the  mode  of
desquamation of the eruption, when the sero-purulent fluid which com-
poses it is absorbed, viz., the aspect of the small, adherent, blackish
crusts  after this  fluid dries up; finally, a persistent and specifically
colored subpapular state  of the eruption.
  The vesicular or vesico-pustular eruptions of syphilis may simulate
the different varieties of varicella; but their antecedents, progress, and
duration, added to the other characters pn which I have just insisted,
will not leave us long in doubt, even if we hesitate  a moment at the
outset.
  Pustular syphilitic eruptions are more common than the preceding;
they sometimes belong to psydracia, at  other times to phlyzacia; the
former resembling tolerably well acne rosacea, the latter  coming under
the head of ecthyma; but, between these two extremes, there are often
shades of difference, the  limits of  which are with difficulty defined.
  All  the  forms of syphilitic pustules are in  reality only a modifica-
tion of other eruptions, occurring in consequence of a greater intensity
of the disease, a later period in its development, or an unhealthy con-
dition of the subject, &c. &c.
  In the psydraceous pustules especially, we  observe the  intimate
connection between this  and papular eruptions, of which their base is
often composed;  ecthymatous pustules, on the contrary, frequently
succeed squamous eruptions, which  it is  not  rare to observe  at the
same time, and which, according  to their variety and  situation, give
the pustules  a peculiar form.
  Those pustules which are  apparently to be  referred to the same
elements  as  psoriasis guttata, are  commonly of the size of a  lentil,
tolerably numerous, but  slightly protuberant, and their base sometimes
indurated; they contain  only a small quantity of yellowish-white pus,
and are surrounded with a  dark areola.  At the outset, it is often
difficult to assign  a limit between  the scales and  pustules, in those
cases of scaly eruptions  which are so common  on the scalp.  On the
face and trunk, they are somewhat rarely followed by ulceration, and
then terminate by the formation  of  a  brownish crust, which, falling
off, leaves  a  slight cicatrix or livid spot, sometimes hard and slightly
projecting.  Yet it is not uncommon for these  pustules to form groups,
take on inflammation, and  suppurate very freely, becoming covered
with thick, greenish, and very adherent crusts, which are surrounded
by  a violet-colored  circle, and which, when detached, expose ulcera-
tions of various depths.
  At other times these pustules are larger and, in that case, frequently
less numerous, affecting  more particularly the extremities and espe-
cially the inferior extremities, although they may  be  developed  on
other regions; they are then to  be referred to the deep variety of
ecthyma; again, either isolated or in groups, they  may resemble im-
petigo ; and, finally, in other cases still, they  take the  form of rupia 
446               CONSTITUTIONAL  SYPHILIS.
with extended bases and protuberant crusts, although it is not possible
for us to detect  the  initial bulla in the great majority of cases;  this
last variety denotes an older affection and a constitution impaired not
only by disease, but sometimes by the abuse or bad administration of
medicine.
   However, in this group of syphilitic eruptions, to which the name of
pustulo-crustaceous should  be given, the crusts are generally brown,
greenish, or black, dry and adherent.  In the ecthymatous form, these
crusts are  set in a circle of thickened, protuberant, violet or copper-
colored skin, just as a watch-glass is set in its rim; in the varieties of
impetigo, the crusts are convex, granular, cleft, and overlap' the  sur-
rounding surface;  finally, in rupia,  they  are protuberant,  conical,
truncated, sometimes, however, concave, stratified like  oyster-shells,
surrounded, so long as they increase in size, by successive zones, which
consist at first of the symptomatic, violet, or copper-colored areola, and
at a later period, of the epidermis elevated by a collection of pus, giving
rise to a new crustaceous circle; when the eruption is at  its height,
these crusts cover the whole surface from which they  spring.
   When these crusts are detached, or  fall  off, we find beneath them
ulcers of various sizes,  but rarely larger than a dollar.   These ulcers
attain various depths; their base is more or less engorged, their edges
thickened,  sometimes everted, often serrated; their floor is  irregular,
grayish, pultaceous, or irregularly granulated, sometimes hemorrhagic,
ecchymotic, furnishing thin pus, which is sanious, sanguinolent, loaded
with organic detritus and gangrenous debris, and is in some cases fetid.
Sometimes the ulcers remain stationary, at other times they continue
to increase; hence two varieties: ulcerous  syphilitic eruptions,  and
ulcerating  syphilitic eruptions.   It is not uncommon for the ulcers to
cicatrize before the crusts are detached, but most frequently the latter
fall off before the former are healed.  Cicatrization usually takes place
from the circumference to the centre;  but in rupia it is often irregular,
and may commence at different points or islets in the centre, while the
borders continue to ulcerate, as occurs in serpiginous  chancres.
   Finally,  a still more  serious variety of syphilitic  eruptions is the
tubercular.  The tubercles may attain even the size of a small hazel-
nut, and are then rounded and very protuberant.  Either isolated, or
several of  them  grouped  together, they are most frequently  situated
on the back, neck, face, and  particularly the forehead,  on  the cheeks
and around the nose; they sometimes appear on the glans penis, where
they may be mistaken for an indurated chancre in the  reparative stage,
or for the mucous patches which are commonly called mucous tubercles;
I  have seen instances of them on the tongue and neck of  the uterus,
which might have been taken for scirrhous or carcinomatous affections.
These tubercles sometimes last a long time, and may terminate in reso-
lution, without leaving any scar; but, in many cases, after their disap-
pearance, the skin  is thinned in the spot which they occupied, and a
cicatrix or depression is left, although there has been no ulceration.
In some patients, the tubercular protuberance remains permanently;
its red and livid tint gradually disappears, and it is finally of a lighter
color than  the rest of the  skin.  I have seen such patients, in whom 
SYMPTOMS.
447
the tubercles might have been compared to the cutaneous tumor which
Alibert designated under the name of chelo'id, except that they were
smaller.  On the extremities, however, and more particularly on  the
trunk, tubercles often assume a serpiginous course, and their form may
resemble circles or parts of circles, letters  and figures, as in the less
severe eruptions Which we have already described, and of which these
are only a modification.
  Though all varieties of tubercles frequently terminate in resolution
or suppuration, yet it sometimes happens, especially in the serpiginous
variety, that they ulcerate and become covered with crusts, giving rise
to a tuberculo-crustaceous variety.
  Syphilitic Affections of the Mucous Membrane.—Syphilitic affections of
the mucous membranes,  as  I  have taught in my clinical lectures for
nearly twenty years,  and  as  Mr. Babington very justly observes, pre-
sent  as many varieties as those of the skin.  In another part of this
volume, I have said that primary symptoms may occur on all the acces-
sible mucous  membranes, and, in  particular, that there is scarcely a
point in the buccal cavity where I have not met with examples of them.
It is well  known that they  are frequently situated in the commence-
ment of the rectum, in the vagina, the uterine  neck and cavities, the
nasal fossas, etc.; and it should be understood that it is not always easy,
in any of these cavities, to distinguish these primary symptoms from con-
stitutional. The antecedents, when the patient has no interest in conceal-
ing them,  the number of  the ulcerations, the concomitant phenomena,
their course and  results,  generally point  to  a rational diagnosis; but
sometimes  artificial inoculation, made within the proper period, can
alone decide the question; and that, too, in embarrassing cases, where
it is  of importance to ascertain the truth.
  With respect to the frequency and severity of secondary symptoms
developed on the mucous membranes, we find  exactly the same laws
as for  the cutaneous  eruptions  which they accompany  or replace.
Thus, the most common form is the erythematous, which, like some of
the spots  on the skin, is frequently so transient and imperfectly cha-
racterized that it is not noticed, or at least not recognized; but, in the
majority of  cases, the erythematous  eruption is soon succeeded by
patches which are perfectly analogous to the mucous patches elsewhere
described  in  this work, and which are so well portrayed in  the third
variety of ulcers  in the throat, of which Mr. Babington  speaks, that
there is little  to add to his description, unless it be that these patches
often take on a  true  tubercular development,  and  that they are not
uncommon in the nasal fossas, and on the uterine neck, where they have
been recently confounded with granulating ulcers, which are generally
entirely foreign to syphilis.  Mucous patches  in the  buccal  cavity,
without analogous symptoms at the anus, are more frequently observed
than mucous patches of the  latter region, the throat and mouth being
sound.
  The proof, in all these  cases, that this affection of the mucous mem-
branes is a modification of the cutaneous squamous eruption  which so
often accompanies it is, that it frequently  appears under the annular
form belonging  to that variety of syphilitic lepra, of which I have 
448              CONSTITUTIONAL SYPHILIS.
spoken, and especially on  the internal surface of the lips and cheeks,
the palatine arch, and the velum palati; the well marked circles of this
eruption are sometimes  very protuberant, whether ulcerated  or not.
Again, in accordance with  the strictest analogy, we find, especially on
the borders of the tongue, small  granulated papules, often unrecog-
nized in practice, and which, more  or less extended, irregularly cleft
and ulcerated, resemble somewhat certain eruptions of stomatitis.
  The mucous papules  of the mucous  membranes, like those of the
skin, are, perhaps, contrary to Hunter's opinion, the  most characteristic
symptom of constitutional syphilis; and  the  former, as well as the
latter, are affections of but little severity, disappearing readily, espe-
cially under the influence of mercurial treatment and reappearing with
the greatest facility, when this treatment is incomplete or badly admi-
nistered.
  The other more serious eruptions of the mucous membranes—and,
contrary to the generally received  opinion, the  less characteristic erup-
tions—whether situated in the nasal fossas or cavity of the mouth, are
the consequence of a morbid action in these parts, analogous to that
which produces pustular or tubercular eruptions on the skin ; ulcera-
tions of various sizes also  result from them, destroying the tissues to
a greater or less depth, and frequently presenting an indurated base,
like ulcerated tubercles in  other regions.
  It is important in all cases, as we shall see presently, to  distinguish
ulcerations which commence in the mucous membranes and may lay
bare the bones, from ulcerations of these membranes which are conse-
cutive to an affection of the submucous cellular tissue or the bones
themselves, and which are to be referred to true tertiary symptoms, or,
as Hunter calls it, the second period of constitutional syphilis.
  Syphilitic Affections of the Eyes.—The eyes,  like  other parts of the
body, may be variously affected in the course of  a syphilitic affection.
Thus, they may be the seat of primary symptoms, or experience the
effects of constitutional.infection.   As I have  previously said, a primary
ulcer or chancre may be developed  on  the eyelids or  conjunctiva as
well as anywhere else;  and, if rarer in these parts, it is only because
infecting matter is less frequently  and less intimately applied to them
than to the genital organs  or other regions.
  But, there is one secondary symptom of which Hunter does not speak,
either because it was not comprised within the system which he had
laid down, or, very probably, because he was not acquainted with it; I
refer to syphilitic iritis, which, moreover, has been  thoroughly investi-
gated only  since the time of Beer, Saunders,  Wardrop,  Lawrence,
Ammon, Harel, Pamard, Sanson, Velpeau, &c.
  This  iritis, belonging to the  group of secondary symptoms, rarely
appears alone.  It is generally preceded or accompanied by a syphilitic
eruption,  and, to a certain  degree, assumes its form.  It may occur at
an  early or late period, and affect a single eye,  or both eyes simultane-
ously or successively.
  At the time of the physiological reaction against  mercury, iritis was
thought to be due to this therapeutic agent, and not to syphilis.  If we
did not remember all the extravagances and  all the errors of that reac- 
SYMPTOMS.
449
tion, it would now be difficult to conceive of such an opinion with the
innumerable cases before us, in which this affection is seen to occur free
from all mercurial influence, and get well the more rapidly and com-
pletely when we  have  recourse  to  this specific agent, which, in this
disease, must be used  bountifully, in large  and frequent  doses, and
sometimes even to free salivation.
  Oculists of the German school, admitting that iritis may be caused
by constitutional  syphilis, have considered it a peculiar species with
peculiar symptoms;  whilst most of the  oculists of the French school,
although they admit the cause, can find nothing in this iritis to dis-
tinguish it from ordinary cases of iritis, unless  it be that it generally
appears under a chronic or subacute  form.   In fact, there  is nothing
peculiar in the color  nor in the irregularity of the pupil, as Beer, among
others, supposed.   What is really peculiar in the case is the eruption,
which takes place on the iris, and which bears as great an analogy to
the eruption on the skin as the anatomical differences of the two regions
permit.
  Syphilitic iritis is  generally preceded  by no premonitory symptoms,
unless, as I have already said, by  some other secondary symptoms,
chiefly situated on the skin.  Indeed, the eye sometimes becomes very
much injected and reddened without the patient noticing it.   In some
cases, however, he has  already suffered from nocturnal pains in the
head, most severe over the supra-orbital ridge; sometimes, also, as in
other forms of ophthalmia, the patient complains of the sensation of a
foreign body in the eye, accompanied with a discharge of tears  and a
feeling of heat.
  If we examine  the eye at the commencement of this affection, we find
that the vessels of the  conjunctiva are injected, but that the injection
is especially marked in the sclerotic vessels; and the latter form a deep
red, radiated circle around the transparent cornea.  If the patient be
still in the early stage  of secondary symptoms, and have, for instance,
an  exanthematous or  rubeolar syphilitic eruption, the iritis will re-
semble this form; and, other things being equal,  it will be less severe
than at other times,  constituting what is called erythematous iritis, and
what some oculists  have  called serous iritis;  cases in which the iris
changes its color, and blue eyes become greenish and dull, and black
or chestnut eyes become fawn colored.  The iris is already swollen on
the appearance of the above symptoms, especially towards its pupillary
margin, which becomes irregular and fringed.  The secretion of the
aqueous humor is more or less augmented, so as  to render the trans-
parent cornea a  little  more protuberant than  usual, and enlarge the
anterior chamber. In  such cases, the sight is already somewhat im-
paired, but  it is not uncommon for the patient to have felt scarcely any
pain, and especially to  have had no photophobia;  but if the disease
slightly increase in intensity, or be accompanied with a papulo-squa-
mous eruption, the fluxion and sensibility are augmented, the pupillary
opening tends to contract, and plastic exudations take place in the sub-
stance of the  iris; the aqueous humor becomes cloudy,  and  the abnor-
mal colors of the iris  deepen; the pupil loses its transparency, and, from
its natural velvet black color, assumes a lactescent, mother-of-pearl hue,
       29 
450
CONSTITUTIONAL  SYPHILIS.
and the sight becomes obscured.   It is especially at this juncture that
the pupil becomes distorted, in consequence of the plastic depositions
having deprived various parts of the circumference of their power of
expansion; whilst the other parts, remaining in their normal state, still
retain their mobility.  Hence arise a great variety of distortions, which
are sometimes angular, sometimes elliptical, and sometimes ovoid.  As
I have already said, Beer thought the longer axis of the pupil in the
last distortion was directed from above  downwards, and from within
outwards, its inferior extremity at some distance from  the great circle
of the iris, and its superior approximated towards it.  But any person
who has seen many cases of syphilitic iritis, with an understanding of
the physical cause of the distortions of the pupil, knows that the latter
are in no way fixed or regular.  In this variety of iritis, the exudations
of plastic lymph often become  organized, and give rise to false mem-
branes,  which form adhesions with the  posterior surface of the trans-
parent cornea in the anterior chamber, or with the lens in the posterior.
The organization of these false membranes within the pupil not only
destroys the mobility of the iris, but forms membranous cataracts.  It
is not uncommon in this case for  the disease to extend to the lens and
destroy  its transparency, whence capsular cataract may arise.
   Independently of  the  symptoms we have just  described, we  often
find, in  the syphilitic iritis accompanying papular syphilitic eruptions,
a more or less perfect development of the vessels of the iris, which, in
some cases, resemble vegetations, and which Beer compares to condylo-
matous vegetations;  but, most commonly, we observe true papules on
the iris, more or less protuberant, of the size of a millet seed at largest,
of a coppery-red color, and as analogous as possible to the papules on
the skin.
   When the iritis accompanies a vesicular or vesico-pustular eruption,
or,, in other words, what may be called the suppurative syphilitic erup-
tions, in a pyogenic state of the system in fine, the eruption on the
iris no longer consists of simple papules, but of true vesicles, or vesico-
pustules, which some oculists have considered abscesses of the iris.  In
these  cases, the inflammatory phenomena are more intense,  the iris
more tumefied and congested; its great circle is  generally of a dark
coppery-red color, and it is not uncommon for the patient to complain
of gravitating and  even pulsating  pains.   Photophobia frequently
supervenes, if it do not already exist, and sometimes  photopsia also;
the* pain in the head  increases, and fever, though generally absent, may
appear.  The disease may still terminate favorably ; perfect resolution
taking place, and the eye returning to its normal state.  But if art do
not intervene  efficaciously and in time, the suppurated points break,
and the pus is discharged into  the anterior  chamber, giving rise to
hypopion, and all its consequences.  Still, the iris may cicatrize in the
suppurating points; though in many cases it is destroyed, to a greater
or less  extent, by consecutive  ulceration.   In these severe cases, the
inflammation often involves the transparent cornea, and causes all the
ravages which  usually follow inflammation  of this membrane.   The
iris can hardly be seen behind the cloudy screen in front of it; closer
adhesions form, and, the inflammation extending backwards, involves 
SYMPTOMS.
451
 the  retina  and  choroid, and thus  excites a very serious  internal
 ophthalmia.
   Though syphilitic iritis most  commonly occasions a diminution in
 the field of the pupil, and tends to produce pupillary atresia, yet I have
 sometimes observed permanent dilatation, a kind of mydriasis, which,
 at first, seemed to be due rather to a lesion of the sensibility than to a
 material or plastic change in the part.
   With the exception of those analogies  which we have mentioned,
 and which are very constant between the syphilitic eruptions and lesions
 of the iris, there is really nothing to establish the diagnosis  but our
 knowledge  of the cause, the antecedents, the concomitants,  and the
 generally less acute course of this variety of ophthalmia;  so  that it is
 quite impossible, in certain cases, to distinguish it from ordinary iritis
 accidentally supervening in a  patient affected with  syphilis.   In the
 absence, then, of pathognomonic signs, we have a right  to inquire, as
 in certain cases of pemphigus in  infants, whether syphilis does not act
 here like any common cause;  for, I repeat, there is usually no differen-
 tial sign apart from the supposed cause.
   All other things being equal, the prognosis of  syphilitic iritis is
 grave;  but it is the less so, when a light affection of the skin accom-
 panies  or precedes it; the pustular and'suppurative eruptions being
 the most serious.
   Infantile Syphilis.—To finish what relates  to secondary symptoms,
 it remains to speak of infantile syphilis.
   In infants born of syphilitic parents—either of a syphilitic father or
 mother, or both—and whether these parents really have constitutional
 symptoms developed at the time, or are simply under the influence of
 a syphilitic  diathesis, particularly in the secondary stage, syphilitic
 manifestations may be seen to appear some weeks or months after birth.
 If we take into account the influence of specific treatment upon .the
 parents, we find  that the new-born infant is in a condition analogous
 to that  of a person who has just become infected, and in whom, unless
 subjected to treatment, the first manifestation of the disease  will appear
 iu the course of six months.
   Pemphigus, which Professor P. Dubois1 has lately asserted is always
 due to constitutional syphilis in infants, may indeed be a specific affec-
 tion, as I have admitted  in my Iconographie de VHopital du Midi, not
 only in adults, but in infants.   But it must be confessed that up to the
 present time, no characteristic sign has been  discovered sufficient to
 distinguish it from the ordinary forms of pemphigus communis, aside
 from the cause to which it is referred. On the other hand, there is no
 inconsistency in admitting that syphilis, which so deeply impairs the
 constitution of the parents, may act like any common cause and excite
 non-specific pemphigus;  for  an  infant is badly lodged and  poorly
 nourished in the womb of an infected mother, apart from the influence
 of the virus.   In  fact, it is not proved that children born of a syphilitic
father or mother in the different stages of the disease, necessarily have

  1 Discussion before the Academy of Medicine (Bulletin de VAcadtmie Nationale de
Me-decine, 1851, t. xvi. pp. 920, 954, 971, 1226). 
452
CONSTITUTIONAL  SYPHILIS.
 syphilis.  But whether simple or syphilitic, pemphigus is a frequent
 cause of death in the foetus or infant.
   The unquestionable syphilitic manifestations in infants follow with
 tolerable regularity the order of evolution which is observed in adults
 and present the same forms.  In infants, however, other things being
 equal, mucous patches or tubercles are far more common.  They are
 found not only in the regions where they usually exist in the adult,
 but also wherever the  skin forms folds, as on the thighs, nates, axillas,
 etc.  Dry, squamous eruptions in infants are much rarer, and are gene-
 rally replaced in the regions which they occupy in adults, by pustules,
 which are flat  and  soft,  or  covered with pultaceous  scales.  True
 pustular and ecthymatous eruptions are also very frequent; they re-
 place the horny eruptions on the palms of  the hands and soles of the.
 feet in adults, and, by careless observers, may be confounded with true
 pemphigus.
   In those regions which are subject to friction and pressure, or which
 are soiled by the stools, eruptions have a great tendency to ulcerate.
 This is especially observed on the sacrum, nates, and heels.
   The mucous membranes are also very frequently the seat of second-
 ary symptoms  in infants.  Independently of papules  and  mucous
 patches on the lips and tongue,  the buccal  cavity may  be the seat of
 various symptoms which we have  already studied  in the adult.  But
 a symptom frequently observed in children  born  with syphilis, is a
 severe coryza, which  interferes with the  respiratory functions and
 nursing, and is accompanied by a muco-purulent, or rather sero-sanious
 and even sanguinolent secretion.  This secretion is a consequence of
 morbid changes in the pituitary membrane, which  are followed by
 ulcerations of various  depths, finally involving the osseous system.
   Infants born  under the influence of hereditary syphilis, are com-
 monly poorly developed, emaciated, and  lank;  their muscles are soft,
 and their skin lax, loose, and dingy; they have the aspect of little old
 men.  Some  of  them die in this state before any syphilitic symptom
 appears; while,  on the other hand, very many  come into the world
 with the appearance of perfect health.
   It is not true  that the diversity of symptoms presented by infants
 authorizes us to admit a congenital and an hereditary syphilis.   What-
 ever the mode of infection, it is impossible to make this distinction.
   On the other hand, infants have no primary symptoms, except those
 resulting from actual contagion during parturition, if the mother have
 inoculable  primary ulcers, or those  which have been communicated
 after birth.
   Hunter, in passing from the subject of secondary symptoms, which
 he calls the first period of constitutional syphilis, to those belonging
 to the second period of confirmed syphilis, and to which I  give the
name of tertiary symptoms, cites some experiments, which, according
 to the results of my researches, must have deceived him or have been
improperly explained.
   If the inoculation on the glans and prepuce, of which Hunter speaks,
gave rise to syphilitic  ulcers, it was because the pus which was used 
SYMPTOMS.
453
was not muco-pus from a gonorrhcea, but pus from a urethral chancre,
as my numerous experiments have proved.
  On the other hand, Hunter's  observation, which at first appears to
be in sufficient detail, is really wanting in precision.   The succession
of the symptoms is not clearly indicated; many of them are intermixed,
and the dates do not fix the exact time of their appearance; so that an
observation of this nature, which might have been perfectly decisive,
like  some that we have since made, leaves the reader undecided, not
only on the question, whether the ulcers produced by inoculation were
truly syphilitic, and whether the  glandular swellings were not simply
an effect of sympathy or non-specific  irritation, but also whether the
ulcerations of the throat and the spots on  the skin due to constitutional
syphilis, might not have been the result of another primary affection;
as one  is at least led to suspect from the reappearance of ulcers on the
prepuce, before the development of secondary symptoms.
   The effects  of the mercurial treatment are, perhaps, in some points,
less  contestable.
   If we now study those symptoms to which I have given the name
of tertiary, we shall find that they not only differ from primary and
secondary  symptoms in affecting the  deeper  tissues,  but also that in
them syphilis loses, in part, its peculiar type.  Though the skin is often
affected at this period with the most severe  tubercular  eruptions, yet
the subcutaneous and submucous cellular tissues,  and the fibrous and
osseous systems are far more frequently involved.   But, in addition to
these parts, where the tardy effects of constitutional syphilis are so
common and clearly admitted by .all good observers, we may ask our-
selves, with Sanchez, and many other authors, if there  be any  privi-
leged tissues of our body which are invariably exempt from the effects
of syphilis ?   We would inquire, also, if syphilitic infection, though
it may not produce all the evils with which it is reproached, be not, in
a multitude of cases, the cause of the  evolution, or putting into action
—to use an expression of Hunter's—of diseases which have previously
existed in a latent state, and of which it is  thus only the exciting cause ?
Observation  replies  in the affirmative  to these  questions, and also
teaches us that tertiary symptoms may continue under  the influence
of the virulent cause, or persist as local effects, after this cause has
been destroyed or neutralized by treatment;  it shows, in a multitude
of cases, that the syphilitic virus, after  having been the  accidental
cause of other diseases, may cease to exist, or persist as a complication;
and  these are circumstances which, though real, are unfortunately not
always easy to appreciate.
   As I have already said, tertiary symptoms rarely occur before the
sixth month following  the appearance of the  primary ulcer,  and the
latter rarely remains at the time of their development; but they are
frequently attended by some secondary symptom.   They never furnish
inoculable  secretions, nor transmit characteristic constitutional syphilis
from parent to child; their only hereditary  influence being the fre-
quent transmission of a taint, as injurious and almost as fearful, viz.,
a scrofulous diathesis.
   Tertiary symptoms, which recognize a chancre as a necessary ante- 
454
CONSTITUTIONAL  SYPHILIS.
cedent, and  which are preceded by secondary symptoms  under the
circumstances we have mentioned, often appear without any other pre-
cursory symptoms.  It is not uncommon, however, after the first symp-
toms of syphilis have disappeared, for patients to  present those pheno-
mena which Hunter describes in speaking of this period of syphilis.
After preceding the tertiary symptoms, these  phenomena may cease,
but they often continue through the whole duration of the former, and
sometimes survive them for a longer or shorter period.
  Before entering into some details on each of the more characteristic
tertiary symptoms, and meanwhile recognizing the judicious observa-
tions of Hunter in respect to the influence of the  different parts of the
body on the  production of tertiary symptoms, from which it results,
however the fact may be explained, that those  parts which are nearest
the external surface are most frequently affected, allow me,  in this
place, to make a profession of faith on the influence of mercury on this
phase of syphilis.
  Some modern innovators, forgetting the history of art, or passing
over in silence what ancient authors, before mercury was used, said of
the manifestations of syphilis in the osseous and fibrous tissues, do not
hesitate to impute  to this remedy what is really  the effect of the dis-
ease.  Others, drawing their conclusions  from imperfectly analyzed
facts, think that they see in the diseases of the periosteum and bones a
combination of the effects of mercury and syphilis; an opinion, by the
way, which was advanced by Antonius Gallus and  Fallopius.  But
here, evidently, they do not or will not recollect that, at the time most
of the statistics on this point were collected, almost all patients were
indiscriminately treated with  mercurials, and, all not being necessarily
cured, every subsequent symptom was of course preceded  by mercurial
treatment, though no one had the right to say, post hoc, ergo propter hoc,
nor to attribute to the mercury all that occurred after its  use. But, at
the present day, when the physiological school  leaves a large number
of patients to themselves, or subjects them  only  to simple treatment,
the entire series of syphilitic symptoms may be observed—as I have
had the opportunity of showing in numerous instances at my clinique
at the Hopital des Ven^riens—without there  being the  least pretext
that they are the effect of mercury.   On the other hand, both at the
hospital and in  my private practice, I have never failed to obtain, by
inquiries, the history of patients who have had a  gonorrhcea; a large
number of such persons, as is well  known, were invariably treated, a
short  time ago,  with mercurials, as many  are still at the  present day;
and now I am able to affirm, and it  is a statement easily verified, that
affections of the osseous and fibrous systems are as rare in these cases
as they are common after chancres  which  have been badly or incom-
pletely treated ;  also, that these rare and exceptional cases are in the
same  proportion as  the constitutional symptoms which  appear after
urethral chancres, and are by no means proportioned to the number of
individuals who have undergone  mercurial treatment for a  simple
gonorrhoea.
  Tertiary symptoms appear after mercurial treatment  in the same
way as secondary; that is to say, when the treatment has been badly 
SYMPTOMS.
455
applied, or has been incomplete, or when the constitution has been
absolutely refractory to it.
  Badly administered  mercurial treatment, like any  other bad treat-
ment, may aggravate tertiary symptoms by impairing the constitution,
but it can never produce them  outright,! as is proved in persons who
are subjected to mercurial influence by their occupation, or by under-
going mercurial treatment for diseases other than syphilis.
  To what Hunter says of the symptoms in question, and to the excel-
lent observations of Mr. Babington, allow me to add the following
remarks:—
  The effects of gonorrhcea and chancre on the testicles are different,
as they are on the eyes.  The first of these diseases gives rise to gonor-
rhceal  epididymitis,  which I have already described, and which  is
entirely independent of any virulent cause; whilst the other, by excit-
ing constitutional infection, produces sarcocele.
  Astruc, and particularly Bell, were  acquainted with this syphilitic
lesion, which  Hunter  did  not  believe possible;  but  Astley Cooper,
especially, has recently done much, and Dupuytren, perhaps, a little, to
call the attention of surgeons to this important • disease, which is still
imperfectly known by most practitioners.
  Syphilitic sarcocele, to which I have given the name of albuginitis,
is not unfrequently one of the first tertiary symptoms to appear, being
almost a symptom of the transition period.  It may occur in the fourth
or fifth month following contagion or the appearance  of a  chancre,
while  early secondary symptoms still  exist;  but it is especially at a
later period, after months or  years, when late  secondary symptoms
have been developed, that albuginitis supervenes, and this, too, whether
mercury has been administered or not for the preceding symptoms;
with this  difference, however, that the swelling often occurs earlier
when patients have taken no mercury, or taken it improperly or insuf-
ficiently.
  There is generally nothing to indicate that this disease is about to
commence.  Most commonly, the attention of the physician or patient
is first called to it by chance, by a slight increase in the weight or
volume of the testicle, or by a sensation of  uneasiness.   Sometimes,
though rarely, a gravitating pain in the loins, felt especially at night,
precedes or accompanies syphilitic engorgement of the testicle.
  At the present time, after having  had numerous opportunities to
observe syphilitic sarcocele in all its stages, and after having often gone
to meet this disease, so to speak, in order to detect it on its approach,
I think I am able to give a more detailed account of it than has hitherto
been done.  Not  to  overstep the bounds, however, which I have set
for myself in this work, I will  confine myself to the most important
points.
  Albuginitis begins in the tunica albuginea or cellulo-fibrous texture
of the  body of the testicle, and may affect one organ alone, or both at
once or successively. Unless some other  morbid cause, as gonorrhoea,
has acted on the testicle, syphilitic sarcocele does not involve the epi-
didymis or vas deferens.  These parts continue perfectly sound through
the  whole course of albuginitis, no matter how great its development; 
456
CONSTITUTIONAL  SYPHILIS.
but when the  tumor acquires- a very large volume, the epididymis
becomes effaced, and cannot be distinguished from the body of the
testicle.
  Anything which can act as a morbid cause on the testicle, may
become the exciting cause of syphilitic sarcocele in patients affected
with constitutional syphilis.
  If we examine  the disease at its commencement, we soon find one
or more indurated spots forming zones, as it were, on the tunica albu-
ginea, or situated deeper in the body of the testicle.  These swellings,
resembling tubercles, never form projections  on the surface so as to
change  the shape of the organ.  The indurated parts are not generally 4
painful, either when left to  themselves or when handled; but if they
be compressed, more or less pain may be excited, which is only an
exaggeration of the physiological sensibility of  the sound testicle;
and the spontaneous pain which is sometimes observed is produced in
the same way by compression.
  If the disease  continue to progress, the induration extends; the
other parts of the testicle become engorged; the tubercular indurations
coalesce and form a single tumor, preserving  the original form of the
testicle, only of a larger size. This increase of volume, though it may
be considerable, is, however, never so great as an encephaloid testicle
may attain.
  A testicle affected with syphilitic sarcocele, either in whole or in part,
gives to the touch a sensation of hardness and resistance.  It is gene-
rally heavy, and draws on the cord by its weight, exciting pain in the
corresponding groin, and even in the lumbar region. When the whole
testicle  is involved, it ceases to be painful, and is  no longer tender to
the touch.
  No matter what size the  testicle attains in syphilitic sarcocele, the
skin of the scrotum does not change its  color or temperature, and re-
mains perfectly free from adhesions.
  The course of albuginitis is generally chronic or subacute; but I
have seen it acute in some young subjects of lymphatic temperament,
and when it was complicated with gonorrhceal epididymitis; in such
cases, the albuginitis might be mistaken for simple orchitis.
  Syphilitic sarcocele may last for months or years.  Generally, as I
have said before, it is very difficult to fix the time of its commencement,
and hence the difficulty of ascertaining its duration.
  Albuginitis generally terminates in  resolution without leaving any
traces of its passage, and the testicle resumes its normal state, espe-
cially when  the pathological changes have been partial, or art has
promptly intervened, before the complete destruction of the seminifer-
ous vessels.   In such cases,  even if the testicles  have become entirely
insensible, it gradually regains its normal sensibility; but this does not
take place when the tumefied vessels  are completely destroyed and the
engorgement is succeeded by atrophy, as frequently occurs.  Atrophy,
which is almost an inevitable result when syphilitic sarcocele  is not
recognized or not  treated, may be partial or  general, like the lesions
which precede it.  It sometimes happens that atrophy is the first symp-
tom of which patients complain.  As may be seen from an observation 
SYMPTOMS.
457
published by M. Vidal, some physicians think that the testicle becomes
atrophied under  the influence of constitutional  syphilis without any
previous lesion.  But the mistake into which M. Vidal and several
other observers have fallen is  accounted for, when it is known that
partial or total albuginitis may occur without the testicle  necessarily
becoming so large or painful as  to excite the attention of patients.
   It may be laid down as a rule that, whenever syphilis alone acts on
the testicle, suppuration never occurs; tubercular tumors of the scro-
tum, like other syphilitic tubercles of the cellular tissue, can  alone
suppurate.
   In some cases, partial or total albuginitis, after having increased the
volume of the testicle to a certain degree, remains in statu quo, in con-
sequence of a  kind of degeneration of  the fibro-plastic tissue which
constitutes the lesion and which  renders the tumor  cartilaginous, or
even osseous, of which I have met with some examples.  It is  also not
uncommon to find persistent indurations of parts of the organ composed
of masses of cicatrices, as it were.
   In syphilitic sarcocele, the seminal secretion undergoes changes which
are more appreciable when the two testicles are affected.   At first, its
quantity diminishes; then its qualities are changed;  the spermatozoa
become less and less numerous; and, if the two organs be entirely in-
volved, finally  disappear with the other  elements of the sperm.   The
genital functions follow the  same course; venereal desire is decreased,
erections become less frequent,  and sexual intercourse, which is less
and less sought after, at last becomes impossible.
   Now that the diagnosis of scrotal tumors is better  understood, and
we are consequently more cautious in performing castration, patholo-
gical specimens of  syphilitic albuginitis  are very rare, especially as it
is essentially a curable disease.
   I have had an  opportunity, however, of studying the pathology of
this lesion, and have found, as I said in  commencing, that it is seated
in the tunica albuginea and the  fibro-cellular structure of the  body of
the testicle; that the engorgement consists of fibro-plastic tissue, which
involves and obliterates the tubuli seminiferi; the gradual diminution
of which can be traced until they completely disappear;  and, finally,
that in the last stage of this  degeneration, the  transition of the fibro-
plastic tissue into inodular fibrous tissue can be followed till it termi-
nates in total atrophy.
   The differential diagnosis, which was formerly obscure, has now ac-
quired a great degree of precision, to which  our clinical studies have
certainly contributed.  We shall find symptoms more than sufficient
to distinguish syphilitic sarcocele from  the diseases for which it  has
been most frequently mistaken,  viz., chronic orchitis, strumous sarco-
cele, true tubercular sarcocele, and cancerous sarcocele, if we take into
consideration the following circumstances; the antecedents  in the case,
as above indicated;  the period (primary,  secondary, or tertiary) which
the syphilitic affection has attained—which may be  generally ascer-
tained from the symptoms accompanying this lesion at the outset—its
frequent  simultaneous or successive invasion of the two testicles;  the
integrity of the epididymis, and especially of the vas deferens, and con- 
458
CONSTITUTIONAL  SYPHILIS.
sequently the absence of all lesions of the vesiculas seminales and the
prostate, unless there be some other complication; the absence, also, of
all sympathy on the part of the lymphatic vessels or venous system;
the evolution of the affection;  the  character of the pain, which de-
creases, and finally disappears completely when the disease approaches
its last stage; the  tendency of the tumor to become more and more
uniform and homogeneous;  the projections  on  its surface gradually
disappearing and leaving the organ in its natural form, whilst the con-
trary takes place in the other affections, which may be confounded with
this;  the fact that the enlargement of the testicle is  confined within a
certain limit; and, finally,  the almost inevitable tendency to atrophy,
the absence of suppuration, and the salutary influence of appropriate
treatment.
   At a  time when syphilitic sarcocele was not understood, its prognosis
was confounded with that of cancer,  and, unfortunately, castration was
consequently too  often resorted to,  as I  convinced  myself from the
pratice of my surgical preceptors.
   Now, thanks to  my semeiology—no offence to  my learned and intel-
lectual  contemporary,  M.  Malgaigne—and  thanks  especially  to the
methodical treatment which I have  introduced and recommended for
the different phases of  syphilis, syphilitic sarcocele has become one of
the easiest syphilitic phenomena to cope with and to conquer; and its
treatment is a true conquest in surgery.  There is, indeed, a great
difference between the diagnostic signs we have just laid down and
the empirical method employed  by Dupuytren and  other surgeons of
his reputation, which consisted merely in trying the effect of mercury
on the case; which, even supposing  it specific, might resist the action
of this therapeutic agent, in which case it was condemned to the knife,
whilst, at the present  day, we  know that it can be  subdued by a
remedy of very different properties, viz., iodide of potassium,  which,
as I have proved,  is the specific  for tertiary symptoms.
   The prognosis  is  always less serious  when the disease is treated
early, and when a  large portion  of the organ still retains its physiolo-
gical sensibility.
   Allow me  to add a word farther.  Iodide of potassium  has been
accused of  producing atrophy of the secreting organs, and especially
of the testes; here,  again, the  disease has been confounded with the
remedy.  The atrophy depends  on the former and not on the  latter;
for if one testicle alone be affected, it  alone  is atrophied. No doubt
but that, in grave affections of the  general system, the testicles, like
other organs, may decrease in size and become emaciated, if I may be
allowed the expression; but in  that case, when health returns, they
recover  their power, vigor, and relative size.  It is a temporary weak-
ness, but not atrophy;  and iodide of potassium, instead of having this
effect on the  secreting organs,  and  especially on the  testes, may, by
modifying the general state of the system, restore them to their natural
size.
  Plastic or fibro-plastic degenerations, which we have just examined
in the case of syphilitic sarcocele, are met with in other organs.   They
are quite common in  the  muscles, particularly in the muscles of the 
SYMPTOMS.
459
extremities.  I have met with them only in the flexors, either from
mere chance or because the disease has a predilection for these mus-
cles.  These plastic degenerations follow the phases which we  have
just described.  They consist at first of indolent indurations of greater
or  less  extent, 'which, by their development, impede the functions of
the muscles rather  than  excite pain.  The patients complain only
when the muscles are stretched in extension; flexion, on the contrary,
or the approximation of the extremities of the affected muscle, excites
no  pain.  The muscles subjected to this kind of induration, in which
the muscular fibres  finally disappear, become contracted, and at last,
if the disease continue and art do not intervene in time, are atrophied
and permanently flexed, supposing that the flexors are the muscles
affected.  I have had an opportunity of observing the same degenera-
tion in the heart, of which a  fine example is given in my Iconographie
de VHopital des Veniriens.
  Osteocopic pains may doubtless  exist alone, continue for some time,
and finally disappear, without our  being able to discover any organic
lesion in the part; but they are commonly the first appreciable symp-
tom of periostitis or ostitis.   These pains are fixed and  located; the
least pressure or the least contact increases them,  but they are height-
ened especially by heat.   It is true, as has been asserted, that they are
generally nocturnal, but this  character is not pathognomonic.
  The period at which osteocopic pains appear, their fixed position in
those parts where changes in  the periosteum and bones afterwards take
place, distinguish them from  the wandering and more superficial pains
which often arise in the neighborhood of the articulations, resemble
rheumatism, and, as we have'elsewhere seen, precede or accompany
true secondary symptoms.
  Decided inflammation of the periosteum is perhaps  rarer than is
commonly supposed. Detachments of the periosteum from the bone,
by  collections of matter giving rise to  tumors adherent at their base,
which pass under the name of periostoses, are generally due to super-
ficial ostitis.  These tumors,  more or less circumscribed, are generally
situated on the superficial bones, as the tibia, clavicle, cubitus, radius,
cranium, sternum, metacarpal bones, etc., and  at the points where the
bones approach nearest to the skin. They are sometimes indolent, but
are generally painful, and pit on pressure, or present true fluctuation.
The skin over them may continue movable for a long  time and not be
appreciably changed. Finally, periostoses are susceptible of complete
resolution, or may terminate in suppuration, the formation of abscesses
or in exostoses resembling epiphyses.
  Periostoses present three principal varieties.   The first variety is
often indolent, and sometimes rapid in its development, generally of
long duration, and terminates in most cases in perfect resolution.  It
contains a serous or sero-albuminous fluid, which sometimes resembles
scrofulous pus, or,  in certain cases,  synovial fluid.  In  the  second
variety,  the  course of which  is of  an acute or subacute inflammatory
type, suppuration supervenes sooner or later, and the subjacent  bone
rarely escapes  being involved first or last.  Finally,  in the third
variety,  the  development of which is slower, and which  is often very 
460
CONSTITUTIONAL SYPHILIS.
painful, both  sua sponte and on  pressure, plastic matter  capable of
organization elevates the  periosteum, which is  thickened  by plastic
depositions between its lamellas;  and thus  one of those varieties of
exostoses which we are about to describe may take place.
   Syphilitic ostitis has  a predilection for  the  same regions in which
periostitis most frequently occurs.   Circumscribed, though sometimes
diffuse, ostitis attacks the superficies or the parenchyma of  the bones.
Generally slow and chronic  in its course,  it often assumes  a subacute
form, and after appearing for some time as a simple ostealgia, is finally
betrayed externally by the swelling which it excites.  The  tumor suc-
ceeding inflammation of the bones is sometimes due  to an  effusion of
lymph, like that which  forms the callus in  fractures, or like that found
in periostoses of the  third variety mentioned.  It then constitutes an
epigenic exostosis resembling an epiphysis, its form and volume vary-
ing  in size, its base  broad  or pediculated,  and its surface smooth or
rough.  These epiphysary  exostoses, due to ossification  of  plastic
periostoses, are sometimes separated from the subjacent bone  by a
layer of periosteum, which is but slightly adherent, and which allows
them to be easily detached  before ossification is complete.  At other
times, the swelling depends on a thickening  of the whole substance of
the bones, giving rise to parenchymatous exostosis or hyperostosis.
   Ostitis  terminates in resolution, suppuration, caries, necrosis, or in
induration forming eburnated exostoses.
   Resolution takes place without difficulty when the swelling depends
on an affection of the cellular tissue of the bone, or on an  effusion of
plastic lymph. When the disease is situated in the spongy  bones, par-
ticularly in the bones of the face,  and, above all, in the superior max-
illary bones, suppuration occurs frequently and easily. Necrosis is
often due to the relative violence of the inflammation  compared with
the vitality of the osseous system, but is produced still more frequently
by the effusions which suddenly take place in the tissues, and the de-
tachment  and destruction of  the surrounding soft parts, involving the
nutritive vessels.   Necrosis may take  place either before, at the same
time, or after caries; but generally—and this is especially true of the
facial bones—what is considered necrosis is  only the  result of caries
in which all the organic tissues are destroyed by that kind of  ulcera-
tion  and suppuration peculiar to bone, leaving only the calcareous sub-
stance, which then forms a very different sequestrum from that of true
necrosis, in which all the anatomical elements of bone remain. Finally,
its termination in persistent induration or eburnation takes place when-
ever the tumor is due to a  deposition of inorganic saline matter,  such
as enters  into  the  natural composition  of bones, with more or less
complete disappearance of  their cellular tissue and fibrous structure.
It is evident that exostoses may, from their  situation, encroach upon
neighboring organs, and give rise to lesions and symptoms  depending
on the functions of the  organs.
  Deep tubercles of the cellular tissue do not ordinarily appear till
very late after the primary ulcer.   With the exception of some slight
cases, they are the consequence of a profound change in a constitution 
SYMPTOMS.
461
under  the  influence of syphilitic  cachexia.  These  tubercles, either
isolated or  in groups, and often somewhat numerous, commence with
a small tumor, scarcely perceptible at first, but  hard, adhering to  the
skin or mucous membrane by a kind of pedicle, and movable on  the
subjacent and surrounding parts. They almost always increase slowly,
and are unattended with  pain.  It  often takes five or six  months or
more for them to attain their limit, when they may be as large as a
filbert  or walnut.   They are still very hard, but soon  become adhe-
rent, and fluctuation may gradually be detected through a kind of cyst,
which  serves as their envelop.  The skin, which up to this time may
have remained unchanged both in texture and  color, becomes of a
brownish-red or violet color, soon grows thin, and is perforated in  one
or more points, giving vent to thin ichorous pus, which contains organic
debris.  Large irregular ulcerations soon succeed these openings, and
the skin becomes thin and detached.  These ulcers last till the elimi-
nation of the tubercular cyst, which begins to suppurate at its centre.
When once these cysts are cast off by the suppuration of the neigh-
boring parts, the ulcers, unless kept open by some other cause, begin
to heal, and finally leave  a cicatrix perfectly  analogous to that of deep
burns.
   These tubercles of the cellular tissue are  rarely developed every-
where  at once.   Most frequently they succeed each other, so as to  last
months or years, no matter how  they are treated.  They are often
isolated, but sometimes agglomerated.   Although they occur most  fre-
quently beneath the skin, especially  on the external  surface of  the
extremities, where the  fascias are most dense, they are also often  met
with in the substance of the lips or cheeks, within the  buccal cavity,
in the  substance of the velum palati, beneath the mucous membrane
of the  -pharynx and in the tongue,  which then seems as if stuffed ^with
small nuts, resembling the inequalities of scirrhus, and, after suppura-
tion and ulceration have taken place, they are  easily mistaken  for
cancer; the same thing is observed in the scrotum.
  Never, at any stage, do these tumors affect the neighboring lym-
phatic  ganglia; and this,  in many cases, will  serve to distinguish them
from an indurated chancre, which is promptly accompanied by its
symptomatic pleiad of ganglia, and from cancer, which does  not  act
on the  ganglia till a much later period.
  Syphilitic tubercles of  the cellular tissue may be developed in  the
deep organs.  I have met with them in the brain, of which I showed
a fine instance to the Academy of Medicine; also in the liver and lungs.
It is evident that in consequence of the situation, texture, and func-
tions of organs, there is, besides the intrinsic symptomatology, as  I would
call it—meaning thereby the symptomatology belonging to the lesion
itself—a relative symptomatology peculiar to each region, on which I
have no need to insist, and which generally marks the true nature of
the disease, when we cannot  refer to the other diagnostic elements,
which are to be found with more or less  ease in a knowledge of  the
antecedents, in a just appreciation of the concomitant syphilitic lesions,
and in  the influence of rational treatment.—Ricord.] 
462
CONSTITUTIONAL  SYPHILIS.
  [Editor.—Dr. G. S. Lagneau, son of the author of the Traite des Mnla.
dies  Syphilitiques, published his These de Paris, in 1851, on  "Pulmonary
Diseases, caused or influenced by Syphilis."  In this thesis, he  collects fifty-
three cases of diseases of the lungs, apparently more or less connected with
syphilis, and endeavors to prove that syphilis may act on the lungs and bron-
chia :—
  I. By producing changes essentially syphilitic in their character and divisi-
ble into two classes :—
  1. Affections, which are generally slight, consisting of acute inflammation
of the bronchia and the  parenchyma of the lungs, intermittent inflammation
of the bronchia or asthma, and chronic inflammation of the bronchia.
  2. Serious affections, which are described by most authors under the head
of phthisis, comprising ulcerous chronic inflammation of the bronchia, chronic
inflammation of the parenchyma of the lungs and the lymphatic ganglia, in-
flammation of the pleura, and syphilitic tubercles.
  II. By  aggravating and hastening the development of pre-existing depo-
sitions of  tubercle.
  M. Lagneau enters at length  into the symptoms of these various lesions,
but it must  be confessed that he does not succeed in establishing any pathog-
nomonic signs by which they may be recognized.
  Within the last few years, certain pathological changes in the viscera have
been noticed by MM. Dubois,  Depaul, and Gubler, in post-mortem examina-
tions of infants who have died of hereditary syphilis ; and these  changes have
therefore been attributed to the influence of  this disease.  For  the following
condensed summary of the  original papers  by the authors mentioned, I am
chiefly indebted to  the recent work of MM.  Maisonneuve  and Montanier,
entitfed Traiti Pratique des Maladies  Vintriennes, Paris, 1853.
  Abscesses  of the Thymus Gland.—Professor Dubois was the first to  call the
attention of practitioners to a  peculiar affection of the thymus gland, which
he considers due to hereditary syphilis, and which consists in the presence of
pus  in  this  organ, either distributed at various points or collected in an
abscess.  The external aspect of the gland is perfectly normal, presenting its
usual color,  volume, and consistency;  but when cut, a number  of small sup-
purating points are observed,  or a collection  of pus ; never, however, very
abundant.   This condition of the thymus gland almost always coexists with
other clearly syphilitic lesions, and especially with pemphigus neonatorum.
It is well to know, however, that  this gland naturally secretes a whitish viscid
fluid, which  might be mistaken for a purulent secretion dependent on infantile
syphilis.   It is sufficient to mention the possibility of this error, which may
be  avoided  with a  little care.   This  affection  may be observed in the dead
foetus, as well as in  children who, born with the appearance of perfect health,
afterwards die of hereditary  syphilis.  (See Gaz. Med. de Paris, 1850, p.
392.)
  Syphilitic Changes  in the Lungs.—Dr. Depaul observed,  about the same
time, an affection of  fhe  lungs in infants, which he attributes to syphilitic 
SYMPTOMS.
463
infection.   This affection appears under two distinct forms, like the abscesses
of the thymus gland; sometimes as masses of simple induration due to infil-
tration of pus,  at other times as true purulent collections, with walls varying
in thickness, and infiltrated with a fluid of the same nature.  M. Depaul has
found evident traces of syphilis on the skin and elsewhere coexisting with the
lesion, and has, therefore, concluded that the latter is always syphilitic.  In
this opinion, he probably  goes too far; for, while we recognize, as he does,
that this affection of the lungs is often produced by syphilis, we think either
it, or  something very analogous to it, is met with in cases where the infant is
certainly not affected with  constitutional syphilis.
   Syphilitic Affection of the Liver.—Several years since, Dr. Gubler described
an affection of the liver also supposed  to depend on hereditary syphilis.
Latterly, he has published an important memoir on this subject in the Gazette
Medicate, of which the following is an analysis :—
   The lesion in question, when considered in relation to its pathological ana-
tomy, may be general ox partial.   When general,  the liver is very large, tur-
gid, of  a  peculiar yellow color, like that of certain gun-flints.  The natural
appearance of the two substances composing the liver has entirely disap-
peared ; the latter is hypertrophied, hard, and very elastic ; when cut, it creaks
under the knife ; if compressed with some force, there flows from the cut sur-
face a limpid, serous fluid, of a citrine color, and  coagulable by heat.  This
general state of the liver is a little less marked in some cases, but its charac-
ters are absolutely the same.
   When the lesion is partial, the  liver, although hypertrophied, is less volu-
minous than  in  the preceding form;  it  presents a singular assemblage of
colors, viz: brown and  red belonging to the healthy portion, and a yellowish-
flint color belonging to the diseased portion.   The yellow portion is always
less extended  than the  other, and is hard and elastic;  presenting, in a word,
all the characters above described as belonging to all parts of the organ when
the affection is general.   The sound portion retains  its normal characters,
but gradually  loses them as it  approaches the diseased part, and assumes
the characters of the latter, so that there is no distinct line of demarcation
between the two.
   In  the indurated tissue,  the vessels are  almost impermeable,  the capillaries
obliterated, and the calibre  of the larger vessels  much diminished—owing,
according  to M. Gubler, to a copious deposit of plastic lymph in the tissues
of the liver, or rather to a fibro-plastic transformation of this organ in the
diseased parts, proving the existence of previous inflammation ; in fact, traces
of the latter are  found on the surface of the  organ, consisting  of pseudo-
membranous pellicles, which  are thin, transparent, not easily  seen  with  the
naked eye, but easily detached with the nail.   The other organs have pre-
sented nothing worthy  of notice, unless it be the lungs, which have exhibited
symptoms  of an acute or chronic pneumonia.
   As to the causes  of  this affection, M. Gubler thinks that it is due only to
syphilis;  in which  disease many other observers have  also noticed it  (MM. 
464
CONSTITUTIONAL  SYPHILIS.
 Trousseau, Lebert, Depaul, etc.).  Other  symptoms of syphilis are almost
 always observed in the infant at the same time, and generally it is not difficult
 to ascertain with certainty that the parents  are also infected; in but one case
 observed by M. Gubler, was this the only lesion presented by the infant.  We
 are, therefore, led to infer that this is really a symptom of hereditary syphilis,
 which our author refers to tertiary symptoms; in his opinion, it consists of a
 fibro-plastic degeneration analogous to tubercles of the cellular tissues and
 orchitis, or syphilitic sarcocele; it appears especially during extra-uterine life,
 but has been observed in the foetus.
   The symptoms of this lesion of the liver are not characteristic ; none being
 observed except those of peritonitis.  In  the words of M. Gubler: " Chil-
 dren  begin to moan, toss about their lower extremities, and, as M. Trousseau
 remarks, weep without shedding tears; vomiting and diarrhoea or constipa-
 tion follow; the abdomen becomes flatulent; the  least pressure on this region
 excites moaning and  agitation ; the pulse is quick and small; the skin pre-
 serves a medium temperature for some time.   Soon, the countenance materially
 changes; the features  become sharp, the eyes excavated, and surrounded with
 a bluish  circle; there is extreme prostration ; the limbs become cold, and the
 little  patient soon dies.
   "These symptoms rarely occur till from two to four.days before death, and
 are far from always  presenting the above characters.   Generally, vomiting is
 the chief symptom, and is accompanied with constipation;  in one case, there
 was diarrhoea; finally, both these functional  derangements  may be wanting.
 Provided the plastic infiltration be not very extensive,  the  secretion of the
 bile still  goes on, and the more important functions  of the system are not
 interfered with.  But  the case is  different when  nearly the whole organ  is
 involved; the  formidable symptoms just mentioned  appear and reveal the
 nature of a disease which is now beyond the resources of art.
   "Before the appearance of the preceding symptoms there is nothing to lead
 one to anticipate a fatal issue.  But is it probable that the early phases of
 this affection are inappreciable ?  Doubtless  not; there must necessarily be,
 at the outset of the disease, certain derangements of  the  digestive organs,
 and perhaps also of the respiratory.   My researches not having  as yet been
 directed  to this point,  I can only call the attention of practitioners to it."
  It is remarkable that with such a lesion neither icterus, anasarca, nor oedema
 of the lower extremities have ever been observed; the patient is always chloro-
 ansemic.
  It is evident from the above that we are not prepared to furnish  the ele-
ments of an accurate diagnosis; still, if we find  serious digestive trouble in
an infant with well-characterized chloro-anasmia, and an increase in the volume
and consistency of the liver, we shall be authorized to infer the existence of
this plastic infiltration of the  organ ; and if there be also symptoms of peri-
tonitis, the case will be no longer doubtful.   This disease is always  fatal,
when the infiltration is very extensive; in other cases it is, to say the least,
very serious.—Editor.] 
TREATMENT.
465
                     CHAPTER  III.

  GENERAL OBSERVATIONS ON  THE  CURE OF LUES VENEREA.

   It has been observed before, that there are three forms of the vene-
 real infection, gonorrhcea, chancre,  and the lues venerea, which various
 forms I have endeavored to account for.  As they all three arise from
 the same poison, and as the first two  depend only on a difference in
 the nature of the parts, and the lues venerea on another circumstance
 which has  been explained, it would  be natural to  suppose that  one
 medicine, whatever it be, would cure all  the  forms  of this disease.
 But we find  from experience that this does  not hold  good; for  one
 medicine, that is mercury, cures only the chancre and the lues venerea,
 and the gonorrhcea is not in the least affected by it; and what is still
 more remarkable  is, that the two which  it cures  are in  no respect
 similar, while the gonorrhoea, which it does not cure, is similar in some
 respects to the chancre, which it does cure.
   It may be remarked in general, that there is not only a difference in
 the form of the disease, but also in  the modes of cure, and in the times
 necessary for the cure of the  different forms of the disease, even when
 the same medicines cure.  The gonorrhcea, in its cure, is the most un-
 certain of the three, the chancre next, and  the lues  venerea the most
 certain, although cured by the same medicine which cured the chancre.
   A gonorrhcea in some cases shall be cured in six days, and in others
 require as many months, which, with regard to  time, is about the pro-
 portion of  thirty to one. A  chancre may  be sometimes cured in two
 weeks, and often requires as many months, which is in the proportion
 of four to one.   The lues venerea in general  may be cured in one or
 two  months, which is only two to  one.  This calculation  shows  the
 regularity and irregularity, as to time, in the cure of each form of the
 disease.
  I have formerly observed, that indispositions of the body often affect
 this disease very considerably, more especially the gonorrhcea and the
 chancre.
  When an increase of symptoms takes place in a gonorrhcea, from an
indisposition of body, nothing should be done for the gonorrhoea, the
indisposition of body being only to be attended to;  because we have
no specific for the  gonorrhcea, and  in time it cures itself.  But this
practice is perhaps not to be followed in a chancre or lues venerea. It
may be necessary in those to  continue the  mercury, although perhaps
more gently; for the mercury is a  specific  that cannot be dispensed
with, because neither the chancre nor lues venerea are cured by them-
selves, but always  increase.
  This form of the  venereal disease  I  have divided into  two stages.
      30 
466
CONSTITUTIONAL  SYPHILIS.
When in the parts most susceptible of the disease, which I have called
the first order of parts, and which  appear to be the superficies only,
the lues venerea is perhaps subject to less variety than either the gonor-
rhoea or chancre, and its mode of cure is of course more  uniform,
although the disease be less easily ascertained,  at least for some time.
In the second order of parts the  lues venerea becomes more compli-
cated, and its cure still less to be depended upon.
  The cure of this form is much more difficultly ascertained than either
of the two former;  they, being always local, and their  effects visible,
become more the object of our senses, so that we are seldom or never
deceived in the cure, although at the same time the cure is often more
tedious and difficult; for whenever the symptoms of the gonorrhoea or
chancre have entirely disappeared, in general the patient may look upon
himself as cured of them; but this is not the case in the lues venerea.
  A lues venerea is the effect  of  the poison having circulated in  the
blood till it has irritated parts so as to give them a venereal disposition,
which parts sooner  or later  assume the  venereal action, according to
the order of their susceptibility.
  When the venereal matter is circulating, I have supposed that cer-
tain parts are irritated by it, and that a vast number of other parts
escape, as is evidently the case with the chancre; for in the case of a
chancre the whole glans, prepuce, and skin of the penis have had  the
matter applied to them, yet only  one or more points are contaminated
or irritated by it, all the others escaping; and we often see in the lues
venerea, that when the parts contaminated assume the action, it is con-
fined to them without affecting other parts, although  the disease be
allowed to go on for a considerable time without any attempt to a cure;
and also, if these parts are imperfectly cured, the disease returns only
in them; therefore these effects, although arising from the constitution,
are in themselves entirely local, similar to the gonorrhcea and chancre,
and like them may be cured locally ; and the person may still continue
to have the lues venerea, although not in these, yet in other parts,  be-
cause there may be many other parts in  the same body that are under
the venereal disposition, although they may not yet have assumed  the
venereal action.   To  cure the local and visible effects of the disease
we must attack it through that medium by which it was communicated,
that is, the blood;  without, however, considering the blood itself as
diseased, or containing the poison, but as the vehicle of our medicine
which will be carried by it to every part of the  body where the poison
was carried, and in its course it will act upon the diseased solids. This
practice must be continued some time after all  symptoms have disap-
peared ; for the venereal action may to appearance be stopped, and  the
symptoms disappear, and yet all return again, the venereal action  not
being completely destroyed.   If  the medicine were also a cure for  the
disposition in the parts second  in order, and could prevent their coming
into action, it would be necessary to continue it somewhat longer on
their account; but this is not the case,  for the visible effects, symp-
toms, or appearances in the first  order of parts, give way to the treat-
ment, while the parts that have only acquired the disposition, and are
still inactive, afterwards assume the action and continue the disease. 
                          TREATMENT.                       467
                      t
This deceives the surgeon, and leaves the groundwork for a second set
of local effects in the parts second in order; but I have asserted that
what will cure an action will not cure a disposition; if so, we should
push our medicine no farther than the cure of the visible effects of the
poison, and allow whatever parts may be contaminated to come into
action afterwards.
   The parts that first assume the venereal action are easiest of cure;
and I have suspected that those effects of the disease being  external,
were in some degree assisted in their cure by the local action of the
medicine, which evidently passes off through those parts.
   When the disease has attacked the parts second in order of suscepti-
bility, it generally happens that they are more difficult of cure than
the former; therefore, when  they are affected at the same time with
the former, and are cured, we may be sure that the first will be also
cured.   From hence, as it would appear that the parts most susceptible
of the disease are also  easiest of cure, it follows that the parts least
susceptible of the disease are also most difficult of cure; and I believe
that this is seldom or never reversed; therefore, those second in order
of susceptibility have this advantage, that we have the local complaints
for our  guide to judge of the whole; and  in such we have only to
continue the treatment  till they all vanish, being certain that the cure
of the first, if there are  any, will be involved in those of the second.
   As the second are attended with more tumefaction or swelling than
the first, it becomes a question whether the mercurial course should be
continued till the whole have subsided.  But I believe it is not neces-
sary to continue the method of cure  till  the whole tumefaction  disap-
pears, for as those local complaints cannot contaminate the constitution
by reabsorption, and as the  venereal disposition and action from the
constitution  can be cured while the local effects still remain, even where
the tumefaction forming nodes on the bones,  fascias, &c. is carried the
length  of suppuration, there can be no  occasion for continuing the
course  longer  than the destruction of the venereal action.  But this
effect of our medicine is not easily known ; therefore it will be neces-
sary to pursue the method of cure till the appearances become station-
ary, and probably a little longer, to destroy  the whole action  of the
disease.  From these circumstances,  it would appear that the venereal
irritation when in  this stage of the disease, is easier of cure than the
 effects of that irritation, such as the tumefaction.

      § 1. Of the Use of Mercury in the Cure of the Lues Venerea.

   Mercury in the lues  venerea, as in the chancre, is the great specific,
and hardly anything else is to be depended upon.   It is necessary that
 we should always consider well the effects of this medicine, both on the
 constitution  at large and the disease  for which it is given.  The effects
 of mercury on a constitution will always be as the quantity of mercury
in that constitution; and when the same quantity affects one constitu-
tion more than another, it is in the proportion of the irritability of that
constitution  to the powers  of  mercury, entirely independent of any
 particular preparation, or any particular mode of giving it. 
463               CONSTITUTIONAL SYPHILIS.
                                           »
   With regard to the preparations of the medicine, and the modes of
applying it, we are to consider two things; first, the preparation and
mode that is attended with the least trouble or inconvenience to  the
patient; and second, the preparation and mode of administering it that
most readily conveys the necessary quantity into the constitution.
   Nothing can show more the ungrateful or  unsettled mind of man
than his treatment of this medicine.  If there is such a thing as a spe-
cific, mercury is one for the venereal disease in two of  its forms; yet
mankind are in pursuit  of other specifics for the disease, as if specifics
were more common than diseases; while at the same time they are too
often contented with the common mode of treating many other diseases
for which they have no specific; and these prejudices are supported by
the public, who have in their minds a dread of this medicine, arising
from the want of knowledge of our predecessors  in  administering it;
and many of the present age, who are equally ignorant, take advantage
of this weakness.
   Mercury in the constitution  acts on all parts of the machine,  cures
those which are diseased, affecting but little those that are sound.  Mer-
cury is carried into the constitution in the same way as other substances,
either externally by the skin, or  internally by the  mouth;  it cannot,
however, in all cases, be taken  into the constitution  in both ways, for
sometimes it happens that the absorbents on the skin will not readily
receive it, at  least no effect will be produced, either on  the disease or
constitution, from such  application;  when this is the case, it is to  be
considered  as a misfortune, for then it must be given internally by the
mouth, although  possibly this mode may be very improper in other
respects, and often inconvenient.  On the  other hand, it sometimes
happens that the internal absorbents will not take up this medicine, or
at least no effect is produced  either upon the disease or constitution;
in such cases, it is  right to try all the different  preparations of the
medicine,  for it  will sometimes happen that one  preparation will
succeed when another will not.  I have never seen a case where neither
external nor  internal applications of mercury were absorbed; such a
case must be miserable indeed.
   I may just observe here  that many surfaces appear to  absorb this
medicine better than others, and  most probably all  internal surfaces
and  sores are of this kind;  for when we find  that thirty grains of
calomel rubbed in on the skin have no more effect than three or four
taken by the mouth, it becomes a  kind of proof that the  bowels absorb
it best; also,  when dressing a small sore with red precipitate produces
a salivation, it shows that sores are good absorbing surfaces, especially,
too,  when we know that  the  lues venerea generally  arises  from  a
chancre.
   A patient with a stump which produced too much granulation was
dressed with ointment containing  a large proportion of red precipitate;
the sore was about the size of a crown piece.  It very nearly brought
on a salivation, and the  patient was obliged  to leave  it off.
   A mulatto woman had  upon her  leg  a very bad  ulcer, which was
about  the breadth of two palms; it was dressed  with red precipitate 
TREATMENT.
469
mixed with common ointment, which soon threw her into a violent
salivation.
  A lady, in the month of December, 1782, was burnt over the whole
breast, neck,  and  shoulders, as also between  her shoulders, on which
parts deep sloughs were formed.   The sores at first healed nearly up,
and  tolerably well for burns; but  they broke out anew, and  then
became more obstinate.  Seven  months  after the accident, she came
to London, with very large sores extending across the breast and upon
each  side to  the  shoulders; they were extremely tender and painful.
They continued to  heal for some time after she came to  London;  but
she became ill, having been affected with extreme irritability, loss of
appetite, sickness, and  throwing up  of her food and medicines.  At
this  time, the sores again  began to spread, and became very large.
After having been two months in  town with little advantage, I tried
warmer dressings, as basilicon, to some parts,  to see if any advantage
would arise from such treatment, and it  was found  that these parts
healed rather faster than  the others; but the soreness  was so great,
even  from the mildest dressings,  that they could only be used in part.
I next tried red  precipitate mixed  with the ointment; and, that it
might increase the pain as  little as possible, I ordered only ten grains
to two ounces of the ointment.  This appeared to agree better with the
sores than the ointment alone; and we were happy in having found a
dressing which both hastened  on  the cure and was easier  than the
former.  But about the fourth  or fifth dressing from beginning the
use of the precipitate, she began to  complain of her gums; the  next
day  began to spit, and  by the seventh or eighth day the mouth was so
sore, and the spitting so considerable, that, upon considering the case,
we began to suspect that it might proceed from the red  precipitate in
the dressing.  The gums, inside of the cheeks, and the breath were
truly mercurial.  We  immediately left off this dressing, except  to a
small corner, and had recourse to the former dressings.  In a few days,
the effects of the mercury abated,  and the  sores looked  more healthy
than  ever, and we  again began to dress part  of the sores with the
ointment containing precipitate, which still agreed with them.   When
the mouth first became affected, she had not used much above one-half
of the ointment;  and by the time  we had discovered the cause, about
three-fourths of it  had been expended in dressings, so that  there was
not quite ten grains of precipitate applied;  and, although this took
up  seven or  eight  days,  and  the ointment  must  have been soon
removed from  the sore by the discharge, yet a considerable spitting
was produced, which lasted above  a month.   It is hardly to  be  con-
ceived that above  a grain or two  could really be taken  into the con-
stitution; for when we consider  the particles of precipitate were
covered with ointment, and a vast  discharge of matter, so as  soon to
remove this small quantity from the sore, we can hardly admit the
possibility of more  being absorbed;  and  if this idea of the quantity
taken in is just, to what must we  attribute the great susceptibility to
the effects of the medicine?  Was it the irritable state of the patient
at the time ?   For the state of the  constitution appeared  to  me to  be
that in which the  locked  jaw often takes place; and I often had this 
470
CONSTITUTIONAL SYPHILIS.
disease in my mind.  The patient afterwards got well by the use of an
ointment in which pitch was an ingredient.1  All this  tends to show
that sores and internal surfaces absorb better than the skin.
  Besides the practicability of getting the medicine  into the constitu-
tion in either way, it is proper to consider the easiest for the patient,
each mode having its convenience and inconvenience, which arise from
the nature of the constitution or of the parts to which it is applied,
or from certain situations of life of the patient at the time. It is there-
fore proper to give it in that way which suits these circumstances best.
  To explain this farther, we find that in many patients the  bowels
can  hardly bear mercury at all;  therefore it  is to  be given  in  the
mildest form possible;  also joined with  such other  medicines as will
lessen or correct its violent local  effects, although not its specific ones
on the constitution at large.
  When  it can be thrown into the constitution with propriety by the
external method, it is preferable to the internal, because the skin is not
nearly so essential to life as the stomach, and therefore is capable in
itself of bearing much  more than the stomach; it also affects the con-
stitution much less;  many courses of mercury, which are absolutely
necessary, would kill the patient if taken by the stomach, proving
hurtful both  to the  stomach and intestines, even when given  in any
form, and  joined with  the greatest correctors; on the  other hand, the
way of life will often not allow it to be applied externally.  It is  not
every one that can find convenience to rub in  mercury, therefore they
must take it by the mouth if possible.   To obviate the inconvenience
often arising from the  visible effects of mercury, many preparations
have been  invented; but any preparation of mercury producing an
effect different from the simple effects of mercury in that constitution,
such as sweating or an  increased discharge of urine,  must be supposed
either not to act  as  mercury, or the substance with which  it is com-
pounded produces this  effect; but, if its peculiar effects are  less than
usual, I should very  much suspect that the mercury is acting in part
as a compound, and not entirely  as mercury.
   Mercury, like many  other medicines, has two effects, one upon the
constitution and particular parts, which is according to its mode of irri-
tation, independent of any disease whatever.   The other is its specific
effects upon a diseased action of the whole body, or of parts, whatever
the disease be, and which effects  are only known by the disease gradu-
ally disappearing.  The first becomes an object of consideration for the
surgeon, as it is in some measure by them he is to be guided in giving
this medicine so as to have its specific effects  sufficient for the cure of
the disease.
   Whatever injury mercury may do to the  constitution it is by its visi-
ble effects, and thence the pretended art in avoiding those visible effects
has been too much the cause of great imposition.  The part upon which
its  effects are most  likely  to fall is the  part that is in most cases

  1 Added : " A gentleman introduced  a bougie into the urethra smeared with mer-
curial ointment, and rubbed in a little on  the fraenum three times, and his mouth
became affected."—Hume. 
TREATMENT.
471
attempted to be avoided, or guarded against, and that is the mouth.  I
believe that we are not possessed of any means of either driving the
mercury to the mouth, or of preventing it from attacking  that part.
Cold and warmth are the two great agents mentioned by authors;  we
find them recommending the avoiding of cold, for fear the mercury
should fly to the mouth, as if warmth was a prevention;  while others,
and even the same authors, when talking of  bringing  the mercury to
the mouth, recommend warmth, as if cold were a preventive.  This
being the case, we may reasonably suppose that neither the one nor the
other has any material effect.1
  In giving mercury in the venereal disease, the first attention should
be to the quantity, and its visible effects in a given time; which when
brought to a pitch are only to be kept up, and the decline of the disease
to be watched; for by this we judge of the invisible or specific effects
of the medicine, which will often inform us that some variation in the
quantity may be necessary.
   The visible effects of mercury are of two kinds, the one on the con-
stitution, the other on some parts capable of secretion.  In  the first it
appears to produce universal irritability, making it more susceptible of
all impressions; it quickens the pulse, also increases its hardness, pro-
ducing a kind of temporary fever;  but in many constitutions it exceeds
this, acting as it were as a poison.  In some it produces a  kind of hectic
fever; that is, a small quick pulse, loss of appetite, restlessness, want
of sleep, and a sallow complexion, with a number of consequent symp-
toms ; but, by the patient being a little accustomed  to the use of it,
these constitutional effects commonly become less, of which  the follow-
ing cases are strong instances:—
   A gentleman rubbed in mercurial ointment for the reduction of two
buboes. He had only rubbed it in a few times when it affected his con-
stitution so much that it was necessary to  leave it off.  He  was seized
with feverish complaints of the hectic kind, a small quick pulse, debility,
loss of appetite, no sleep, and night-sweats.   He took the  bark, with
James's powder, and asses' milk,  and  got gradually rid of the com-
plaints.  As the buboes  were advancing, it was necessary to have re-
course to mercury again; and  I told him that now it would  not pro-
duce the same effects so quickly nor so violently as before.   He rubbed
in  a considerable quantity without his constitution or mouth being af-
fected; but the buboes suppurating, I ordered it to be left off a second
time; and when  they were  opened he had  recourse  to the ointment
again for the third time, and without producing any disagreeable effects.
The buboes put on a healing disposition for a while, and then became
stationary, showing that a new disposition was forming.   He  was
directed to leave off the ointment and to bathe in the sea, which he
did, and the buboes began to heal. In about three weeks,  however, it
 was thought necessary to use more friction, and, when he began, which
 was the fourth time, it had almost an immediate and violent effect upon
his mouth ; he left oft'again till his mouth became a  little  better, and
then returned to the mercury a fifth time, and was able to go on with it.
1 The whole of this paragraph omitted.—Home. 
472
CONSTITUTIONAL SYPHILIS.
   A stout healthy man used mercurial friction for a bubo till it affected
his mouth; it farther brought on very disagreeable constitutional com-
plaints, such as loss of appetite, watchfulness, sallow complexion, las-
situde from the least exercise, and swelled legs; and, although various
means were used to reconcile the constitution to it, yet it continued to
act as a poison.
   Mercury often produces pains like those of the rheumatism, and also
nodes which are of a scrofulous nature;  from thence it has been ac-
cused of  affecting the  bones, " lurking in them," as authors have  ex-
pressed it.1
   It  may be  supposed to  be unnecessary to mention, in the present
state of our knowledge, that it never gets  into the bones in the form
of a metal, although this has been asserted by men of eminence and
authority in the profession, and even the dissections of dead bodies have
been brought in proof of it; but my experience in anatomy has con-
vinced me  that such appearances never occur.  Those authors have
been quoted by others, imaginary cases of disease have been increased,
the credulous and ignorant practitioner misled, and patients rendered
miserable.
   [Ricord.—Though at the time Hunter wrote, he may have doubted
whether mercury can be found after death in the tissues of persons who
have taken it, this  fact is  no longer questionable at  the present day,
now that more exact pathological researches and more accurate chemical
analyses have enabled us to demonstrate its presence, even in a metallic
state, both in certain liquids and in certain solids of the economy. For
information on this subject, consult the interesting work of M. Strohl
(These Inaugurate soutenue a la Faculte de Strasbourg, Nov. 27, 1838);
the memoir of M.  Reynaud,  of Toulon,  on a remarkable case of the
presence  of mercury in the brain (pamphlet, 1839).  In a patient who
died under  my care of encephalitis occurring during mercurial  treat-
ment, M.  Grassi, at that time chief Pharmaceutist at the Hopital du
Midi, found mercury in the softened and suppurating substance of the
left anterior lobe of the cerebrum.  Moreover, the possibility  of find-
ing mercury in various organs and in certain secretions, is placed be-
yound a doubt by the observations of Mr. A.  Colson, on the presence
of mercury in the  blood, by Barruel's analyses, and  especially by the
skilful researches  of our  illustrious teacher,  Professor Orfila.   Mr.
Colson's observations, it is  true, were contradicted by M. Cullerier, but
have recently been verified.
   It would  appear  from the recent researches of MM. Chevalier and

   1 The following paragraphs are added :—
  "Mercury often produces an itching of the  skin, so much so in some that they can
hardly bear it.
  " Although mercury does not always  affect the  mouth, yet it sometimes affects the
constitution of the person whose mouth cannot be affected, producing loss of appetite,
pains of the rheumatic kind, and all the constitutional symptoms of hectic fever, and
at the same time shall  be curing the venereal disease effectually.
  " A person had pains  in his shoulders and blotches on the skin, supposed to be vene-
real.  He never could be affected with mercury.  I made him rub in two drachms of
strong mercurial ointment every night, and the symptoms entirely disappeared, with-
out any effects being produced by the mercury on the mouth, skin, or kidneys. "—Home. 
TREATMENT.
473
Ossian Henry (Journal de Chimie Medicale, de Pharmacie et de Toxico-
logic, 1839), that mercury does not pass into the milk of nurses, as very
many practitioners have  thought.  M. Peligot seems to have arrived
at the same result from his researches on the milk of animals.  Berruel,
however, met with mercury in the breasts  of  a female who died of
puerperal peritonitis, under M. Velpeau's care, after being treated with
copious mercurial inunctions.  M. Personne, the present chief phar-
maceutist at the  Hopital  du Midi, has at last shown by recent analyses
that mercury may be found in the milk  of nurses subjected to mer-
curial treatment.—Ricord.]
   [G. G. B.—The symptoms which mark what the  author has denomi-
nated the poisonous effects of mercury are of such importance as to
require a  more particular description.  They assume two different
forms, the one having an acute, the other a chronic character.
   The former constitutes what has been denominated  mercurial  ere-
thism us.  The effect of the  poison is here  chiefly felt on  the  heart.
The pulse becomes hurried, small, and  irregular; the  action  of the
heart violent, but at the  same time irregular and fluttering; and the
weakness and imperfection of the circulation are  farther testified by
paleness of the  countenance, by frequent sighing  and  anxiety about
the prascordia, and by unsteadiness of the limbs. In very severe cases
the countenance becomes contracted, and the extremities cold.  Never-
 theless, the stomach and  bowels show no signs of derangement, and the
 tongue, though unsteady and tremulous, is clean. Under these circum-
 stances, muscular exertion is often suddenly fatal.  Syncope ensues,
 from which the heart is  too weak to recover.
   If mercury is discontinued, and proper remedies are used, the action
 of the heart will be restored  to its natural tone and regularity, and the
 affection will entirely disappear, leaving no consequences behind  it.
   In the second form, the derangement may be less immediately  dan-
 gerous, but it more extensively pervades the whole system, and is more
 permanent.  There shall be  no palpitation of the  heart, but the pulse
 shall be small and accelerated; there shall be loss of sleep and of appe-
 tite, a sallow paleness of the countenance, often a loaded tongue, and
 always great debility and emaciation.   The general aspect shall be
 that of extreme ill health.  If this state be allowed to continue, other
 symptoms indicative of  general cachexia will supervene.  There will
 be scrofulous enlargements of the glands, rheumatic pains in the limbs,
 or languid inflammation of  the joints, having something of a scrofu-
 lous character.  The ulcerative will everywhere supersede the adhesive
 process.  Slight wounds will  form sores, and when fractured bones
 have recently united the union will give way.
    This state of constitution, if once fully established, is not easily cor-
 rected.   Years  frequently pass before all traces of it are removed.  It
 is the result not so often of  an inordinate dose of mercury continued
 only for a short period,  as of a long and obstinate perseverance in the
 exhibition of moderate  doses, notwithstanding evident signs of  dete-
 riorated health  and diminished powers.
    The expression  of the author, added in a subsequent edition, that
 mercury " at the same time shall be curing the venereal disease effect- 
474
CONSTITUTIONAL SYPHILIS.
ually,"  must be  understood as referring to the absence of ptyalism,
not to the existence of the  poisonous effects of the remedy.  Experi-
ence fully proves that these poisonous effects are altogether inconsist-
ent with its action as an anti-venereal; and  that perseverance  in  its
use, after they have shown  themselves, while it exposes the patient to
imminent danger, at the same time  in no degree answers the object
of the surgeon in the removal of the disease  for which  it is given.—
G. G. B.]

         § 2. Of the Quantity of Mercury necessary to be given.

  The quantity of mercury to be thrown into the constitution for the
cure of any venereal complaint must be proportioned to the violence
of the disease.  Two circumstances are, however, to be strictly attended
to in  the administration of this medicine; which are, the time in which
any given  quantity is to be thrown in, and the effect it has on some
parts of the body, as the salivary glands, skin, or  intestines.  These
two circumstances, taken together, are to guide us  in the  cure of the
disease; for mercury may be thrown into the same constitution in very
different quantities so as to produce the same  ultimate effect; but the
two very different  quantities must be also in different times.  For in-
stance, one ounce of mercurial  ointment, used in two days, will have
more effect upon the constitution than two ounces used in ten; and
to produce the same effect in the ten days, it may perhaps be necessary
to use three ounces or more.
  The effects on  the constitution of  one ounce used in  two days are
considerable, and also its effects upon the diseased  parts;  therefore, a
much less quantity in  such a  way  will have greater  effects.  But if
these effects are principally local, that is, upon the glands of the mouth,
the constitution at  large not being equally  stimulated, the effect upon
the diseased parts must also be less, which is to be determined by the
local  disease not giving way in proportion to the effects of the mercury
on some particular part.
  If  it  is given  in very small quantities, and increased gradually,  so
as to  steal insensibly on the constitution, its visible effects are less, and
it is hardly conceivable how much may at  last  be  thrown in without
having  any visible effect at all.1
  These circumstances being known, it  makes mercury a much more
efficacious, manageable, and safe medicine than formerly it was thought
to be;  but unluckily, its visible effects upon  some particular parts,
such  as the mouth and the  intestines, are  sometimes much  more
violent  than its general effect upon the constitution at large; therefore,
a certain degree of caution is necessary not  to stimulate these parts too
quickly, as that will prevent the necessary quantity being given.
  The constitution, or  parts, are more susceptible of  mercury at first

  1 To give an idea of this, ten grains of the ointment, used every day during ten
days, affected a gentleman's mouth.  The ointment' was of equal parts of mercury and
hogs' lard. But, by means of omitting the ointment occasionally, and returning to the
use of  it, he at last rubbed in eighty grains every night for a month, without having
his mouth, or any of the secretions, visibly affected. 
TREATMENT.
475
than afterwards; if the mouth is made sore, and allowed to recover, a
much greater quantity may be thrown  in  a second time, before the
same soreness is produced; and indeed I  have seen cases where it
could not be reproduced by as much mercury as  possibly could be
thrown in.  Upon a renewal of the course of mercury, therefore, the
same precautions  are  not necessary  as at first.  We are, however,
every now and then deceived by this medicine, it being hardly possi-
ble to produce visible effects at one time; and afterwards the mouth
and intestines shall all at once be affected.
   Mercury, when  it falls on the mouth, produces  in many constitu-
tions violent  inflammation, which sometimes  terminates in mortifica-
tion.  The constitutions in which this happens I suspect are of the
erysipelatous kind, or what  are called the  putrid;  therefore, in such,
greater  caution  is necessary.   Mercury in  general, that is, where it
only produces its common effects, seldom or never does any injury to
the constitution;  it should seem only  to act for the  time, and to leave
the constitution in a healthy state.  But this is not always the case,
for probably mercury can be  made to  affect every constitution very
materially, being capable of producing local diseases, as has been men-
tioned, and  also capable  of retarding the  cure of chancres, buboes,
and certain effects of the  lues venerea, after the poison has been  de-
stroyed.  .

          § 3. Of the Sensible Effects of Mercury upon Parts.

   The sensible effects of mercury are generally an increase  of  some
of the  secretions, a  swelling in the  salivary glands, and increase of
saliva;  an increase  of the secretion of the bowels, which produces
purging, and an increase of the secretion of the skin, producing sweat,
also often an increase of the secretion of urine.  Sometimes one of
these secretions only is affected, sometimes more, and sometimes all of
them together; but the effects upon the mouth are  the most frequent.
   Mercury often produces headaches, and also costiveness, when its
action on other parts  becomes sensible, especially upon the glands of
the  mouth.
   When the mercury  falls upon the mouth, it does not affect all parts
of it equally, sometimes attacking the gums, at other times the cheeks,
which become thickened and ulcerate, while the gums are  not  in the
least affected, as appears.by the patient being capable of  biting  any-
thing hard.
   Mercury, when it falls upon the mouth, and parts belonging to the
mouth, not only increases the discharge of those' parts, but  it brings on
great tumefaction, which  is not  of  the true inflammatory kind, where
coagulable lymph is  thrown out, but rather resembling erysipelatous
tumefaction.   The tongue, cheeks, and gums swell, and  the  teeth
become loose; all which effects are in  proportion  to the quantity of
mercury given, and  the susceptibility of the parts  to such irritation.
It produces  great weakness in the parts, in which ulceration easily
takes place, especially if they are  in  the least irritated, which is often
done by the teeth, and even mortification sometimes ensues.  How far 
476
CONSTITUTIONAL SYPHILIS.
it produces similar effects when it falls on other parts, I do not know.
The saliva, in such cases, is generally ropy, as if principally from the
glands affected.   The breath acquires a particular smell.1
  As mercury generally produces evacuations, it was  naturally ima-
gined that it was by this means that it effected a cure of the venereal
disease;  but experience has  taught us that, in  curing the venereal
disease by this medicine, evacuations of any kind produced by it are
not  at all necessary.  And this might have been supposed, as similar
evacuations, produced by other medicines, are of no service; therefore,
it was reasonable to imagine that  these evacuations, when produced
by  mercury, were also of no service, except we could suppose that
the evacuation produced by the mercury was not the same with that
produced by other medicines, but that it was  a specific evacuation;
that is to say, a discharge carrying off the venereal poison by its union
with the mercury, and therefore the faster the mercury went off' the
sooner would the poison be carried out of the constitution.  But this
is  not found  to be  the  case in practice; on the contrary, evacuations
produced by the medicines retard the cure, especially if the secretory
organs are too susceptible of this stimulus; for then the quantity which
is necessary or sufficient for the cure of the disease cannot be taken in,
the effects of the medicine upon particular parts being greater than the
patient can bear, and the quantity of mercury to be thrown into the
constitution must be limited and regulated according to the quantity
of evacuation, and not according to  the extent of the disease.  On the
other hand,  if it  is given with care, so as to avoid violent evacuation,
any quantity may be thrown  in sufficient  for the cure of the disease.
  Certain evacuations may be supposed to be a mark of the constitu-
tional effects  of mercury, but they are not to  be entirely depended
upon, the secretions being only a proof of the susceptibility of some
parts to such a stimulus; however, it is probable that in general they
are a good gauge of its constitutional effects.   Some have gone so far
as  to suppose that  quantity  of mercury alone, without any  sensible
effects, is sufficient for the cure of the disease; and this is in  some
degree the case, but not completely so, for we  have  no good proof of
its affecting the constitution but by its producing an increase of some
of the secretions.

                    § 4. Of the Action of Mercury.

  Mercury can have but two  modes of action:  one on the poison, the
other on the constitution; we can hardly suppose it to  act both  ways.
If mercury  acted upon the poison only, it might be supposed to be in
two ways, either by destroying its qualities by decomposing it,  or by
attracting it and carrying it out of the constitution.   If the first were
the  action of mercury, then we might reasonably suppose that quan-

  1  Added: " A person could not have mercury applied externally without its occa-
sioning violent infiammation.  He could take ten or twelve grains of the mercuriua
calcinatus every day without affecting his bowels or mouth, but it affected his head,
so  that he could hardly walk; and, to use  his own expression, he did not know
' whether his head was off or on.' "—Home. 
TREATMENT.
477
tity alone would be the thing to be depended upon; if the second, that
the quantity of evacuation would be the principal circumstance.
  But if it act upon the principle  of destroying the diseased action of
the living parts, counteracting the venereal  irritation by producing
another of a different kind, then neither quantity alone, nor evacuation
will avail much; but  it will  be quantity joined with sensible effects
that will produce the quickest cure, which, from experience, we find
to be the case.   But although the effects that mercury has upon  the
venereal disease are in some degree in proportion to its local effects on
some of the glands, or some particular part of the body, as the mouth,
skin, kidneys, and intestines, yet it is not exactly in this proportion, as
has  been mentioned.  When mercury disagrees, as it were, constitu-
tionally, producing great irritability and hectic symptoms, this action
or irritation is not a counter-irritation to the venereal disease, but is  a
constitutional  irritation having no effect on the disease, which continues
to increase.   Mercury, losing its effects upon the disease by use, gives
a proof that it neither acts chemically, nor by carrying off the poison
by evacuation, but by its stimulating power.
   The effects  will always be in proportion to the quantity in a  given
time, joined with the susceptibility of the  constitution to the mercu-
rial irritation.  These circumstances require the minutest attention;
and in order to procure its greatest action with safety, and to procure
this in  the  most effectual way, it  must be given till it produces local
effects somewhere, but not too quickly, that we may be able to throw
in  a proper quantity; for local effects,  produced too quickly, prevent
the sufficient quantity being thrown in for counteracting  the venereal
irritation at large.  I have seen cases where the mercury very readily
acted locally,  and yet the constitution was hardly affected by it, for the
disease  did not give way.
   A gentleman  had a chancre which he  destroyed with caustic,  and
dressed the sore with mercurial ointment.  He had also a slight uneasi-
ness in  one of his groins, which went no farther, but which showed an
absorption of the poison.  The chancre soon healed, and he rubbed in
about two ounces of mercurial ointment.  He began this course with
small quantities: that is, a scruple at each rubbing, and increased it;
however, it  soon affected his  mouth, and he  spit for about a month.
Two months after, he had a venereal ulcer in one of his tonsils.  Here
was a considerable  sensible effect from a small quantity of  mercury,
which proved ineffectual, because  its  specific  effects, as I apprehend,
were not in proportion to its sensible effects, the salivary glands being
too susceptible of the mercurial irritation.
   On the other hand, I have seen cases where quantity did not answer,
till it was given so quickly as to affect the constitution in such a man-
ner as to produce  local irritation, and consequently sensible evacua-
tions, which is a proof that the local effects are often the sign of its
specific effects on the constitution at large, and shows that the suscep-
tibility  of the diseased parts to be affected by the medicine is in pro-
portion to the effects of it upon the mouth.   Its effects are not to be
imputed to evacuation, but to its irritation; therefore, mercury should
be given, if possible, so as to produce sensible effects upon some parts 
478              CONSTITUTIONAL SYPHILIS.

of the body, and in the largest quantity of mercury that can be given
to produce these effects within certain bounds; and these sensible effects
should be the means of determining how far the medicine may be
pushed, in order to  have its best effects upon the disease without
endangering the constitution.   The practice here must vary according
to circumstances;  and if the disease is in a violent degree, less regard
must be had  to the constitution, and the mercury is to be thrown in
in larger quantities; but, if the disease be mild, it is not necessary to
go beyond that rule, although it is better to keep up to it on purpose
to cure the disease the sooner.
  If the disease  is  in the first order of parts, a less quantity of mercury
is necessary than if it were in the  second order of parts, and had been
of long standing, with its first appearances only cured, and the vene-
real disposition  still remaining in the secondary parts.  To cure the
disease, whether in the form of chancre,  bubo,  or lues venerea, proba-
bly  the same  quantity of mercury is necessary, for one sore requires
as much mercury as fifty sores in the same person, and a small sore as
much as a large one; the only difference, if there is any, must depend
upon the nature of the parts affected, whether naturally active or indo-
lent.  If  there be  any material difference between the recent and con-
stitutional, which I apprehend  there is, it may make a difference in the
quantity.  I do conceive that the  recent  are, upon the whole, more
difficult to cure; at least they commonly require longer time, although
not always.
   Having thus  far premised  these  general rules and observations, I
shall now give the different methods of administering mercury.

 § 5. Of the Different Methods of giving Mercury: externally—internally.

   Previously to the giving of mercury, it is very proper to understand,
as much as possible, the constitution of the patient with regard to this
medicine, which can only be known in those  who have already  gone
through a mercurial course; but,  as many of our patients are obliged
to undergo this treatment more than once, it becomes no vague inquiry;
for, as there are many who can  bear this method much better than
others, it is very proper that  this should be known, as  it will  be a
direction for our present practice.   I think that few constitutions alter
in this disposition, although I knew one case which admitted of a con-
siderable quantity at one time without being visibly affected; but about
a twelvemonth after the patient was affected with a very little.
   When mercury is given  to  cure  the lues venerea, whatever length
we mean to go in  the sensible effects of it, we should get to that length,
if possible, and  we should keep up to it.   For we shall find it difficult
to bring its effects to that standard again if we allow it to  get below
it.   If the mercury should get beyond what we intended, we should be
very much upon our guard in lowering it, and should probably begin
to give it again before its effects are reduced to the intended standard;
for the same quantity now will not operate so powerfully  as before,
insomuch that what at first produced greater effects than was intended
will not be sufficient afterwards. 
TREATMENT.
479
  Mercury is best applied externally in form of an ointment.  Unctu-
ous substances keep it divided, attach it to surfaces, and do not dry;
it may also be supposed that they become a vehicle for the mercury,
and carry it through the absorbents to the general circulation;  for it
is probable that oil is as easy of absorption as watery substances.
  If the symptoms are mild in the first order of parts, and the patient
not accustomed  to mercury, or it is known  that he cannot bear  the
medicine in great quantity, and it is intended to conduct the cure by
almost insensible means, it is proper  to begin with small quantities.
One scruple, or  half a drachm, of an ointment made of equal parts of
quicksilver and  hog's lard, rubbed in every night for four or six nights,
will be sufficient to begin with.  If the mouth is not affected, the  quan-
tity may be gradually increased, till two or three drachms are rubbed
in at each time; but  if  the first  quantity has affected the mouth, we
may be almost certain that the glands of the mouth are very suscepti-
ble to the mercurial stimulus;  therefore, it will be proper to wait  two
or three days till that effect begins to go off.
   When we begin the second time, the quantity may be gradually in-
creased, at least a scruple every time, till two  drachms  or more are
rubbed in each night, which may be done, without affecting the patient
very considerably a second time, as has been already observed.
   If all the symptoms gradually disappear, there is no more to be done
 but to continue this practice for a fortnight longer by way of security.
   This method, steadily pursued, will cure most recent cases of  lues
 venerea, but it is not sufficient if the  disease has been  merely kept
 under by slight courses of mercury; a greater quantity becomes neces-
 sary, from a kind of habit the constitution has acquired by which  it is
 rendered less susceptible of the mercurial stimulus.
   If the disease should return in the second order of parts, we may be
 certain the same quantity of mercury will not be sufficient to cure them,
 their action being slow under the venereal irritation, therefore requir-
 ing more than what had been  first given.
   I may be allowed to remark, that where the venereal symptoms have
 been  ulcers in the mouth or throat, I have suspected that the mercury
 being brought to the mouth, and the saliva being impregnated with it,
 and acting as a mercurial gargle, cured  those  parts locally, and  that
 the constitution has remained still tainted, the mercurial action  in it
 having been much inferior to what it was in the  mouth.  Perhaps
 something similar may take place in eruptions of the  skin where the
 mercury passes off by  sweat;  for we know  that sulphur will cure the
 itch by passing off in perspiration.  If these are facts, then it may in
 some degree account for the local symptoms in the first order of  parts
 being easier of cure than those of the second.1
    The manner of living under a mercurial  course need not be  altered
 from the common, because  mercury has no action  upon the  disease

   1 Added: " After venereal blotches on the skin have been removed by mercury they
 sometimes recur afterwards, which has led many to have recourse to mercury again;
 but the proper practice is to desist some time, to see what becomes of them, as they
 often disappear again spontaneously; but as in some they may be a recurrence of the
 disease, in such mercury must be given."—Home. 
480
CONSTITUTIONAL  SYPHILIS.
which is more favored by one way of life than another.  Let me ask
any one what effect eating a hearty dinner and drinking a  bottle  of
wine can have over the action of mercury upon a venereal sore, either
to make it affect any  part sensibly, as falling upon the glands of the
mouth, or prevent its effect upon the venereal irritation ?  In short, I
do not see why mercury should not cure the venereal disease under
any mode whatever of regimen or diet.1
  I own, however, that I can conceive cold affecting the operations  of
mercury upon  the venereal disease; it is possible that  cold may be
favorable to the venereal irritation, and therefore contrary to that pro-
duced by mercury; and there  is some show of reason for supposing
this, for I have before asserted that cold was an  encourager of the
venereal irritation; and therefore keeping the patient warm may dimi-
nish the powers of the disease while under the cure.
  Mercury, given internally, is in many cases sufficient, although  in
general it is not so much  to be depended on as the external  applica-
tion ;  therefore  I would not recommend it, or give it in  cases where the
disease has not been sufficiently cured by former courses of mercury.2
It is the most convenient way of giving this medicine, for many will
swallow a pill who do not choose to rub the  body with the ointment;
indeed, there are  many circumstances in life which make this mode  of
introducing it into the constitution the most convenient; but, on the
other hand, there are many constitutions that cannot bear mercury
given internally.   When  these two  circumstances  meet in the same
patient it is unfortunate.
  Mercury, taken internally, often produces very disagreeable effects
upon  the stomach and intestines, causing sickness in the one,  and grip-
ing and purging in the other.
  If it be found necessary to give it internally, and it  disagrees either
with the stomach or intestines, or both, even in  the most simple prepa-
ration, its effects,  whatever they are, must be corrected or  prevented,
by joining with the mercury other medicines.   If it affect the stomach
only,  the mercury may be joined with small quantities of the essential
oils, as the essential oil of cloves, or chamomile flowers, which will in
many cases take off that effect.  If it disagree both with the stomach
and bowels, I believe it arises either from the mercury meeting with
an acid in the stomach, by which part of it is dissolved, forming a salt,
or from being given in the form of a salt, both of which will generally
purge, and become the cause of their own expulsion.  There are two
ways  of obviating these effects; the first is by preventing the salt from
forming;  the second, by  mitigating  its effects  on the intestines  if
formed, by taking off their irritability. To prevent the salt from form-
ing, the best way is to join the mercury with alkaline substances, either
salts, or earths; and when given in a saline state it may be joined with
opium, or some of the essential oils.
  To  prevent the formation of the salt,  take  of the  preparations  of
mercury, such as mercurius  calcinatus, mercurius fuscus, or calomel,

  1 The last sentence omitted.—Home.
  2 The last part of the preceding sentence, beginning at "although," omitted.—Homb. 
TREATMENT.
481
forming them into pills, with the  addition of a small quantity of soft
soap, or any of the alkaline salts; the alkaline salt  also prevents the
pill from drying; or, instead of these, a calcareous earth may be joined
with the mercury, such as chalk or crabs'-eyes;  upon this principle is
the mercurius alkalizatus, which is crude mercury rubbed down with
crabs'-eyes.  But these substances add considerably  to the bulk of the
medicine, no less than twenty grains being necessary for a dose, which
contains seven  grains and a half of crude mercury.  The mercurius
calcinatus, rubbed with a small portion of opium, makes an efficacious
pill, and in general agrees well both with  the stomach and.bowels.
Opium has long been joined with mercury to cure the venereal disease.
By some as much has been attributed to the opium as to the mercury;
however, opium should be given with care, for it is not every consti-
tution with which it agrees, often producing irritability, in some lassi-
tude and debility, in others spasms.
   If the mercury is not given in the above manner, but in the form of
a salt, or the salts are allowed to  form, then it should  be joined with
one-third of opium, and a drop of the oil of cloves, or chamomile, which
will make it agree with the stomach, and prevent its purging; or, if it
is found still to disagree both with the stomach and bowels, compound
it still farther, by joining with the mercury the alkaline salts, the opium,
and some essential oil.
   A grain of mercurius calcinatus made into a pill, with the addition
of such medicines as the  stomach or bowels may require, may be given
every night for a week; and if in that time it has not affected the mouth,
it may be repeated evening and  morning;  and  after  the patient has
been accustomed to the medicine, and it is found not to fall much upon
the mouth, it may be increased to two  grains in  the evening, and one
in the morning.
   The same directions hold equally good either with  the mercurius
fuscus or calomel; but it requires more  of these last preparations of
mercury to have the same medicinal effect upon the disease than of the
before mentioned; perhaps the proportion of their effects is about two
or three to one.   Why this should be the case is probably not easily
accounted for, the quantity of mercury being very nearly the same in
a given weight in both, for in eight grains of calomel there are seven
grains of crude mercury.  Three grains of these preparations appear
only equal to one  of the mercurius  calcinatus.  The  crude  mercury
given in the same quantities with either of the former appears the least
efficacious of all;  for fifteen grains of crude mercury rubbed down with
any mucilage, seems only equal to one or two of the mercurius calci-
natus.
   The corrosive sublimate, which is a salt capable of stimulating vio-
lently, is generally given  in solution in common water, brandy, or some
of the simple waters, and has been used with the appearance of con-
siderable success.  It would appear that it removes ulcers in the mouth
as soon, if not sooner, than any of the other preparations; but this I
suspect  arises from its application to these parts  in  its  passage to the
stomach, acting upon them locally as a gargle.  However, from expe-
rience, it appears not to have sufficient powers over the venereal irri-
       31 
482
CONSTITUTIONAL SYPHILIS.
tation ;  in recent cases only removing the visible local effects, without
entirely destroying the venereal action; for many more have been found
to relapse after having taken this preparation than from many of the
others,  which is  owing  to its passing very readily off  by  the  skin.
Besides, it disagrees much more with the stomach and intestines than
any of  the other  preparations.
   A grain of this medicine, dissolved in about an  ounce of some fluid,
is generally the  dose, and increased according as it agrees with the
bowels, and according to its effects upon  the mouth and disease.1
   As corrosive sublimate contains an acid, and as  you must be guided
by the effects of  the acid on the bowels, the quantity of  mercury you
can give  in this form is necessarily smaller than in the other prepara-
tions.  Ward's drop, containing less acid, can be given in larger quan-
tity, and  is more efficacious on  that account.   Perhaps any of these
preparations  united with a scruple of gum guaiacum may have more
effect than when given alone, since guaiacum is found to have consider-
able effects on the venereal disease.2
   This practice, continued for two months, will in general cure a com-
mon lues venerea; but here it is not meant that  any time should  be
specified.  After all  the symptoms of the  disease  have disappeared,
this course should be continued at least a fortnight longer;  but if the
symptoms disappear  very suddenly, as they often do, perhaps within
eight or  ten days, probably from  the medicine  going  off by those
surfaces where the disease appears, the medicine should  be continued
three weeks,  or perhaps a month longer, and the  dose increased.   In
such cases the visible local effects appear to be cured while a venereal
disposition remains in the parts.
   Various are the preparations of  mercury recommended for internal
use, while practitioners have generally been satisfied  with but one for
external application.  Every practitioner  finds some one of the prepara-
tions answering better to appearance in  some one case than another,

   1 The passage stands thus in every edition, and  yet there must be some error, for the
dose is larger than has ever been recommended by practitioners deserving of credit,
and could not be taken without danger.   The usual quantity is from a quarter of a
grain to half a grain in the course of the day, and even this is generally divided into
at least two doses.
   But larger quantities of corrosive sublimate maybe given with safety, if proper pre-
cautions are used.  The object is that it should be introduced into the system, without
producing any irritation on the surfaces which immediately absorb it. And this object
is best answered by administering it in the form of a pill, and by giving it at the time
of meals, so that it may mix with the food, and its acrid qualities may be corrected by
dilution.   It will be found that corrosive sublimate may be  given in this way, in the
dose of one third of a grain, three times in the day, or of one  grain daily, without more
inconvenience, or more risk of derangement of the stomach or bowels, than is incurred
from the ordinary doses given without these precautions.
   An opinion  prevails that a course of corrosive sublimate gives the patient little
security against a relapse. The observation applies chiefly to the smaller doses of the
remedy, which scarcely admit of the introduction of a sufficient quantity of the mer-
cury, unless the course be very greatly prolonged. If it be given in the dose which ia
mentioned above, and if the course can be continued for the usual period without in-
terruption from its effects on the bowels, or the mouth, it  may be doubted whether
relapses are more frequent than after the exhibition of other preparations of mercury.
—G. (i.B.
   2 See page 493. 
TREATMENT.
483
which casts the balance in favor of that medicine in his mind;  or others,
finding  the bad  effects of a particular preparation  at one time, have
generally condemned that  preparation, not  to  mention that deceit is
often practised in the cure of this disease.  One would naturally sup-
pose that the simplest preparation is the best, that which is easiest dis-
solved in the animal juices, does least mischief to the stomach  or general
health, and is least disturbed or hindered in its operations; for we can
hardly suppose that any substance joined with mercury, which  alters
either its chemical or mechanical properties, out of  the body, can add
to its power in the body, except a substance which had a similar power
when acting alone.  The preference generally given to the  ointment
shows this;  and, if we could find a preparation still more simple than
the ointment,  that  preparation should be used in  preference  to the
crude mercury.

      §  6. Of the Cure of the Disease in the Second or  Third Stage.

   In the more advanced stages of the disease the mercurial course must
be pushed farther.   The greatest quantity of that  medicine that the
patient can bear at a time is to be thrown in, and continued with steadi-
ness till  there is great reason to suppose the disease is destroyed.   It
will not be possible in such cases to  prevent  the mouth from  being
considerably affected, the quantity of mercury necessary to be used for
the cure of these stages of the disease being such as will in most cases
produce that effect.
   Before the disease has advanced so far the patient  most probably has
taken mercury, and it is proper to inquire how he has been affected by
it, and what quantity he can bear, which will in some degree direct us
in the quantity now to be begun with.  If  the patient  has  not  taken
mercury for a considerable time, and is easily affected  by it, which is
the case that admits of the least quantity, it will be  necessary to begin
cautiously, regulating the quantity according to circumstances;  but if
the person  has taken mercury lately,  although  easily  affected  by it,
more freedom  may  be used on returning to it, because it will have less
power on his mouth, as also on the disease.  Again, if the person has
been taking mercury very lately, and is with difficulty affected  by it,
which is the case that admits of the greatest quantity, then  it may be
administered freely so as to affect the constitution in the proper time.
If the mercury is brought to the mouth in  six or eight days,  and a
considerable soreness is produced in  twelve, it will in  general be a
good beginning.  In  such  cases the constitution is, if  possible,  to be
surprised by the medicine, so as  to  produce its greatest effects, but
with such caution as to be able to keep up these effects by quantity.
   Mercurial friction will answer better than mercury given internally ;
for in this way we are surer of throwing in a larger quantity  in a given
time than could be taken internally without hurting the stomach.
   The quantity of mercury applied in this way should be, under certain
circumstances, in proportion to the surface on which it is applied, and
the surface should be completely covered with  the ointment; for half
an ounce of mercurial ointment, rubbed in upon a given surface, will 
484
CONSTITUTIONAL  SYPHILIS.
have nearly the same effect as one ounce rubbed in on the same sur-
face ; therefore, one ounce to have double the effect should have double
the surface.  The quantity of ointment must therefore be adapted  to
the quantity of surface, for, on a certain extent of surface, no more than
a determined quantity of ointment can be applied so as to be absorbed,
and applying a greater quantity would be useless; and, if the quantity
of surface is greater, the  same portion of ointment cannot be diffused
so as to employ fully all the absorbents.   Every surface which is used
may therefore have its full quantity of ointment, but  certainly should
not have more, if we are to attribute the effects  of the mercury to the
quantity.
  It has most probably been always the practice to rub the mercury
well in, as it  is termed;  but I suspect that this  arose rather from an
idea of the surface being porous like a sponge than of absorption being
performed by the action  of vessels; and  it is probable that this action
in  the  vessels producing  absorption  may  be rather disturbed than
excited by friction.
  How long the course is to be followed is not to be exactly ascertained;
it may be thought proper to continue it till  the local appearances, as
nodes, have subsided;  but I suspect that  this is hardly  necessary,
except they give way readily, for in such cases the  local complaints,
or  tumefaction, &c, generally require a longer time to be removed
than the venereal action; and local applications must be of service,
especially if such tumefactions are obstinate.
  The manner of living under such a severe  course, which is in every
respect weakening, is to be particularly attended to.  The patient must
be supported; and the local effects of the medicine, in the mouth, pre-
venting his taking many kinds of nourishment,  especially such as are
of a solid form, fluids must form his only nourishment, and these should
be such as will become solid after they are swallowed ; milk is of this
kind.  An egg beat up with a little sugar, and a little wine, sago, salep,
&c, form a proper diet.   In many cases wine and bark must be given
through the whole course.  Sugar, perhaps, is one of the best restora-
tives of any kind we are acquainted with, when a constitution has been
very much debilitated by long fasting, from  whatever cause, whether
from the want  of food when  in health,  or in the time of disease, or
where the food has  not been  allowed  to answer the constitutional
waste, as in a course  of mercury; and when the disease or course of
mercury is gone, then sugar will restore such constitution, probably
better than anything else.
  Although it is not  a common opinion, and therefore not a common
practice, to give sugar entirely with this view, yet there are sufficient
proofs of its nutritive quality over almost every other substance.  It
is a well-known fact that all the negroes  in the sugar islands  become
extremely lusty and fat in the sugar-cane season; and they hardly live
upon anything else.   The horses and cattle that are  allowed to feed
upon them all become fat;  the hair of the horse becomes fine.  Birds
which feed upon fruit never eat it till it becomes very ripe, when it has
formed the greatest quantity of  sugar, and even  then only such as fur-
nish the largest quantity of sugar.  Insects do the same; but we can- 
TREATMENT.
485
 not have a stronger instance of this  fact than in the bee.   Honey is
 composed of sugar, with some other juices of plants, with a little essen-
 tial oil; but sugar is the principal ingredient.  When we consider that
 a swarm of bees will live a whole winter on a few pounds of honey,
 keep up a constant heat about ninety-five  or  ninety-six degrees, and
 the actions of the animal economy equal to that heat, we  must allow
 that sugar contains perhaps  more real nourishment than any other
 known substance.
   We see too  that whey is extremely fattening, which is the watery
 part of the milk, containing neither the oil nor the coagulable matter;
 this arises principally from the sugar it contains, for being composed
 of the watery part it holds all the sugar of the milk in solution.   If
 the milk is allowed to become sour it is not so fattening, because it is
 the sugar which is become sour.
   Although the nutritive qualities of sugar have not been so generally
 known as to introduce it  into universal practice, yet  they have not
 entirely escaped the notice of practitioners.   Mr. Vaux, from observing
 the negroes in  the West Indies growing fat in the sugar season, has
 been induced to give it in very large quantities to many of his patients,
 and with very good effects.  Honey is perhaps as good a mode of taking
 this substance  as any.  Sweetening everything  that is either ate or
 drank, whether by sugar in honey, or sugar alone, is probably imma-
 terial.  Yet it is probable that the other ingredients in honey may add
 to its nutritive quality.

                      § 7. Of Locatyi'reatment.

   If  the local effects have gone no farther than  inflammation  and
 swelling, either of the soft  or hard parts, most probably no local treat-
 ment will be necessary, for the treatment of the constitution will in
 general remove them entirely.
   It sometimes, however, happens that  the local complaints will not
 give way, but the parts remain swelled in  an indolent and inactive
 state, even after there is every reason for supposing the constitution is
 perfectly cured.  In such cases the  constitutional treatment is to be
 assisted by local applications of mercury to the part,  either in the
 form of a plaster or ointment.  The latter is by much the  best mode.
 If these are  not sufficient, as often happens, we must endeavor to
 destroy this disposition  by producing  an  inflammation of  another
 kind.  I have  seen a venereal node, which gave  excruciating pain,
 cured by an incision only being made down to the bone  the whole
 length of the node; the pain has ceased, the swelling  has decreased,
 and  the sore healed  up kindly, without the assistance of a grain of
 mercury.  Blisters  have been applied  to  nodes with  success; they
 have removed the pains and diminished the swellings:  so far furnish-
 ing a proof that local treatment may assist mercury in many cases.
  This treatment has not only been  used to assist  mercury in those
cases where the medicine did not appear to be equal to the disease,
but it has been  used at the commencement of the cure, and even before
mercury had  been applied; but it was  still thought necessary to  go 
486
CONSTITUTIONAL SYPHILIS.
through the same mercurial course as if nothing had been done to the
local complaints.
  It may be asked, What advantage arises from the incision or appli-
cation of the blister ?  The advantage is immediate relief from violent
pains;  and as there are two powers acting, it is natural to suppose the
cure will be more speedy.
  After all the above-mentioned trials, it may happen that the local
effects shall still remain, forming as it were a new disease, which mer-
cury may increase; and therefore  other methods of cure may be tried,
as will be described hereafter.

                   § 8. Of Abscesses—Exfoliation.

  When an abscess forms in a node in the periosteum the bones  are
generally  affected,  and make part of the abscess.   Great attention
should be paid to them, for suppurations in them are not like suppu-
rations in common abscesses;  they are seldom produced from the true
suppurative inflammation, and therefore are  slow in their progress,
rarely  producing true  matter, but a mucus,  something resembling
slime, which lies flat upon the bone.   This  circumstance makes it
difficult to determine when suppuration has taken place, and in many
cases to detect matter, even where it  is formed.   Another circum-
stance which renders  the  presence of matter in such cases doubtful,
is, that  the progress  of the disease is generally checked very early
by the use of  mercury.  This rnatter  is often reabsorbed during a
mercurial course, and it  is proper, particularly in an early state of
the complaint, to give it this chance; but if the  absorption does not
take place, and the complaint is in an advanced state, it must be opened.
  The surgical treatment of the  parts under such circumstances is the
same as in other diseases of these parts; opening with great freedom
is absolutely necessary; for the more parts are  exposed, the more  in-
clinable they are in general to  heal, and still more so here; for vio-
lence assists in destroying the venereal disposition.  No skin covering
a bone should  be removed  from an  abscess, especially in the lower
extremities.
  If the abscess is opened freely, and  an exfoliation takes place, which
is generally the case, it is to be treated as any other exfoliation.  Ex-
foliations succeed much better here than in many other cases, because
the disease from which they»proceed can generally be corrected, which
is not the case in many diseases of bones where exfoliation takes place.
Cases, however, sometimes occur, in which, after the venereal disposition
has been corrected, another disease takes place in the bone, the nature
of which will be explained when we shall consider the effects remaining
after the disease is cured, and the diseases sometimes produced by the
cure.

          § 9.  Of Nodes on Tendons, Ligaments, and Fascial.

  The observations made on the nodes of the  periosteum and bones
are applicable  to  swellings and suppurations of the ligaments  and 
TREATMENT.                      487
fascias;  but it is still more difficult to ascertain the presence of matter
in them than in the former.
   When a  thickening only of the ligaments  or fascias  is the conse-
quence  of the disease, it is very obstinate, as in many cases the diseased
part may be cleared of all venereal taint and still the swellings remain.
Blisters may often  be applied here with success; but if they fail, then
it will  be absolutely necessary to make an incision into the  part, to
excite a more vigorous action; for although the complaint has  nothing
venereal in it, nor is any contamination to be feared from it in future,
yet as it leaves often very obstinate and disagreeable swellings, which
neither give way to medicine nor time, it is proper to use every means
for their removal.

         § 10. Of  Correcting some of the Effects of Mercury.

   Formerly, when  the management of mercury was  not so well under-
stood, nor its effects in this disease so well known as they are at pre-
sent, it was generally supposed to act by evacuation from the  salivary
glands, and was therefore always given till that evacuation took place;
and, as  its effects in the cure were imagined to be in proportion to the
quantity of this evacuation, it was pushed as far as possible without
endangering suffocation.   From  this treatment,  it often happened in
' constitutions which were very susceptible  of the mercurial irritation,
 and in  which the medicine produced much  more violent effects on some
 particular secretions than could be wished, that  recourse was obliged
 to be had to medicines correcting the effects of mercury, as these effects
 were often a hindrance to its being given in sufficient quantities for the
 cure of th£ disease.
   I mentioned, when treating of the effects of mercury, that the sensi-
 ble increase  of the secretions produced by  it were in the following
 order:  first of saliva, then sweat, then urine, and often of the mucus
 of the  intestines, producing  purging; I also observed, that when any
 of those secretions became  too violent, the hand of the surgeon was
 tied up till they were moderated. Attempts have been made to lessen
 those effects in two ways, either by the destruction of its power on the
 body in  general, or by its  removal, but neither of these  means has
 succeeded.  It  never  has once  been thought necessary to attempt to
 lessen  its powers on the  organs of secretion, so  as  still  to  retain the
 same quantity in the constitution, or even to throw in more, which, if
 it could be effected, would be sometimes of great service;  but as we
 are not yet acquainted with  powers sufficient for these purposes, we are
 obliged to observe great caution in our mode of giving the medicine.
   I have endeavored to show that this medicine need not be given with
 a view to  procure  those evacuations, and that it may be given in any
 quantity without increasing either of those secretions in any evident
 degree; however, after every precaution we may still be deceived, and
 the medicine will  every now and then produce greater effects than
 were intended.   It is very necessary, therefore, to seek for a preventive
 of the  effects of mercury, when likely to be too  violent; or to remedy
 those effects when  they have already taken place.
• 
488               CONSTITUTIONAL  SYPHILIS.
  The common practice, when mercury produced violent effects upon
the intestines, was to counteract  these effects;  but this was not done
with a view to retain the mercury in the constitution, but to relieve
the bowels that were suffering by the action  of the medicine; whereas,
the proper practice would be to stop its progress here, as in every other
outlet, that more mercury may be retained in the constitution.
  Although  these increased secretions arise from the  constitution's
being loaded with mercury, yet there is no danger in stopping them,
for they do not arise from an universal disposition becoming a local
or critical one; and  therefore, if such an action be checked or stopped
in one place, it must necessarily  fall upon some other; but it is from
the part being more susceptible of this irritation than any other, and
the quantity now in the constitution being equal to the  susceptibility
of the part;  and, therefore, though its effects are stopped here, it does
not break out anywhere else, every other part being capable of sup-
porting this quantity, and of remaining unaffected till more is thrown in.
  When the mercury attacked the salivary glands, it increased that
secretion so much as in some cases to oblige practitioners to administer
such medicines as were thought likely to remove this new complaint.
This susceptibility of the glands of the mouth, and the mouth in gene-
ral, to be easily put  into action by this medicine, was generally sup-
posed to arise from a scorbutic constitution, to which most complaints
of the mouth are attributed.  I am of opinion that scrofulous people,
and those of a lax and delicate habit, are more subject to have it fall
on  the mouth than those of a contrary temperament.
  Purges were given upon a supposition that mercury could be carried
off by the evacuation produced by them,  and  they  were repeated
according to the  violence of the effects of the medicine and fhe strength
of the patient; but  I can hardly say that I ever  have seen the effects
of mercury upon the mouth lessened  by purging,  whether it arose
spontaneously, was produced by purging medicines, or even when aris-
ing from the mercury itself.   As this method was not found sufficient
for the removal of the complaint, other medicines were tried; sulphur
was supposed to  be  a specific for the removal of the effect of mercury.
Whether this idea arose from  practice or reasoning  is not material,1
but I think I have seen good effects from it  in some cases.   If we can
suppose purging of  any service,  purging with sulphur would answer
best, as it would exert its effects  both as a purge  and a specific.
   Sulphur certainly enters  the  circulation  as sulphur,  because our
sweat  and urine  smell of it; if it does not combine with the mercury,
and destroy its properties  as mercury,  it  is  possible, agreeably to the
opinion of those who first  thought of giving it with this intention,
that it may so combine as to form asthiops mineral, or something simi-
lar, for we know that the asthiops mineral,  however formed, does not
in general salivate.  It is possible, too, that  sulphur may act as a con-
trary stimulus to mercury, by counteracting the effects  of it  in the

  1  Sulphur, united with any of the metals, probably destroys their solubility in tho
juices, or at least their effects in the circulation; none of the cinnabars act either  as
sulphur'or  mercury. Crude antimony, which is regulus and sulphur, has no effect.
Arsenic, where joined with sulphur, has no effect;  nor has iron.
♦ 
TREATMENT.
489
constitution.   Sulphur has even been supposed to hinder the mercury
from entering the circulation.  Upon the whole, as these preparations
of sulphur and mercury are still supposed to have good effects, and as
I think I  have seen good effects in other cases, we must either allow
that they enter the circulation or that their whole effects are on  the
stomach and intestines,  with which the rest of the body sympathizes.
The good effects from sulphur in lessening or altering the immediate
effects of mercury can only take place when that medicine is really in
the constitution; therefore • a distinction is to  be made between such
as arise immediately from mercury and one continued from habit after
the mercury has been evacuated from the constitution; a case  that
sometimes  happens, and which will  be taken  notice of in  its proper
place.1
  The taste in the mouth, from the use of mercury, has been known
to go off, and not be perceived for a fortnight, and the same taste has
recurred;  this, I am informed, has happened twice  to one gentleman,
fr;om the first  quantity of mercury taken.  To account for this  js  not
easy;  in whatever way it happens, it is a curious fact.
  When the mercury has  fallen upon  the mouth and throat,  washing
those parts with opium  has often good effects; for opium takes off irri-
tability, and  of course  the soreness, which is  one means of lessening
the secretion.   A drachm of tinctura  thebaica to an  ounce of water
makes a good wash or gargle.2
   When the mercury falls upon the skin, it is neither so disagreeable
nor so dangerous as when it falls upon the mouth; however, it  may
often happen  that  it will  be proper  to check such a discharge, both
upon account of its being troublesome and of its lessening the effects
of the medicine in  the  constitution by carrying  it off.  The  bark is,
perhaps, one of the best correctors of this increased secretion.
   When the medicine attacks the kidneys and increases the secretion
of those glands, it is not so troublesome as when it produces sweating,
though it is possible that it may carry off the  mercury too soon;  but,
as we have but few medicines that can lessen that secretion, in most
cases it must  be allowed  to  go  on.  The bark may in such cases be
given with advantage.
   When the mercury falls upon the bowels, it proves often more  dan-
gerous and troublesome than in any of the former cases, especially the
last two; but it  is,  perhaps, most in our power to prevent or palliate.
Opium should be given in such quantities as  to overcome the com-
plaint, and I believe will seldom fail of removing all the symptoms.3

  1  Nitric acid has far more power than any other medicine in checking and curing
soreness of the gums and ptyalism.—G. G. B.
  2  My using opium in this way was from analogy.  Finding that opium quieted the
bowels when a purging came on in consequence of mercury, I tried it by way of gargle
to the mouth, and found good effects from it, but not equal to those which it produced
in the bowels.
  3 Opium will often prevent the occurrence of disorder of the  bowels from mercury;
but, when  dysenterical symptoms are actually present, it will seldom remove  them
unless it be preceded by a purgative.—G. G. B. 
490
CONSTITUTIONAL  SYPHILIS.
§ 11. Of the  Form of the different Preparations of Mercury when in the
                            Circulation.

  It would appear  from reason, and  many circumstances, that mer-
cury must be in a state of solution in the juices of the body before it
can act upon the venereal disease, and  indeed before it can act upon
any  other disease.   That mercury is  in a state  of solution  in  our
juices, and not in a state of any preparation of mercury that we know
of, is very probable from the following facts:—
  First. Crude mercury, every salt of  mercury, and calx of mercury,
is soluble in the spittle, when taken into the mouth, by  which means
it is  rendered sensible to the taste; from thence  it  must appear that it
is capable of solution in some of our juices.
  Secondly. Crude mercury,  when divided into small parts  by gum
Arabic, &c, so as to be easier of solution when taken into the stomach,
generally purges; but crude mercury, taken without such division, has
no such powers, not being so readily  dissolved in the juices of the
stomach.   The simple calx of mercury has the same effects, purging,
and  much more violently, from being, I suppose, readier of  solution
in the animal juices; for if it only purged from its union  with the acid
which happened to be in the stomach, it most probably would not
purge more than crude mercury ; although it is very probable that the
calx is easier of solution in a weak acid than even the crude mercury.
  Thirdly. Every preparation of mercury producing the same effect
in the mouth, and also having one and the same effect in the constitu-
tion, shows that they must all undergo a change  by which they are
reduced  to one particular form.   We cannot say what  that  form is,
whether it is the calx, the metal, or any other that we are acquainted
with;  but it is probable that it is not any of them, but a new solution
in the animal juices peculiar to  the animal itself.  This is rendered
still more probable by  this circumstance, that every preparation of
mercury  put into  the mouth undergoes  the same change,  and the
spittle has the same taste from every one of them.  If every different
preparation of mercury had  the  same properties  in the constitution
that it possesses out of it, which we must suppose  if it enters and con-
tinues in  the same form, in that case the venereal poison must he
eradicated in as many different ways as there are preparations.   Crude
mercury would  act  mechanically by increasing the weight and  mo-
mentum of the blood; the calx would  act like brickdust, or any other
powder that is heavy;  the red precipitate would stimulate by chemical
properties in  one way, while the corrosive sublimate would act in
another, and the mercurius flavus in  a third; this last would most
probably  vomit, as ipecacuanha does,  which vomits whether  thrown
into the stomach or circulation.
  Fourthly, all the preparations of mercury, when locally applied, act
always in one way, that is, as mercury;  but some  have  also  another
mode of action, which is chemical, and which is according  to the specific
nature of the preparation.  The red precipitate  is a preparation of this
kind, and acts in both  these ways; it is either a stimulant or an escha-
rotic. 
TREATMENT.
491
  To ascertain whether this opinion of mercury being in solution in
our juices was just, I made the following experiments upon myself.  I
put some crude mercury into my mouth, as a standard, and let it stay
there, working it about, so as to render it easier of solution, till I tasted
it sensibly; I then put into my mouth the mercurius calcinatus, and let
it remain till I perceived the taste of it, which was exactly the same ;
but I observed that it was easier of solution than the crude mercury.
I tried  calomel in the same way, and also corrosive sublimate, after
being diluted with the water, and the taste was still the same.   It was
some time before  I perceived the  taste of the crude mercury in my
mouth.  I tasted the calx and calomel much sooner.   The corrosive
sublimate had at first a mixed taste, but when the acid was diluted it
had exactly the same taste with the former;  all of these different pre-
parations producing the same sensation or taste in the mouth.
  From the effects of these experiments it would appear that the mer-
cury in every one of them was dissolved in the spittle, and reduced to
the same preparation or solution.
  To try whether mercury in the constitution would produce the same
taste in the mouth, I rubbed in mercurial ointment upon my thighs till
my mouth was affected, and  I could plainly taste the mercury; and, as
far  as I could rely upon my  memory, the taste was exactly the  same as
in the former experiments.
  I allowed some time for my mouth to get perfectly well and free from
the taste; I then took calomel in pills till it was affected again in the
same way.  I afterwards took mercurius calcinatus, and also corrosive
sublimate. All these experiments were attended with the same result;
the mercury in every form producing the same taste, which was also
exactly the same as when the  several preparations were put  into the
mouth.
  From the above experiments it must appear, that when mercury pro-
duces evacuation by the mouth it certainly goes off' in that discharge;
and from  thence we may reasonably conclude, that when other evacu-
ations are produced from the medicine when in the constitution,  as purg-
ing, sweating, or an increased flow of urine, that it also goes off by
these evacuations, which become outlets to the mercury.
  From the above experiments it appears to be immaterial what pre-
paration of mercury is used in the cure of this disease, provided it is
of easy solution in our juices, the preparations easiest of solution being
always the best.

          § 12. Of the Operation of Mercury on the Poison.

  Mercury may be supposed to act in three different ways in curing the
venereal disease.  First, it may unite with the poison chemically, and
decompose it, by which means its powers of irritation may be destroyed;
secondly, it  may carry it out, of the constitution by evacuation; or,
thirdly, it may produce an irritation in the constitution which counter-
acts the venereal and entirely destroys it.
  It has been supposed that mercury acts simply by its weight in the
circulating fluids,  but of this we can form no adequate idea;  and if it 
492
CONSTITUTIONAL  SYPHILIS.
were so, other substances should act on this disease in proportion to
their weight, and of course  many of them should cure it.  But from
experience we find  that such  bodies as have considerable weight, as
most of the metals, have no effect on this disease.  We have no proof
of mercury acting by a decomposition of the poison from any of  tho
concomitant circumstances.
  Mercury certainly does not cure the venereal disease by uniting with
the poison and producing an evacuation.  For in those cases where
mercury is given  in such a way as to produce considerable  evacuations,
or in those constitutions where evacuations are easily excited by mer-
cury, its effects upon the diseased action are the least; and the same
evacuations produced by any other means  have not the least effect ou
the disease.
  Whether the mercury be supposed to carry off the circulating poison
or to decompose it, in  neither way could it produce, when locally  ap-
plied, any effect on a venereal inflammation  or sore arising from  the
constitution; for as long as any of the poison existed in the circulation,
none of them could be healed by local applications, the circulation con-
stantly carrying the poison to them; but we find the contrary of this
to be true, for a venereal sore arising from the constitution may be
cured locally.
  The last or third of our modes of action of mercury seems to me  the
most probable, and for many reasons.  First, because the disease can
in many cases be cured by raising a violent stimulus of another kind;
and perhaps, if we could raise such a constitutional irritation without
danger, as we often can in local cases, we might cure the venereal dis-
ease in the same manner, and in one quarter of the usual time.  Secondly,
we find that mercury acts as an universal stimulus, causing great irri-
tability in the constitution, making the heart beat faster, and rendering
the arteries more rigid, so  as to  produce a hard pulse,  as has been
already observed.  It  may farther be said to produce a  disease, or a
peculiar or unnatural mode  of action, in a certain degree.  The follow-
ing case will illustrate this.  A gentleman had electricity recommended
to him for some complaint he had.  The  electricity was  applied, but
without any visible effect.   Besides the complaint for which he used
electricity, he had a venereal one, for which he  was first  put under a
course of  mercury, and while under it the electricity was applied for
the former complaint; but he had become so irritable that he could
not bear the shocks of one half their former strength.  But the most
curious part of the case was that the shocks had a much greater effect
on the disease than what they had before when twice as strong, and he
now got cured.  This gave the  surgeon  a hint; and having another
occasion to  use electricity, also without effect, he put the patient under
a gentle course of mercury, and then found the same effects from  the
electricity as in the former case, and the patient also got well.
  The powers of mercury upon the constitution appear to be as the
quantity of mercury and  the  susceptibility of the constitution to be
affected with it, without any relation to the disease itself;  and we find
that the power of mercury upon the disease is nearly in the same pro-
portion.   This fact gives us an idea of the irritation of mercury upon 
TREATMENT.
493
the constitution, and consequently an idea of administering  it, and of
the cure of any disease for which it is a remedy.
   As we find that a given quantity of mercury produces double effects
in some constitutions to what it does in others; also, that in those cases
it produces its effects upon the disease, we are led to believe that it is
this effect upon  the constitution which cures the disease; and, there-
fore, if it did not produce this effect it would also not have performed
a cure.  I have already observed that the cure does not go on exactly
in proportion to the visible effects upon the constitution, except quan-
tity in the medicine is joined with it, which, if true,  would incline us
to believe that  there was something more than simply a constitutional
stimulus, which most probably is a peculiar specific effect  which is not
regulated entirely by its  visible effects, either constitutional or local,
although they appear to have some connection.
   This fact being known, obliges us to be more liberal in giving mer-
cury in those constitutions where it makes but little  impression, than
in those which it easily irritates; although in these last we must  not
be entirely regulated by its local effects, nor depend upon  a commonly
sufficient quantity, but  be ruled by the sensibility  of the constitution
and quantity joined; for in those where the constitution appears to be
very susceptible of the mercurial irritation, where small quantities pro-
duce  considerable local effects, it  is still necessary to have quantity,
although it is  not so necessary to take the quantity in general that is
supposed to be sufficient.   We must be guided by the three following
circumstances: the disappearance of the disease, the quantity of irrita-
tion produced,  and the quantity of the  medicine taken.


   § 13. Of Gum Guaiacum and Radix Sarsaparilloe in the Venereal
                              Disease.

   I have hitherto only recommended mercury in  the cure of the vene-
real disease, and,  indeed, it is the only medicine to be depended upon.
However, as both the guaiacum and sarsaparilla  have been recom-
mended as powerful remedies  in  this complaint, I  took a favorable
opportunity of trying their comparative powers in the venereal disease
upon the same  person.
   The guaiacum,11 found, had considerable  specific power over the
disease; consequently it may be of service  in slight cases,  where it
may be inconvenient or improper to give mercury on account of some
other disease.   These cases, however, I have  not yet ascertained; or
it may be given in those cases where it is apprehended that the quan-
tity of mercury necessary to subdue the disease  would be too much
for the constitution to bear, cases which sometimes occur.   The sarsa-
parilla appeared to have no effect at all.
  I shall relate  exactly the case in which their comparative powers
were  tried.  A man came into  St. George's  Hospital with  venereal
sores  over almost his whole  body; there were many excrescent sores

  1 The lignum guaiaci was imported by the Spaniards from Hispaniola, as a cure for
the venereal disease,  in the year 1517, having been given to  one of them by a native. 
494              CONSTITUTIONAL  SYPHILIS.
in the armpits, some of which were about the size of a half-penny;
there were the same appearances about the anus, between the buttocks
along the perineum, between the scrotum and thigh, where those parts
come in contact with one  another.   Those upon the skin in general
had the common appearance.   I  ordered a poultice of the gum  guaia-
cum to be applied to the sores in the right armpit; also a poultice of
a strong decoction of sarsaparilla and oatmeal, mixed, to be applied to
the left armpit.   These  poultices were changed every day for  a fort-
night; the excrescent sores in the  armpit were entirely healed, and
become even with the skin, and covered with a natural skin, although
somewhat discolored; the  sores  in the left  armpit, which were poul-
ticed with sarsaparilla, were rather worse than when the poultice was
first applied, as, indeed,  were all the sores, except  those in the right
armpit.   I then ordered  the poultice  of guaiacum to be applied  to the
left armpit, which  was done, and the sores there  also got well in  a
fortnight.  I was now perfectly convinced that the gum guaiacum had
cured these eruptions locally.
  I next wished to see what effect the gum guaiacum would have upon
the remaining sores when  given internally; that  is, those about the
anus, scrotum, and on the skin in general.  The  patient began with
half a drachm three times every day, which purged him ;  but this was
prevented by joining it with opium.   In about four weeks all the erup-
tions were cured, and he  was allowed to stay in the  hospital some time
longer,  to see if he would  continue well; but about a fortnight after,
he began to break out anew,  and in a very short time was almost as
bad as ever.  I began a second time the gum guaiacum internally, but
it had lost its powers, or  rather the constitution was no longer affected
by it.   He was put under a course of mercury and cured.1
  [Ricord.—In Hunter's   general observations on the treatment of
constitutional syphilis, there are some points which deserve particular
attention, and others which cannot be allowed to pass, if not without
refutation, at least without commentary.
  In the first place, allow me to call attention to the marked difference
which Hunter establishes between the curative effects of mercury in
the different forms of venereal disease;  a difference which is so true
and so important, and from an ignorance of which have arisen so many
scientific  controversies, so many opposite prejudices, so many false doc-
trines ;  and above all, and  what is a thousand times worse than  all, so
many sad consequences for the victims of absolute systems.
  Mercury, the action of which is so favorable in the  treatment of in-
durated chancres, and which is so powerful  a remedy for  secondary
symptoms, has no curative effect upon gonorrhoea, and loses its efficacy,
if it be not positively injurious, in the tertiary symptoms of syphilis.
Hunter was well aware of these truths, which experience teaches to all
who will  hear her lessons with an unprejudiced mind.

  1 For a detailed examination into the use of these and other remedies in the vene-
real disease, the reader is referred to " Observations on the Effects of various  Articles
of the Materia Medica in the Cure of  Lues Venerea," by John  Pearson, a work which
contains the result of a long and  extensive experience, chiefly devoted to the investiga-
tion of this particular subject, and is in every part replete with excellent practical
remarks.—G. G. B. 
TREATMENT.
495
  But though these truths are fundamental, we cannot receive as such
the propositions which Hunter would establish relative to the compara-
tive ease  of curing  gonorrhoea, chancre, and constitutional  syphilis.
In the first place, as regards gonorrhoea, laying aside the cases in which
the discharge is symptomatic of a concealed chancre, and which come
entirely under the head of chancres, no parallel  can be drawn between
the two diseases, since, as I have already proved, gonorrhcea has nothing
in common with syphilis.1
  With regard to chancre and constitutional syphilis, is it indeed pos-
sible, when all the ravages which  the latter is capable of producing
are known, to admit  as a  general  rule that it is more easily and cer-
tainly cured than  chancres are?   Even Hunter's theory on  the  pro-
duction of constitutional symptoms will not justify this proposition.
Though, in  some cases, certain secondary symptoms disappear sooner
than certain forms of chancre, there are quite as many chancres which
get well a hundred times sooner than many secondary symptoms; the
latter not being always cured at will.   Moreover, in treating syphilis,
there are two very distinct things to be considered;  first, the cure  of
the existing symptoms;  and secondly, the destruction of the diathesis,
or at least the complete neutralization of the disposition which certain
organs and certain tissues  have acquired; and in virtue of which, ac-
cording to Hunter's  theory, fresh symptoms subsequently appear.
  Admitting, then, these two distinct conditions, the primary symptom
or chancre has undoubtedly the advantage.  In spite of all the preju-
dices which still faintly prolong the contest, and in spite of the super-
annuated ideas which are vainly thrown in the way of  progress, when
it shall be once admitted that a chancre at its outset is a local affection,
which requires a certain time to infect the economy, and when the effort
shall be generally made to destroy it before it  can produce  constitu-
tional effects, by attacking  it as soon as possible with all rational means,
then will its cure be recognized  as more  easy, rapid, and  complete,
than that of all other syphilitic symptoms.
  Hunter says that when complications occur in the course of  gonor-
rhcea, the former should occupy our attention rather than the original
disease, which  may get well of itself;  while, in cases of chancre and
secondary syphilis,  which never  get well  spontaneously,  we should
insist on the use of mercury in spite of everything.  This view of the
subject is too contrary to  the laws recognized  by Hunter himself to
allow it to  pass without  refutation.  It is  now  conclusively proved
that there are as many chancres which heal of themselves without
mercury as there are gonorrhoeas that get well without treatment, and
that some secondary symptoms will disappear  without medicine,  or
can be cured, at least in the sense that Hunter meant, without mer-
curial treatment.  Having established these facts—and I do not think

  1  The remarkable work of M. Baumes (Precis Thtorique et Pratique des Maladies
Ve'ne'riennes, Lyons, 1840, 2 vols, in-8), confirmatory of most of the doctrinal points
which I establish or maintain, has added weight to my convictions on those which
appeared contradictory to the learned author, to whom I am happy to render the justice
due to the impartiality and sincerity with which he has  collected his observations,
though the latter are to my mind susceptible of a different explanation. 
496              CONSTITUTIONAL SYPHILIS.
that a single observer  can call them in question—the treatment  of
chancres and constitutional syphilitic symptoms must be included un-   *
der those rules which Hunter laid down  for the treatment of gonor-
rhoea.  If complications exist, they must be  met according to their
degree of  importance.   If  mercury be  indicated for the principal
affection, and the complications do  not counter-indicate it, it should
be administered.  But beware, unless you wish to do harm, of always
obeying one indication alone, that which requires mercury, in a disease
which is so often complex as syphilis is.   Up  to the present  time,
mercury has doubtless been the most energetic  remedy in the thera-
peutics  of  syphilis,  but it is  not the  only remedy for this  disease.
Though it  be often indispensable and without a  substitute, yet  there
are some cases in which we can do without it, others in which we ought
to abstain from it, and still more numerous  cases in which it  is only
one among various means which should be  employed to conduct the
patient to a perfect cure.
   Whether, in those cases to which it is applicable, mercury acts radi-
cally and independently of the form in which it  is administered, and
whether  it  always passes  into the state of a bichloride, as M. Mialhe
asserts, or not, it is none the  less true that the form of  its administra-
tion is not  immaterial, and that a person who is refractory to one form
of mercury will be too strongly affected by another, and will receive
no medicinal or curative effect, except from the particular one which
is best adapted to his constitution.   For example, the skin in all pa-
tients is not affected  in the same way by all mercurial ointments.  I
have often shown  patients  at the  Hopital des Venenens, on whom
frictions had been made for a long time with large quantities of strong
mercurial  ointment  without any effect, but who subsequently either
experienced the curative action of mercury or were salivated, after the
application of Vigo cum mercurio plaster for four or five days over a
certain portion of the skin, as for example the two thighs.   The same
is true of mercury given internally; one preparation has no effect on
a patient, another has a morbid action, and it is only by a skilful selec-
tion in each individual case that we can obtain a preparation that, suit-
ably administered, will effect a cure.
   I have elsewhere drawn up in a concise manner the  rules which I
follow in administering mercury, and I will repeat them in this place.
   1. Give  mercury internally, whenever the state of the digestive or-
gans permits.
   2. Apply it to the skin in contrary cases.
   3. When the mucous passages are irritated too  soon, and the skin,
equally irritable, will not allow of a complete course of  external treat-
ment, the two methods should be judiciously alternated.
   4. Some patients  cannot be reached either by the skin  or the di-
gestive passages, but are favorably affected by the inhalation of mer-
curial vapors, which, in a multitude of  cases, are perhaps  too much
neglected.
   5. It is rarely necessary to wait longer than a week to perceive the
effects of mercury, either as a morbific or curative agent; and so long
as no favorable change is produced in the disease, the daily dose of the 
TREATMENT.                      497
remedy should be increased eve^ week, unless some supervening symp-
tom contra-indicate it.
   6. As soon as a change for the better is obtained, we should stop at
the quantity which produced it, and only increase it when the disease
arrives at a status quo.
   7. If mercury produce any unpleasant symptoms, the mode of using
it should be modified, or it should  be entirely suspended, experience
in such cases having  proved, with a few rare exceptions,  that, even if
the syphilitic symptoms be not always aggravated, the cure at least is
almost invariably retarded.
   8. When the mercurial symptoms  have subsided and the syphilitic
symptoms  still remain,  mercury should be resumed with  such modifi-
cations as  the peculiar  nature of the former require, as  regards  the
surface to which it is applied, the form in which it is administered, or
the quantity employed.
   9. The same inconveniences do not always  reappear on resuming
the  remedy after suspending or  simply modifying it.  . It sometimes
happens, as Hunter observes, that we are obliged to suspend and resume
mercury several times in the course of certain syphilitic affections.
   We should beware of accepting  literally Hunter's  proposition rela-
tive to the quantity of mercury to be introduced into the system, which,
he states, should be proportioned to  the  violence  of the disease.   The
disease, as we have seen, may be violent in different ways, either from
its acuteness, from the complications which aggravate  it, from  the
multiplicity of the symptoms which it excites at the same  time or suc-
cessively, from the  parts which it affects, or finally from its obstinacy
and resistance to therapeutic agents.  One and the same rule cannot be
followed under all these different circumstances, for there  are a multi-
tude of indications to fulfil, and, far from administering  mercury in
proportion to the violence  of the disease, we must often limit its quan-
tity  or entirely suspend it.   But whenever mercury is administered to
a patient, and there is no contra indication, it  should be  known that
its effects are the more efficacious, in the larger doses it is  given.   For
this  purpose, the relative tolerance of patients  under mercury should
be measured by the rules which we have laid down, and the necessary
quantity should be determined only by its curative action on the syphi-
litic symptoms; any quantity which leaves them in statu quo, or which
allows them to  increase, being insufficient, and any  quantity  which
surpasses a curative action and produces morbid mercurial  effects being
too much.—Ricord.]

   [Editor.—As long as any  symptoms of constitutional syphilis remain, we
have a guide as to the  quantity of mercury to be given in the effect of the
remedy upon such symptoms.  Any dose which produces an amelioration in
the symptoms is sufficient; if no improvement be manifest, the  dose is to be
increased.
  But after  the disappearance of all syphilitic manifestations, we are still to
continue our treatment  for some time, as a prophylactic;  and  what are we
then  to take as a guide  as to the  quantity of the remedy to be  administered,
       32 
498                CONSTITUTIONAL  SYPHILIS.
and the frequency of its repetition ?  The best indication under these circum-
stances, that the system is fully under the influence of mercury, will be found
in the condition of the gums.   As soon as any irritation of the gums is pro-
duced, decrease slightly the dose of the mercurial, so as to avoid salivation;
continue this quantity for several weeks, and then carefully try the effect of
increasing it, for it generally happens that the system becomes habituated to
the drug, and  will support a dose which  previously salivated.  By a  succes-
sion of  such experiments on the power of the system to support the  mercu-
rial, and constantly giving as large doses  as can be borne without salivating,
we are sure of attaining the full effect of the remedy.
  Mercury exerts its greatest effect upon early constitutional symptoms.  Its
curative action gradually diminishes, the  more distant the symptom from the
period of infection; until finally in tertiary syphilis iodide of potassium sup-
plies its  place, and is to be relied on  for a cure  of the disease.   This salt
may indeed be called a specific for tertiary syphilis.
  But, in addition to its marked action in this form of syphilis, it also exerts
a prophylactic effect  against any future manifestations.  Hence no treatment
of constitutional syphilis should be considered complete unless the administra-
tion of  mercury has  been  followed by that of iodide of potassium.   In this
way alone can we provide for the future,  and hope to prevent any late mani-
festations of the acquired  diathesis.
  It remains to determine  for what length of time this combined treatment
should be continued in order to insure the greatest probability of no  farther
symptoms occurring.  No  treatment  continued  for any length of time  will
afford certain immunity; all we can do is to render immunity probable.  To
stop treatment as soon as all syphilitic symptoms have disappeared, is to leave
our patient with almost a certainty of their return.   To continue treatment
for as long a time after, as has been required to obtain their disappearance,
is also an unsatisfactory rule.   In many cases it would be too short  a time,
in others too  long.   Clinical observation of a large number of cases can
alone furnish us with  the best guide ;  and Ricord, from his  extensive  experi-
ence, comes to the following conclusion :  " Six months  of treatment by mer-
cury, in such  daily doses as to exert a curative action  on the symptoms as
long as they remain, and after their disappearance to show by its physiologi-
cal effects that it is still acting  on the system; afterwards, three months of
treatment by iodide of potassium, in order to prevent any late manifestations
of the diathesis; such is the mode and length of  treatment which has  been
found to be most successful, and which,  in the great majority of cases, neu-
tralizes,  as it were, the syphilitic poison.   It is to be understood, however,
that this rule is frequently to be modified to suit the circumstances of indivi-
dual cases."   Ricord, Lecons sur le Chancre, p. 216, et seq.—Editor.]

   [Ricord.—Whatever theory be adopted with regard to the mode of
the curative  action  of mercury—and each  school gives its own expla-
nation—it is very certain that syphilis is never cured by the exaggera- 
TREATMENT.
499
tion of any  of its effects, as  fever, increase of the  urinary  secretion,
alvine evacuations, cutaneous irritation or salivation.  On this  point
Hunter agrees with the majority of good observers;  and, to mention
only one of its effects, I will observe that the  method of treatment by
extinction, so called, is at the present day universally preferred to the
old and defective method by salivation.
   It is proper in this place to add a few words to what Hunter says of
salivation, a peculiar and common effect of mercurials, which deserves
special attention, since it must be regarded as  a complication interfer-
ing with treatment, and often obliging us to suspend it.
   Mercurial salivation is very rare previous to the first dentition, mer-
cury acting at this age rather on the digestive passages or on the skin.
It is easily produced in women, in lymphatic temperaments, in scrofu-
lous subjects, and especially in those of a scorbutic predisposition—in
 all persons, in fine, whose blood  is deficient  in  plasticity.  Habitual
 constipation and a foul state of the mouth (want of cleanliness or carious
 teeth) predispose to it in a remarkable degree.  Very high and very
 low temperatures have  the  same  effect, especially when encountered
 suddenly.
   The soluble preparations  of mercury do not determine it so soon as
 the insoluble.
   The quantity of mercury necessary to produce salivation depends on
 the individual.                                          .  .
   Salivation usually occurs during the first week of the administration
 of a uniform quantity of a  mercurial preparation; but it may  appear
 within twenty-four or forty-eight hours, though it is generally after the
 fifth day.  Whenever the quantity given daily is increased, salivation,
 though previously absent, may appear; but it is very certain that  pa-
 tients are most susceptible to  it at the commencement  of treatment,
 and that, in general, the farther they progress in the treatment, the less
 salivation is to be feared.
    When salivation has  not occurred eight or ten days after stopping
 mercurial treatment it is no longer to be feared, and the cases of  late
 salivation, reported by authors, especially those supposed to occur after
 an interval of a year, should be referred to simple ulcerous stomatitis,
 which is so common and so easily mistaken  for mercurial stomatitis.
    Mercurial salivation, mercurial ptyalism or mercurial stomatitis does
  not commence  in the salivary glands; these are  at first only sympa-
  thetically affected, as shown by pathological anatomy.   An increase in
  the salivary secretion may be the first thing which excites the attention
  of the physician and patient; but the first part materially affected  is
  the mucous membrane of the mouth.   This membrane becomes tume-
  fied in whole or in part, and the swelling partakes of the nature both
  of erysipelas and oedema.  The  patient has an uneasy feeling about
  his mouth, a sensation of heat and a coppery taste; the teeth  are raised
  in the alveoli, rendered movable, and seem separated from each other
  by the interposition of a foreign body; patients think them longer than
  usual, and that thus the dental arches come  together sooner when the
  laws are closed; the tongue becomes swollen, sometimes to such a de-
  gree as  to overlap the dental arches  and protrude between the  lips, 
500              CONSTITUTIONAL SYPHILIS.
 bearing the impression of the teeth; the cheeks and the lips are also
 swollen, and their lining, mucous membrane, soon forms a projecting
 ridge corresponding to the interval between the jaws. The more intense
 these symptoms are, the more the saliva, which escapes involuntarily,
 becomes abundant, viscous, and has a mercurial odor,1 a kind of metallic
 fetid smell, which  simple inflammations of the  mouth sometimes  pre-
 sent to a  certain degree, but which is here very marked, and may be
 detected in the patient's breath before ptyalism  has occurred.
   Meanwhile, wherever the swollen mucous membrane is subjected to
 any pressure, a kind of pseudo-membranous exudation takes place, of
 a whitish or grayish color, and is especially marked around the necks
 of the teeth, where it resembles a festoon.   This is succeeded by ulce-
 rations which sometimes bleed readily, and  which, in most cases,
 appear to  be the result of the combined action  of gangrene and diph-
 theritic inflammation.  Again, the progress of the disease may be such
 that the tongue is mortified in whole or in part, or the mucous mem-
 brane of the cheeks more or less completely destroyed, so as to prevent
 the necessary opening of the mouth after cicatrization has taken place;
 the cheeks may be completely perforated, the teeth detached, and even
 the jaws affected with caries and  necrosis.
   Still, except from blind adherence to a system, unpardonable at the
 present day, gross ignorance in the treatment, or idiosyncrasies which
 are fortunately rare, serious cases of mercurial  stomatitis are  so un-
 common that I am scarcely  able to show an instance of it each season
 at my clinique, at the Hopital des V^ne'riens.   Mercurial stomatitis is
 usually partial, at  least  when it is first detected, and  may then be
 arrested in its progress.
   In order of frequency, the lower jaw is first affected, and commonly
 the mucous membrane situated  behind the wisdom tooth, especially
 when this tooth is badly set or crowded, and above all, when it is not
 fully grown; the upper jaw is next in order, especially the part behind
 the middle incisors; the border of the tongue, the cheeks, and  the in-
 ternal surface of the lips, are generally involved later; the velum palati
 and the pillars of the isthmus of the fauces seem  to be the limit beyond
 which the disease  never passes  in  ordinary cases.  An observation
 which I have made repeatedly, and which I submit to others to verify,
 is that mercurial  stomatitis, other things  being equal, is  developed
 especially on the side on which the patient is in the habit of lying.
   Mercurial stomatitis is rarely ushered in by  fever, the first symp-
 toms, as I have said, being  confined to the mouth;  but, though fever
 may be absent during the whole course of this affection, yet it some-
 times attends it, especially in  its severer  forms, and  may survive it
 under the hectic type, when the patients have suffered severely and for
 a long  time.  To  the  impairment of the functions of the mouth and
 tongue, the pain which  the  patients suffer, and their want of sleep,
 other symptoms are often added, such as oedema, erysipelas of the face,

  1 Some curious and  important researches of M. Gmelin (L'Experience, Journal de
 Me'decine, Paris, 1837, No. 11) prove that mercury is found, in substance, in the saliva
of persons affected with ptyalism after using this  metal.  I have, however, had these
experiments repeated without success. 
TREATMENT.
501
 swellings of the neighboring lymphatic ganglia, gastro-intestinal affec-
 tions, oedema of the glottis, and  all the direct or sympathetic conse-
 quences of  these complications.
   The course of mercurial stomatitis is generally acute, and it attains
 its maximum intensity in a  few days;  but it may assume a  chronic
 type, and last an unlimited  time, either when  the use of mercury is
 continued, or when, abandoned to itself, it is  kept up by accessory
 causes,  as a scorbutic disposition, which may have previously existed
 or have been excited by it.   But in ordinary cases, when the cause is
 removed and suitable treatment applied, it is rare for it to last beyond
 a few weeks, and it is generally arrested in a few days.
   Mercurial stomatitis often terminates in speedy resolution, but gene-
 rally ulcerations occur, and  sometimes gangrene.  Death may  ensue
 from the progress of  the mortification, the exhaustion of the patient
 from suppuration and  loss of saliva, from the  almost absolute impos-
 sibility in some cases of administering food, etc., but it is fortunately
 very rare.
   The diagnosis of mercurial stomatitis is almost always easy.  In the
 first place, when the symptoms above described appear during a course
 of mercury, or soon after, it is rational to refer the former to the latter.
 Again,  mercury itself is the best test of mercurial ptyalism, this affec-
 tion growing worse, if the use  of the mercury be continued, and soon
 disappearing  if it be stopped.   Though some  syphilitic symptoms of
 the mouth may be aggravated by mercury, most of them yield to this
 powerful remedy, which always increases and never cures the symp-
 toms which it  itself  has produced.  On the other hand, if we take
 into account the ordinary seat  of syphilitic lesions of  the mouth and
 fauces, their more marked outline, their peculiar aspect, their slower
 and more chronic course, the absence in most cases of that cedematous
 erysipelatous state of which we have spoken, the induration which
 often exists to an  appreciable degree, and which is very different from
 the clammy, pitting state of the mucous membrane in mercurial ptya-
 lism, the antecedents,  the concomitants, the peculiar circumstances in
 which the symptoms appear,  and  if, above all, we examine the effects
 of mercury on the case,  we shall always attain, if not  to an  absolute
 diagnosis, at least to  a rational one, which is sufficient to guide us in
 the use  of mercurials.   In cases of aphthas, or simple ulcerous stoma-
 titis, which  are the diseases most easily confounded with salivation, a
 rigorous diagnosis is not necessary, since these affections, analogous to
 the effects of mercury, contraindicate this mineral so long as they last.
   The treatment of mercurial stomatitis should, above  all, be prophy-
 lactic; remove predisposing causes, when possible, diminish the quan-
 tity of the mercury given, defer its administration till it can be borne,
 or suspend it entirely; these are the first measures to be taken; clean-
 liness of the mouth, the use of astringent gargles, and keeping the
 bowels open, are of the first importance  in preventing, or, at  least,
 retarding salivation.  But when it  has already taken place, the most
effective treatment in all its stages, and one which never fails, consists
in touching  the diseased tissues with pure hydrochloric acid.  This
should be done once  a  day, the  acid being applied to the mucous 
502
CONSTITUTIONAL  SYPHILIS.
membrane by means of a small  brush, avoiding the teeth.   Where
there are no ulcerations, it produces scarcely any pain;  but when the
surface is ulcerated, the pain is often very severe, and the parts gene-
rally bleed at each application;  but  this temporary suffering soon
subsides and  the  patients experience such relief that they themselves
beg for its renewed application.  If the surfaces be not ulcerated, an
astringent gargle should be prescribed; in the contrary case, a slightly
acid gargle is to be preferred.  The best drink for these patients is
made of dilute nitric or sulphuric acid.  In fulfilling these, the most
urgent indications, no others which the individual case demands should
be neglected, as derivatives to the lower extremities and intestinal
canal, aided especially by laxative or purgative enemata; leeches along
the border of the lower jaw; venesection  when there is  much  general
reaction; sedatives and opiates, when there is nervous excitement and
want of sleep; diet  or  nourishment proportioned to the general and
local state of  the patient.1
  I will not, in this place, attempt a history of all the symptoms which
mercury may produce;  I will  only say that  the cutaneous affections
which it sometimes excites, particularly  when applied as a  topical
agent, are much less frequent, and  especially much less severe, than
has  been asserted.   As to  hemorrhages,  in  consequence  of its anti-
plastic action, they are so rare that, up to the present day, I have never
seen an instance.   Mercury, doubtless, has a very powerful action on
the nervous system, but unpleasant symptoms are certainly not observed
with the  preparations and the doses in which it is employed in a me-
thodical course of treatment.   In  my long practice, and  among the
numerous patients  I have treated, I have met  with only one  case  of
mercurial tremor, and that was in a ward-tender, who for many years
had  administered fumigations of cinnabar to the patients at the Hopi-
tal du Midi.
  Mercury has been considered to have the power  of producing abor-
tion. Granting it this property, rigorously speaking, it is more rational
to say that, when wTisely employed, it prevents more abortions than it
causes.
  As to mercurial cachexia, the methodical and more restricted use of
mercury, at the present day, renders it more and more rare.   Since I
have been at  the Hopital du Midi, not a single example  of  it has been

  1 The best treatment of mercurial stomatitis is the internal administration of chlo-
rate of potash.  The dose is from one to two drachms daily, given in divided portions
and largely diluted, as this salt is not very soluble.
  Prior to some  recent experiments of Ricord, some doubt was felt as to the curative
action of the chlorate, since the mercury was always suspended at the same  time that
this treatment was commenced.  Ricord, however, has shown that the  mercury may
be continued or even increased in quantity after  salivation has taken place, and yet
the unpleasant symptoms will disappear under the use of chlorate of  potash.  The
same may also be used as a prophylactic from the outset of a mercurial course in per-
sons peculiarly susceptible to the action of mercury.
  Moreover, Ricord has shown that the concurrent administration of the chlorate does
not in any way interfere with the curative action of the mercury on the constitutional
symptoms.  See Lecons sur le Chancre, p. 336.  These results have been more recently
confirmed by M. Laborde.  See Gaz.  des Hopitaux, April 24, 1858.—Ed. 
TREATMENT.
503
seen in my wards, and patients to whom I myself have administered
mercury have never been affected with it.
  One of the doctrines which'have done the most to throw discredit
on the mercurial treatment of syphilis, is that according to which this
treatment should be the more energetic, the deeper seated and older
the symptoms are. I will not repeat what I have said on this subject;
but I will observe, in this  place, that it is proved to the minds of all
unprejudiced observers that, though mercury be one of the most
effectual remedies for pure secondary symptoms, its energy is exhausted,
and  its good effects frequently succeeded by injurious ones, in  the
treatment of tertiary symptoms.   For the latter symptoms, in which
syphilis seems to have  undergone, if not a complete transformation, at
least a profound modification, there are, at the present day, other thera-
peutic agents which should be preferred.
  When tertiary symptoms  exist alone, the treatment which has suc-
ceeded best in my hands consists in the use of iodide  of potassium.
  Two scruples a day may be given at first.  This quantity is to be
taken  in three doses in the course of  the day, in  three glasses  of  a
decoction of sarsaparilla, hops, or saponaria.   Fifteen grains  should
be  added every five days to the quantity given daily, until a drachm
and a half is taken a day, which I have rarely gone beyond.
  Besides its curative effects, iodide of potassium may act on different
parts of the economy in a manner which it is perhaps well  to mention.
  The digestive organs generally tolerate it readily; but, in some cases,
patients complain of pain, and an uneasy sensation in the region of
the great cul-de-sac of  the stomach, sometimes analogous to pleurody-
nia, but differing from  it in being deeper.   In certain cases the thirst
is augmented, although more generally the appetite alone is increased,
and the patients soon  become fat.  I have  rarely observed vomiting
and diarrhoea.  A very frequent phenomenon is a kind of salivation or
ptyalism very analogous to that  of pregnant females.   It consists in a
regurgitation of salty,  metallic saliva, which may, to a certain  degree,
resemble mercurial salivation, since a slight erythematous and cedema-
tous swelling of the gums is met with in some patients; but there  is
never any ulceration or fetid metallic odor, as in mercurial salivation.
Iodide of potassium acts, perhaps, more frequently on the  pituitary
membrane and conjunctiva.  Most patients, at the commencement of
this treatment, are attacked with coryza, which is sometimes very acute.
At  the same time, marked symptoms of catarrho-oedematous ophthal-
mia are observed with more or less decided chemosis and oedema of
the lids.  But here, as well as in  the coryza, it is rare for a muco-puru-
lent secretion to supervene.   I have also seen, but more rarely, symp-
toms of bronchitis. Certain phenomena may appear on the skin; thus,
it is not uncommon to observe an eruption of acne or ecthyma consist-
ing of very small pustules.   The urinary passages are much affected
in some subjects, and the secretion of urine very much increased.  The
circulation has not appeared to me  to receive any effect worthy of
notice, at least in the majority of cases.  With regard to the nervous
system, some patients experience what has been called iodic intoxica-
tion, characterized by  a  little uncertainty in the voluntary motions, 
504
CONSTITUTIONAL  SYPHILIS.
twitching of the muscles, heaviness of the head, a kind of intellectual
sloth, and sometimes slight derangement of the mind.  Iodide of potas-
sium has been charged with producing atrophy of the glands, and par-
ticularly of the breasts and testes.   It is, indeed, one of the most power-
ful resolvents that I am acquainted with; but it acts only on diseased
organs, the atrophy of which it does not always prevent, and may even
favor, but it cannot of itself produce it.
  These phenomena, however, are always very light, even when the
remedy  is administered in the extreme quantity which I have men-
tioned.  But their appearance, and especially their tendency to become
aggravated, are always to me an indication that I have reached a limit
where it is  necessary to stop; and, again, whenever one  of the symp-
toms improves, I stop at the quantity of the remedy which produced
the amelioration, and increase it, according to  the rules already laid
down, only when the disease remains in statu quo.
  When the symptoms have been correctly determined, a marked and
decided  improvement rarely fails to appear during the second week of
the treatment and sometimes sooner.  The tubercles are absorbed; the
ulcerations become clean;  the suppuration diminishes;  the osteocopic
pains cease, and the osseous  tumors, if they be not permanently indu-
rated or eburnated, soon begin to take on resolution.
  When, however, symptoms of transition between the secondary and
tertiary  periods are present, as deep tubercles of the skin and  mucous
membranes, and when, especially,  tertiary symptoms are accompanied
by marked secondary symptoms, treatment with iodide  of potassium
is not sufficient, and mercurials should be added to it.  Here, again,
with the exception  of  the cases mentioned, I prefer the proto-iodide
of mercury.
  In these cases, whichever class of symptoms disappears first, the
remedy  corresponding to it is  omitted, following the rules  already es-
tablished.
  Yet in the treatment of secondary and tertiary symptoms as in that
of the primary, direct or local applications should not be neglected; if,
in the primary symptoms, this be the first  indication to fulfil, in the
other two orders of symptoms, it is undoubtedly the second.
  Whenever any of the cutaneous eruptions are attended with exces-
sive irritation, or  more or less decided inflammation, simple, gelatinous
or amylaceous baths  are very useful; emollient, sedative, or  opiated
fomentations,  and emollient  cataplasms should  frequently  be  em-
ployed.   In asthenic  eruptions,  simple vapor  baths,  and especially
local or  general fumigations of cinnabar are often of great use.   When
it is desired to make the symptoms disappear  rapidly, which is so im-
portant for  most patients, especially when they are situated on the face,
there is  perhaps no  more  efficacious means than the Emplastrum de
Vigo cum mercurio.
  Resolution of the papular and tubercular  eruptions  of secondary
syphilis may be promoted by mercurial ointments, and  especially by
an ointment of the proto-iodide of mercury;  but they sometimes re-
quire the use of baths of corrosive sublimate, which are much more
efficacious here than in some other syphilitic eruptions. 
TREATMENT.
505
  I have often shown at my clinique the good effects of M. Emery's
tar ointment1 upon squamous syphilitic eruptions, but I do not, how-
ever, neglect constitutional mercurial treatment.
  But as a powerful local application, and one which gives more rapid
cures than any other, we cannot estimate too highly the combined use
of the  oxychloride of sodium2 and calomel in the treatment of mucous
papules.
  The diseased tissues should be washed twice a day with the oxychlo-
ride of sodium either pure or sufficiently diluted with water to  excite
only a slight smarting sensation, and then be powdered over with calo-
mel.   This treatment, continued for eight or ten days, is generally
sufficient to produce complete resolution of these eruptions,  which
often resist other means for months.
  When eruptions of this form are situated  in the mouth,  local appli-
cations of the liquid acid nitrate of mercury  are to be preferred.
  The local treatment of secondary ulcers is but little different from
that already directed for primary ulcers.   When the reparative stage
commences, the best dressing, if the situation of the ulcers permits its
application, is with small strips of Emplastrum de Vigo cum mercurio.
  When the ulcerations are situated in the mouth and throat, we should
have recourse to  emollient gargles, if inflammation be present; or to
opiates, quinia, and  hydrochloric acid if there be a tendency to gan-
grene, as is sometimes observed; but when these ulcerations-are indo-
lent, and attended with induration of the tissues, gargles of a decoction
of conium and dulcamara,  with the addition of one grain of bichloride
of mercury to the ounce, should be preferred.
  The velum palati  is sometimes divided by syphilitic ulcers, but, in
that case, the state of the tissues often renders the operation impossi-
ble, which M. Roux has practised with success in other cases.
  The local treatment of syphilitic iritis consists in the application of
leeches to the temples, mastoid processes, and alas nasi.  In addition to
revulsives to the  intestinal canal and lower extremities, mercurial fric-
tions should be immediately applied around the orbit, and extract of
belladonna  may  be  combined with them, as my learned friend, M.
Sichel, does with great success in his practice; or this extract may be
applied separately to this region and within  the nostrils.  As soon as
the inflammatory symptoms  have subsided,  or when they are absent
at the  outset, we  may resort immediately to the application of blisters
to the  temples or above the  orbit; the vesicated  surfaces should be
dressed with mercurial ointment, and the  blisters  be  renewed as fast
as they dry up, until they  are no longer necessary.
  The other local applications which may be required in this case do
not differ from those in use  in other severe ophthalmias, but they should
be promptly aided by the  administration of the  proto-iodide of mer-
cury, which I prefer  to calomel, and which I  combine with belladonna
either in the form of the  powdered  leaves or  the extract.

  1 M. Emery's tar ointment consists of one part of tar to three parts of cerate.  Un-
guentum creasoti may be substituted for it, and has not the disadvantage of its dark
color.—Ed.
  2 Labarraque's Disinfecting Liquid.—Ed. 
506               CONSTITUTIONAL  SYPHILIS.
  With  regard to the treatment of syphilitic sarcocele, besides local
mercurial frictions  and the application of Emplastrum de Vigo  cum
mercurio, no better application can be made than the methodical com-
pression, of which I have spoken in connection with gocorrhceal epi-
didymitis.
  The falling of the  beard and hair, and the affections of the nails,
accompanying ulcerations and eruptions on the skin, cease  under the
influence of the remedies already mentioned.  But the fresh growth of
the hair may be promoted, after shaving the head, by the use of fric-
tions with an ointment of the proto-iodide of mercury, or with Dupuy-
tren's pomade of cantharides,1 or with light frictions of tincture of can-
tharides diluted with alcohol.
  For the nails, it is generally sufficient  to apply the same local treat-
ment as for mucous papules.
  If we now pass to the local treatment of tertiary symptoms, we shall
see that,  in  cases of deep tubercles of the skin and mucous membranes
attended with inflammation, it is often  necessary  to  have recourse  to
local antiphlogistics, as emollients, sedatives, and narcotics.  But when
the tubercles are indolent, as is generally the case, their resolution is
often promoted by  means of Biett's formula of honey  and the proto-
iodide of mercury (one part of proto-iodide of mercury to  twelve  of
honey).  Chlorinated lotions, combined with  calomel and the Emplas-
trum de -Vigo cum  mercurio, may also  be successful;  but one of the
most efficacious topical  applications, especially when there are ulcera-
tions, is a solution of iodine :—
                       R;.—Tincturse iodinii 3j ;
                           Aqua? destillatae §iv ;
                           Potassii iodidi, q. s.—M.
  In some cases, however, it is necessary to have recourse to cauteriza-
tions with  the liquid acid nitrate of mercury, or to  applications  of
caustic solutions of corrosive sublimate, sulphate of copper, &c.
  Though  osteocopic pains  sometimes  yield  to the application  of
leeches, emollient  cataplasms, opiated frictions, &c.,  yet the mode  of
treatment which is  perhaps the most efficacious and the most speedily
followed by relief is  by means of blisters.   One  must witness the re-
sults which they produce in the great majority of cases to believe  in
their marvellous effects.  Many times at my clinique  at the Hopital
des Veneriens, I have shown patients who had been deprived of sleep
for entire months,  and who, by the use  of blisters, were freed from
their  excruciating  pains in twenty-four  or forty-eight hours!   The
blister should be applied over the seat of the pain, and it is unneces-
sary to detach the  epidermis  after its  removal.  The dressing may
consist of opiated cerate, covered with an emollient cataplasm.  If the
pain continue after the blister has dried up, another should be applied.

  1 Formula for Dupuytren's Pomade. (Formulaire Magistrate.)
                   R>—Medullse ossium bovis §j ;
                       Plumbi acetatis %j ;
                       Balsami Peruviani ijij ;
                       Tincture cantharidis §ss;
                           "   caryophylli,
                           "    canellae, aa  gtt. xvj.—M.—Ed. 
TREATMENT.
507
In some cases, it is necessary to keep up the suppuration, or to make
a deep incision, including the periosteum, in the suffering part.
  The local treatment of periostitis or periostosis differs but little from
that of osteocopic pains.  Most commonly, antiphlogistics, emollients,
narcotics, and especially blisters, quiet the pain and soon produce reso-
lution of any nodes  that may have  formed; but in many cases, to
obtain this effect, it is necessary, besides the use of  blisters, to make
applications of mercurial ointment or tincture of iodine diluted with
distilled water, gradually increasing their strength so as to slightly
cauterize the skin.  I have sometimes derived great advantage from a
blister and a caustic solution of corrosive sublimate, as  mentioned in
speaking of the treatment of buboes.
   When the disease remains stationary in spite of these means, com-
pression may be employed whenever the situation of the parts permits.
   If the periostosis has given rise to suppuration, after having attempted
its resolution by appropriate means, we must not wait for the skin over
it to become affected  and  undermined by the pus, and sound portions
of the bone to be denuded; but suitable openings should immediately
be made with a bistoury.
   Commencing ostitis requires the same treatment as osteocopic pains
and periostoses.  When the tumor is developed, we should rely chiefly
on blisters dressed with strong mercurial ointment and the application
of poultices.
   When suppuration or  caries  occurs, especially of the bones of the
face which are so often necrosed in these cases, we should never fail to
remove them so soon as they can be separated from  the sound parts.
We must recollect that caries engenders caries;  that when the organic
tissue of a bone  has  been destroyed by suppuration or has lost its
vitality, it cannot be regenerated by any constitutional or local treat-
ment whatsoever, and that its debris should never be left to spontaneous
evolution, for they are true foreign bodies,  keeping up and extending
the suppuration  which, involving important parts, may occasion the
most serious symptoms, and finally death.
   When ostitis has produced exostoses, which have passed into a per-
manent eburnated state, these tumors should not be operated upon
unless they cause excessive deformity, or interfere with important
functions.
   Deep tubercles of the subcutaneous or submucous cellular tissue re-
quire special attention in their local treatment, and the more so because,
in some instances, they seem to be the final manifestation of constitu-
tional syphilis, the germ of which may have become extinct.
   M. Cullerier, the nephew, has proposed to  attack subcutaneous tuber-
cles, like buboes, with a blister  and caustic solutions.   This method
has often been successful  in my hands, but in many cases I have had
special reason to be  satisfied with the extirpation or enucleation  of
these tubercles, performed before suppuration has taken place, and the
neighboring parts have become affected; but when suppuration has
already occurred, the pus should be evacuated before it has produced
any great ravages.  Still, at the present day, it is within the bounds of
truth to say, that the  methodical administration  of iodide of potassium 
508
CONSTITUTIONAL  SYPHILIS.
not only effects the resolution of all tubercles before the suppurative
period, but even causes them to be absorbed and disappear when sup-
puration is already established.
  If, as suppuration is taking place, or afterwards, there be symptoms
of inflammation, we should resort  to antiphlogistics and emollients.
When the suppuration is succeeded by foul  ulcers, we should make
use of digestive ointments, excise the portion of the skin which is too
much changed to take part in cicatrization, employ, according to the
case, the various dressings already indicated for other ulcerations, and
especially applications of tincture of iodine, and, so soon as the repara-
tive stage declares itself, apply small strips of Emplastrum  de Vigo
cum mercurio.
  When situated beneath the mucous membranes, and more particu-
larly beneath that  of the  mouth and pharynx, abortive treatment and
enucleation of the  tubercles being hardly possible, we should carefully
watch  for  the first appearance of  suppuration, open the  abscesses
promptly, and after satisfying the first indications which require the
use of emollients, antiphlogistics, and sedatives, speedily have recourse
to gargles of tincture of iodine (a drachm to  six ounces of distilled
water), gradually increasing the strength  till a curative effect be pro-
duced.—Ricord.]
                      CHAPTER   IV.

OF  THE  EFFECTS REMAINING AFTER  THE DISEASE IS  CURED,
  AND OF  THE  DISEASES  SOMETIMES  PRODUCED BY THE
  CURE.

  In treating of the local effects of the venereal disease, the gonorrhcea,
and chancre, as  also the bubo, I observed, that after the virus was
destroyed there remained in many cases some of the same symptoms,
and  particularly after the gonorrhoea.   It was also observed,  that
though all the symptoms were entirely cured,  yet they were  liable to
break out again.   A gleet will appear, sometimes attended with pain,
so as to  resemble a gonorrhoea;  after chancres there will  be sores
resembling them; and buboes, after  the virus is gone, will  not heal,
but spread.  In the lues venerea  the  same thing often happens, espe-
cially if the inflammation and suppuration have been violent  in the
parts.  These cases puzzle considerably; for it is difficult to say when
the venereal virus is absolutely gone.  In such doubtful cases, the
treatment to be followed  becomes more undetermined.
  Such complaints are more common in  the tonsils than in any other
part, for we often find  that while a mercurial  course is going on, and
the ulcer on the tonsils healing, or even  healed, they shall swell, be-
come excoriated, and the excoriations shall sometimes spread over the
whole palatum molle, which renders the nature of the disease doubtful. 
SEQUELS.                        509
 I believe  these  excoriations,  as  well  as  such other appearances of
 disease as  cOme on during the use of  mercury, are  seldom or  never
 venereal.  In all such cases, I would recommend not to continue the
 mercury longer than what appears sufficient for overcoming the origi-
 nal venereal complaints, not considering those changes in the case as
 venereal.  The bark is often of service here, and may be given  either
 with mercury, or after the mercurial course is over.
   It  often happens that venereal abscesses will  not heal up, although
 they  have  gone  a  certain length towards it, for while the venereal
 action remained  in the part, the mercury disposed that part to heal;
 but under that course the constitution and part had acquired another
 disposition, proceeding from a venereal and mercurial irritation affect-
 ing a particular habit of body or part, at the time, which new disposi-
 tion differs from the  venereal, mercurial, and natural, being a fourth
 disposition arising out of all the three.   I  suspect,  however, that it
 depends chiefly  on the  constitution, because if it  was owing to  the
 other two, we should always have the same disease; and what makes
 this opinion more  probable is, that it  differs in different people, at
 least  it is not cured in all by the same means.  The constitution  being.
 predisposed, the other two become the immediate causes of action.
 As soon as  the  venereal irritation  is destroyed by  the  mercury, or
 becomes weaker  than the other two, then the effects of the others take
 place.  While the venereal action prevails, the mercury is of service,
 and the sore continues healing; but when it is  lessened to a certain
 degree,  or destroyed, the mercury not only loses  its powers, but
 becomes a  poison to the new disposition  that is formed; for if mercury
 is continued, the sore spreads; it should, therefore,  be immediately
 left off.
   Some  of the sores formed in this way not  only  resist all means of
 cure,  but often inflame, ulcerate, and form  hard callous bases, so as to
 put on the appearance of a cancer, and are often supposed really to
 be so.
   We find also that new diseases arise from the mercury alone.  The
 tonsils shall swell where no venereal disease has been before; the perios-
 teum shall  thicken, and  also probably the bones, and the parts over
 them shall  become cedematous and sore to the touch; but as these com-
 plaints arise while under a mercurial course,  they are  not to be reckoned
 venereal, but a new disease, although they are too often supposed to be
 venereal, and on that  account the mercury  is pushed as far as possible.
 In such cases, if the complaints for which the  mercury was given are
 nearly cured, and the medicine has  been continued a sufficient  time
 after to complete the cure of those complaints, then  of course it should
 be left off;  and, if there be any doubt, it should be left off rather sooner
 than if no such complaint had taken place, because it is probably pro-
 ducing a worse disease than the venereal; and if, after the cure of these
 complaints from the mercury, the venereal disease begins again to come
 into action, mercury must be given a second time; and now the consti-
 tution will  be better able to bear it, especially  if attention has  been
paid to the restoring the strength of it.  Those diseases of the tonsils
and periosteum I suspect to be of scrofulous origin. 
510
CONSTITUTIONAL SYPHILIS.
  Besides local  complaints, arising  from the combined action of the
mercury, the disease, and the constitution, there is sometimes a consti-
tutional effect, which is a weakness or debility, a languor, want of appe-
tite, frequent sweats threatening  hectic; but these happen mostly in
those constitutions with which mercury disagrees.  These complaints,
local as well as  constitutional, arise in  some measure from  weakness.
They are  difficult of cure, whether arising from a venereal chancre,
bubo, or the lues venerea.  Strengthening medicines are of most ser-
vice ; the  bark is of great use, though in general not sufficient, as it
can only more or less remove the weakness, the specific qualities still
remaining.  What these are is, I believe, not yet known;  but I suspect
that  many partake of the scrofula, and this opinion is strengthened by
their frequently giving way to sea-bathing.1


  § 1.  General Observations on the Medicines usually given for the Cure.

  A decoction  of the woods, among which are commonly included
guaiacum and sarsaparilla, is one of the  first  medicines  in the cure,
and  many of the cases  yield to it, which gives them the credit  of
curing the venereal  disease, while such diseases were supposed to be
venereal.   The sarsaparilla was often given alone, and was found  to
produce nearly the same effect.   The good effects of it  in one  case
gave it some reputation.2   A diet-drink discovered at Lisbon was also
of considerable  service, and  as it cured  cases  similar to those cured
by the sarsaparilla, it was imagined that the diet-drink consisted prin-
cipally of a decoction of  this root.  This was still on  the supposition
that  all those cases were venereal;  but it  was observed  at last  that
those medicines  did not cure this  disease till mercury had been given,
and  in a  tolerably large quantity.  This  was sufficient to  lead some
thinking minds  to doubt whether  they were venereal or not; and their
being cured by different medicines ought  to  produce a conviction  of
their being different from the venereal disease, and that they are them-
selves of different kinds.
  The mezereon has also been found to be of  service in some symp-
toms of the lues venerea, such as  nodes of the  bones;  but their being
venereal was taken  for granted.  The mezereon is  seldom given  in
venereal ulcers in the throat, or blotches on the skin, which, of all the
venereal symptoms,  are the most  certain, and the most easy of cure;
yet it was conceived that it removed such symptoms  as are the most
difficult of cure; but  all  those cases in which  the mezereon has been
given with success plainly appear not to have been venereal.
  When the hemlock came into fashion in this country, it was given
in almost  every  disease, and of course was tried in some of those com-

  1 In a case of an ulcerated rib from a venereal cause, and five nodes on the shin-bone,
of twelve months' standing, a deep salivation of six months was undergone, after fruitless
attempts by gentle  friction. None of the sores were healed by the mercury, and the
patient was ordered to bathe in the sea, and take the bark.  In three or four months
the sores all healed up very kindly, but the side the last  of all.
  2 See London Medical Essays, a  case  published  by M. Fordyce, now Sir William
Fordyce. 
SEQUELAE.
511
plaints consequent to the venereal disease, and some of these it was
found to cure, so that it now stands upon the list of remedies. Velno's
vegetable  syrup has  had similar effects in some  of these cases, and
opium appears also to have  many advocates.  Opium, like the sarsapa-
rilla and mezereon, was supposed by its first introducers to cure the
lues venerea,1 but, like the  sarsaparilla, it  appears to have no  effect
till mercury has done its best or its worst.2  It has certainly consider-
able effects in many diseases, both in such as  are consequent to the
venereal disease, and  others arising from other causes.
   It has been long a  favorite medicine of  mine, not only as relieving
pain, for that is its common effect,  but  as a medicine capable of  alter-
ing diseased actions and producing healthy ones. In all sores attended
with irritability, a decoction of poppy  heads, made into a poultice, is
an excellent application.  Bleeding sores that do not arise from weak-
ness, but from irritability, have  the  bleeding stopped immediately by
this application.  Mr. Pott is, I believe, the first who showed the world
its use in mortifications.   My first mode of applying it for the cure of
diseases was locally, in which I  found it had most salutary effects in
some cases, and it was ordered  afterwards internally upon the  same
principle;  and it was also found to have salutary effects in this mode.
In two cases that had been long suspected to be venereal, its effects
were very  remarkable, and,  by its having cured them, it confirmed me
in my opinion that they were not.  But  when I was  informed that
they cured the venereal disease  in the army in America by opium, I
then began to question myself whether I had formed a right judgment
of the nature of those two cases which were cured by opium.  To as-
certain whether opium would cure the  lues venerea or not, I made the
following trial at St. George's Hospital.
   A woman was taken into the hospital with blotches  on her skin,
which had arrived to the state of scabs, and with well-marked venereal
ulcers on both tonsils.  A grain of opium was ordered to be taken the
first night, two the second, and  so on, increasing a grain every night,
unless something should arise to forbid it.  This was closely followed
till  the nineteenth night, when she was  ordered a dose of physic, as
she had become costive, and the  opium was omitted.   On  the  20th,
she began again, and continued increasing  the dose as before, till it
amounted  to thirty grains, no alteration being produced in  the  sores,
except what  arose from the loss of time, whereby they were rather
worse.  I concluded  that if she had taken mercury to affect the con-
stitution as much  as the opium did,  the venereal disease must have
been nearly cured, or at least much lessened; but as that was not the
case, it convinced me that  the  opium had no effect whatever on the
venereal disease.  I then put her under a course  of mercury by fric-
tion, and  in  a short  time it affected her mouth; the sores soon began
to look better, and they  went on healing without interruption, till the
disease was cured.  I may  just observe, the inconvenience from the
opium was not  considerable, for, although  it kept her quiet, she was
not constantly dozing.

             1 See Medical Communications, vol. i. page 307.
             2 See a pamphlet published by Mr. Grant. 
512              CONSTITUTIONAL SYPHILIS.
   Luke Ward was admitted into St. Bartholomew's Hospital January
 12, 1785; his complaint was  an ulcer in  the throat of three months'
 standing, which, both from its appearance and  the  symptoms which
 preceded it, seemed  to  be venereal.   He was ordered two grains of
 opium twice a day, which he took a few days without any other effect
 than  that of sleeping better  at night than usual, when the dose was
 increased to two grains  three times  a day.  His throat now gave him
 less pain, but upon  inspection was  not found to be at  all mended.
 After two days  the  dose was increased to three grains thrice  a  day;
 from  this quantity he felt little or  no inconvenience; he complained
 of being a little drowsy; his  eyes were rather inflamed, and his face
 rather flushed.  He continued to take this quantity for five days, and
 then it was increased to three grains four times a day. Next morning
 the redness and heat of his face were much increassd, and had extended
 over his whole skin; he complained of pain in his  head.   His pulse
 was full and strong; he was  bound in his body, and his belly was
 tense and painful.   The opium was  omitted, and such remedies as the
 present symptoms seemed to require were given, but without effect, all
 his symptoms continuing  to increase till  he died, which was  on the
 fourth day after; during this time the ulcer increased much, and the
 discharge of saliva was  so great as to resemble a slight salivation.
   This case proves in the first place, that the opium had no effect upon
 the ulcer in the throat;  and, in the  next, that it is a medicine capable
 of producing very violent effects on  the skin, requiring therefore great
 caution in the mode  of administering it.
   John Morgan was admitted into St. Bartholomew's Hospital  with
 an ulcerated  leg.   The common applications  were tried for seven
 weeks, at the end of which time he was in every  respect worse, having
 no sleep from constant pain,  and  he was  sinking very fast.  Two
 grains of opium were given every two hours for twenty-three days;
 it made him hot and costive, and his pulse became strong and full, but
 without sleep or abatement of  pain.  The dose was  increased to four
 grains every two hours  in the day, and eight grains every two hours
 during the night.   The effects were  costiveness, retention of urine,
 loss of appetite, an  inflammatory disposition, no sleep,  without  any
 amendment of the ulcer.   On the third day of taking the last-men-
 tioned quantities he awoke from a short sleep delirious, and continued
 so for twelve hours, when it left him very weak, sick at  his stomach,
 and with a low pulse.  In three or four hours the delirium returned,
 and continued forty-eight hours; the pulse, on its return, immediately
 rose, and his strength returned to a  very great degree. When it went
 off he fell into a sound  sleep for about eight  hours, and  awoke very
 tranquil, though weak;  no more opium was given, and the leg in the
 space of a month healed.
   In the first twenty-three days he took twenty-four grains a day; for
the last three days he took seventy-two grains a day.  In twenty-six
days he  took seven hundred  and  sixty-eight, which is  nearly two
 ounces of opium.
   Sarsaparilla, from  the comparative experiment made with it  and
the guaiacum,  would appear to have no effect upon  the venereal irri- 
SEQUELS.
513
tation itself, and therefore  can be of no service  till that irritation is
destroyed;  and as mercury is the antidote to that poison, and becomes
one of the  causes of the complaints in which sarsaparilla is  useful,
therefore mercury is  not only  necessary to destroy the  poison, but
also assists in forming the diseases we are now treating of.
  It is easy to conceive it in many cases to  be  of use in preventing
the formation  of the disease arising  from mercury.  When  given
along with the mercury it is often  joined with the gum  guaiacum, or
the wood of the guaiacum,  which we know will have some effect.
  The sarsaparilla  is generally given in form  of a  decoction, three
ounces to three pints of water, boiled down slowly to a quart, and the
half or whole is drunk every day,  generally at three  different times,
often at meals.   It is sometimes ground to a powder and taken every
day with the same effect; but I should prefer the extract made into
pills, as the easiest way  of taking this medicine.
  In many of these cases I have seen good effects from the hemlock,
of which the following is an  instance; and I would farther refer the
reader back to my observations on this medicine, which I gave when
treating of the disease produced  in consequence of a bubo, p. 387.
  A poor  woman  had undergone repeated salivations,  which  had
always relieved the most pressing  symptoms; but after that  she was
afflicted more or less for three or four years, ulcers broke out in her
nose,  and  all  over ber face,  with what  is called  a true cancerous
appearance.  The  sores became soon very deep, and  gave very con-
siderable pain.  Mercury, sarsaparilla, and bark were given without
effect; the  sores getting daily worse, the parts  affected were ordered
to be held over the steam of a decoction of hemlock every four hours,
and as much extract to  be taken internally as the patient could bear.
She had sleep, and was  free from  pain the first night;  and in a  few
days the sores put on a healing  appearance.  She lost her nose and
one side of her mouth ;  but in six weeks' time every part was skinned
over.   She remained well for three months, when th3 disease returned
with redoubled violence, and soon  destroyed her.

               § 2. Of the Continuance of the Spitting.

  It sometimes happens that the spitting continues after there is every
reason for supposing the mercury to be entirely out of the constitution.
As  it is only a continuation of an action, or an effect of mercury
having been in the constitution, it is necessary to distinguish  it from
the original, or from the immediate effect of mercury; since on  this
distinction  rests the method of  cure.   Such constitutions have been
generally supposed scorbutic; and where there is  a great suscepti-
bility of the mercurial stimulus in  these parts, the salivation will con-
tinue for months after the mercury has been completely removed; but
this medicine not being given now in quantity  sufficient to produce
such violent effects on the salivary glands, these  cases seldom  occur.
  In such cases I would recommend strengthening diet and strengthen-
ing medicines.  Sea bathing is one of the best restoratives of relaxed
       33 
514                     PROPHYLAXIS.
habits, especially after mercury.  Mead's  tincture of cantharides is
supposed to be of service in those cases.
  The alveolar processes have  sometimes  become dead, dnd exfolia-
tions  have taken place; and this alone has kept up a discharge of
saliva.  When this happens we must wait  till separation takes place,
and extract the loose pieces, after which the salivation will subside.
  I have seen part of the jaw exfoliate from this cause.  In most cases
the teeth become loose, and in many they drop out.
                      CHAPTER  V.

          OF PREVENTING THE  VENEREAL DISEASE.

  As diseases in general should not only be cured, but when it is pos-
sible prevented, it will not be  improper to show, as far as we know,
how that may be done; for, in this disease, we can with more certainty
prevent infection, its origin being known.
  Preventives  are  previous or immediate  applications, and may be
divided into various kinds; as those that will not allow the venereal
matter to come in contact with the parts, those which wash it off before it
stimulates, and  those which will act  chemically and destroy the poison.
  Oils, rubbed  on a dry part, stick  to it and prevent anything that is
watery from coming in contact with it; and, as the venereal poison is
mixed with a watery fluid, it is not  allowed to touch the part.
  Everything which has a power of mixing with the venereal matter,
and removing it from the part to which it is applied, may prove a pre-
vention.  Caustic alkali is the best for this purpose; it  unites with the  -s
matter, forming a soap, and is then  easily washed off.
  It is possible this union with the  alkali may destroy the poison; the
alkali must be much diluted, or it will excoriate.
  Lime-water would make a good wash.
  If both these methods were put in practice there would be still more
security.
  Corrosive sublimate in water, about a grain or two to eight ounces,
has been known to prevent the catching of the disease.
  [Ricord.—As Hunter says, we  should not only pay attention to the
cure of diseases, but, in  every  possible way, aim at their prevention.
Under the latter point of  view, there is, perhaps, no affection the pro-
phylaxis of which has been the subject of more conscientious researches,
and, I must  add,  the occasion of  more  speculations,  than syphilis.
Whilst impudent charlatanry has proclaimed futile or dangerous resorts,
false modesty,  timid morality, and religious  prejudices have  often
retarded the  progress of art.   Yet, as Jenner made  himself  forever
renowned by discovering vaccination as a prophylactic means against
smallpox, so he who shall find as absolute a protection against syphilis
will  acquire  a  claim to immortality.   But, while waiting for the dis-
i 
PROPHYLAXIS.                     515
covery of a sure preservative, the existence of which is rendered more
than probable  by our certainty of the specific nature of syphilis, let
us examine, with all the gravity that so delicate a subject requires, the
means which art possesses for protection against venereal diseases.
  Generally, when the prevention of these diseases has been considered,
no division of the subject has been made, and no regard  paid  to the
different circumstances in which individuals may be placed.  To arrive
at any more positive or at least  more rational conclusions,  it is abso-
lutely necessary to divide persons into three classes:  1. Those already
diseased, and capable of infecting others;  2. Sound persons who expose
themselves to the disease ; 3. Infants at the time of conception, during
gestation and parturition.
  1. Infected Persons.—If our passions did not  often get  the mastery
of our consciousness  of right—if men were  convinced that there  is,
perhaps, no more culpable act than to communicate a disease, the con-
sequences of which are so serious, and which is not  only  a scourge to
the individual compromised, but descends  from one  generation  to
another—a conscientious reserve  and voluntary retirement on the part
of infected persons, up to the time of their entire purification, would
extinguish syphilis forever.   But either from  unconcern, unpardonable
thoughtlessness, or ignorance, diseased persons abstain from acts capa-
ble of communicating the disease only  when the pain surpasses the
pleasure.   Again, and in accordance with the  preceding considerations,
women are more dangerous than men;  and  it is much more common
to find that a woman has infected a large number of men, than that a
man has infected several women.
  In any country where the public hygiene is subjected to absolute
laws, it is more important  to establish lazarettos  for syphilis, that
common and universally threatening disease, than for the plague and
yellow fever, the contagion of which is much more questionable.   I
am well aware that the religious  restraints of the Jews are not of our
age; that  Saint-Germain-dvs-Pres, that bastile for the infected,  cannot
be rebuilt; that  shaving the hair, as pertain tribes of Abyssinia do,
would disfigure  too  many heads, and that,  if the fear of the conse-
quences and the pain of the disease have no effect, the old scourge of the
petites-maisons de Bicetre would be just as ineffectual.  We  are, there-
fore, reduced, at  the  present day, to' warning patients of their condi-
tion, and confining all coercive action to public women who follow the
tolerated trade of prostitution.1
  It is generally easy to ascertain if a  man be diseased, since those
parts which are the ordinary seat of primary symptoms  can be easily
and thoroughly inspected; but in a woman, the case  is often different;
and as  Michel Cullerier wittily remarked, though we can frequently
discover when  a woman is  diseased, who can  ever  assert that she  is
not; especially if we confine ourselves, as at his time, to an external
examination ?
  When a man comes to a  surgeon to inquire if he can communicate
any disease, if  it be important to examine with the greatest care  all

  1 Consult Parent-Duchatelet, De la Prostitution  dans  la ville de Paris; Paris, 1837, t.
ii. p. 454, et seq. 
516                     PROPHYLAXIS.
 the parts of his person capable of being infected, and to abstain from
 a decided opinion in doubtful cases, where, for example, the glans, in
 consequence of phimosis, cannot be entirely uncovered, it is absolutely
 impossible to come to any reasonable conclusion  on the state of a
 woman without a careful speculum examination, since the deep parts
 of the vagina and  uterus may be the seat  of disease, presenting no
 external symptoms.
   In respect to the earliest  time in which syphilis  is contagious, my
 experiments on inoculation  having taught me that symptoms capable
 of being communicated to  others may be  developed within two or
 three days after exposure, those persons who are liable to become foci
 of infection should be examined within this time.  It will be seen from
 this consideration, how little security is afforded by the visits  which
 are  made  to public women,  once a week  when  they are collected
 together in houses of ill-fame, and once a month when they live alone.
   It is often difficult to express a decided opinion on the symptoms of
 a person who comes to inquire with regard to  their contagiousness, and
 whether he may be allowed  sexual intercourse, which is sometimes obli-
 gatory.   We know very well that a chancre in its progressive stage is
 the only syphilitic symptom which can be inoculated; but is it always
 easy without previous trial to distinguish a primary syphilitic  ulcer
 from other ulcerations foreign  to syphilis,  or which belong  to its
 secondary form? Certainly not; and when the slightest doubt remains
 in the mind,  all sexual connection should  be  forbidden.   But though
 it be necessary to  keep within  the bounds  of prudence, there is no
 need of falling into the exaggerations of some ancient and modern
 speculators and some over-timorous authors.   Thus, in gonorrhoea, as
 I have said in other parts of these additions,  so long as the discharge
 is purulent, sexual intercourse should be forbidden ; but when it is
 only mucous, and with still stronger reason when there are only shreds
 or flakes in the urine, or those sticky, lactescent or curdy drops at the
 meatus in the moring,  which go by the name of the morning gleet, or
 goutte militaire, then, to prevent sexual connection would be to condemn
 a large part of the population to absolute celibacy! We cannot, indeed,
 the next day after a discharge has stopped, assert that there is no more
 danger of contagion, and the same is true when a mucous discharge
 again becomes purulent; but, with these exceptions, an  oozing of
 mucus is not contagious.  I might add  thousands of observations to
 those given on  the  authority of Bell; and,  among others, that of a
 distinguished specialist, who has been married for several years, and
 whom I have often heard say that he himself was of this number.
  Again, if marriage or sexual intercourse  be allowed to men only
when their canal is absolutely dry, I do not see why the same caution
should not be required of women; and, in that case, how many  could
be found of whom this is strictly true?  Certainly not the majority of
women.  In cases cited as  contrary to  the opinion which I here ad-
vance, persons have either been more credulous than my daily experi-
ence allows me to be, or  they have been deceived as  regards the
presumed nature of the discharge, the limit between gonorrhoea and
catarrhal inflammation not  being always an  easy thing to determine 
PROPHYLAXIS.
517
for positive  people.  I can affirm without fear of being contradicted
that women give a hundred claps where they receive one.
   With respect to prophylaxis,  we should regard as of the first im-
portance  all those modes of treatment which, by extinguishing the
foci of the disease, prevent its propagation.   Those remedies therefore
should be preferred which make  contagious  symptoms disappear the
soonest, in spite of antiquated doctrines, which, happily, are crumbling
to pieces  on all sides, and which cannot be sustained by the  plastering
up that some retrograde authors give them.
   When  a person is afraid that he is diseased, and  d fortiori when he
already has some suspicious  symptom,  and he will  not, or in some
cases cannot abstain from sexual intercourse, the greatest care  should
be taken  with  regard to cleanliness.  Lotions  should be carefully ap-
plied to all accessible parts, and  injections made into those which are
deep-seated.  It  is evident that  this is absolutely  indispensable in
public  women, since they may  harbor contagious  matter in their
genital  organs  for some time,  without  becoming diseased themselves.
In general, if women were more cleanly, venereal diseases, as a whole,
would be less common.
   With regard to persons capable of communicating the  disease to
others, lotions  of the chlorides, soap, the alkalies, diluted acids,  acetate
of lead, alum,  wine, and,  in  fine, of anything which can chemically
change the  contagious pus, may prevent infection.   I have known
several medical  students who frequently had connection with, women
affected with chancres immediately after cauterizing them with nitrate
of silver, and who never caught any disease.
   2.  Persons who expose themselves to Infection.—In this class of per-
sons, the  prophylactic means to be employed before, during, and after
the sexual act,  are different.
   Before the act, a scrupulous  examination of the  parts should be
made to ascertain that there is no solution of continuity of the tissues.
At this time, cleanliness, and  especially alkaline, or soapy lotions, are
injurious, for they increase the danger .by removing the natural secre-
tions which protect the parts.   But the same  is not true  of lotions
applied a long  time beforehand, which act as astringents, and give an
increased tone  or strength to the tissues, without, however, imparting
too  much rigidity.  In this way, habitual  lotions at the toilet,  with
solutions  of acetate of lead, alum, wine, and tannin, protect  some per-
sons  who before were  easily infected.   Just before  coitus,  fatty sub-
stances will  often  guard against infection; and surgeons,  who are
obliged to apply their fingers  to affected parts for any length of time,
should never neglect this precaution,
   Of all prophylactic means, the  one which seems to promise the most
material  protection is the condom;  a  means which doubtless  shocks
the  sensibilities, but which  necessity  sometimes tolerates.  Yet we
must beware of according to condoms a blind  confidence.   A coat of
mail against pleasure, as an illustrious woman said, they are a spider's
web against  danger; frequently, in fact, they become torn ; at other
times their substance is permeable; or, they may have  been used before
and  not  thoroughly washed ; and, finally, when of good and  sound
materials, they really protect only a part of the genital organs. 
518
PROPHYLAXIS.
  During the act, there are certain precautions which are not of indif-
ferent importance. Thus, intercourse should not be wilfully prolonged,
as Nicholas Massa remarks  in his sixth chapter, De animi passione et
coitu: u Si vero quis cum infecta muliere coire voluerit, quod fatuum est,
non moretur in coitu;" and the act should be completed by the ejacula-
tion of the semen.   It is undoubtedly true that infection of the urethra
occurs during the time which precedes the emission of the sperm; and
that, in the fortunate cases were  no infection takes place, the sudden
and rapid passage of the semen, carrying with it the contagious matter
which  may have been introduced within the urethra, is one of the
greatest means of preventing it.  It is for this reason that the emission
of urine after coitus offers so many advantages.
  But it is especially after the act, which it is not  always possible to
anticipate, that the most careful cleanliness is requisite;  every fold of
the exposed tissues should be explored, and  repeated  applications  be
made of alkaline or soapy lotions; or,  better still, of the diluted chlo-
rides, so as to  decompose any morbid matter on the parts, without,
however,  exciting artificial irritation.  Finally, every solution of con-
tinuity, without exception, should be immediately cauterized.  This pre-
cept is so important that I would have it posted up in every place
where persons are exposed.
  3. Prophylaxis of  Infants  at the time of  Conception, during  Gestation
and Parturition.—It follows,  from  what I have elsewhere said, that the
presence of every primary symptom without distinction does not give
rise  to constitutional syphilitic infection, nor, consequently,  to  the
danger of transmitting  syphilis  by  hereditary descent.  Gonorrhcea,
for  example, as we  understand  it;  that is, discharges which do not
depend on concealed chancres, have no influence on generation. With
regard to primary ulcers or chancres, the parents may be infected with
them at the  time of  conception without  the infant having  syphilis;
unless, during gestation, they cause secondary symptoms in the mother.
  In respect  to prophylaxis as  applied to infants, all chance of con-
ception should be entirely removed, whenever constitutional symptoms
exist, or the nature of the primary symptoms renders them probable.
Our caution  should  be carried still farther, and, in the absence of all
appreciable symptoms,  we should  assure ourselves by the antecedents,
so far  as  possible, that  the parents  are not under the influence of a
syphilitic diathesis; in which case  they  may give birth to infected
infants until  appropriate treatment  shields the latter  from infection.
With  still' stronger  reason,  when the mother during  pregnancy is
affected with primary syphilitic sj^'mptoms, of such a  character as to
give rise to  secondary symptoms, or if  the  latter  already exist, we
should hasten to cope with them ;  and, far from regarding pregnancy
as a contra-indication to treatment, should recollect that it generally
prevents  the disease in the  infant,  and, when skilfully administered,
obviates the frequent abortions which  syphilis excites.
  When  primary symptoms have been contracted by  the mother a
short time before delivery,  since the infant  may be  infected in  its
pa-snge into  the Avorld,  the same course should be followed with  it as
with a person who has just exposed himself to an impure connection.—
Ricord.] 
PART   TIL
                      CHAPTER  I.

OF  DISEASES  RESEMBLING THE LUES  VENEREA,  WHICH
                HAVE BEEN MISTAKEN FOR IT.

  There is probably no one disease to which some other may not bear
a strong resemblance in some of its appearances or symptoms, whereby
they may be mistaken  for each other.  The situation of a complaint
also may mislead the judgment.  A lump, for instance, in the breast of
a woman may resemble a cancer so much as to be mistaken for one, if
all the distinguishing marks of cancer are not well  attended to.   An
ulcer on the glans penis, or in  the throat and nose, creates a suspicion
of the venereal disease.  Even the way in which a disease is caught
becomes a cause  of suspicion.  The fluor albus in women sometimes
produces a simple gonorrhoea in men.   Drinking  out of the same cup
with a venereal  patient was formerly supposed  to be capable of com-
municating the lues venerea, but this notion is, I believe, now exploded.
Of late years, a new mode of producing the venereal disease is supposed
to have arisen ; this is by the transplanting of a tooth from the mouth
of one person into the mouth of another.  That such practice has pro-
duced diseases is undoubted; but how far it has been venereal remains
to be considered.
  Diseases which resemble others seldom.do it in more than one or two
of the symptoms; therefore, whenever the nature of the disease is sus-
pected, the whole of the symptoms should be well investigated, to see
whether it agrees in all of them with the disease it is suspected to be,
or only in part.  This observation  seems to be more applicable to the
venereal disease  than any other, for there is hardly any disorder that
has more diseases resembling it in all its different forms than the vene-
real disease; and when a disease resembles the  venereal in some of its
symptoms, but not at all in others, then those other symptoms are to be
set  down as the specific or leading  ones of the disease to which it be-
longs, the resembling symptoms to the venereal being only the common
ones.  But if a disease is suspected to be venereal, though it is  not
perfectly marked, yet if it resembles the venereal in most of its symp-
toms, it must be  supposed to be venereal, that being the most probable,
although it is by no means certain;  for probably the venereal  can 
520                   PSEUDO-SYPHILIS.
hardly be demonstrated in any case, especially in the form of the lues
venerea, from its not having the power of contamination.
  [G. G. B.—There has been much confusion respecting syphilitic and
pseudo-syphilitic diseases, which would have been in a great measure
avoided had due attention been paid to the obvious principles which
should determine the identity or diversity of diseases.   This confusion
is in a very slight degree chargeable on Mr. Hunter.  Yet there are a
few instances  where he seems  to have  been misled by preconceived
opinions respecting the venereal diseases, which a longer  observation
would have shown him were more than doubtful.
  Diseases may be confounded writh syphilis which have no connection
with any virus whatever.  This is  frequent  in sores on the genitals,
where superficial  excoriations,  which by proper treatment may be
healed in three days, and  herpetic vesicles, which exactly  resemble in
their appearance and course those which so  frequently occur on the
lips, have been often erroneously treated  as venereal.   The same ob-
servation  applies with  equal force to some forms of sore  throat and
cutaneous eruptions.
  The existence of a morbid  poison as  the  cause of lues venerea is
inferred from two facts. In the first place, the primary symptoms have
been ascertained by long observation to be the consequence of commu-
nication with infected  persons, and  to be capable in the same way of
infecting others.  In the second place, these  primary symptoms have
been observed to be followed  after an interval of time by secondary
symptoms.  It is true,  that in practice the nature of the case precludes
us from obtaining full proof of these points in every individual instance,
and we are forced to determine the treatment on probable conjecture
rather than on certainty.  But they have been ascertained  to be gene-
rally true of the class of symptoms which is called venereal.  It is on
their truth that the received opinions of the pathology of the disorder
rest, and in a medical argument, unless one or both of them is satisfac-
torily ascertained, it cannot be denied that we have no adequate proof
of the existence  of any virus at all.
  The mode  in which  the disease has been derived, if it exists alone,
may mislead, since there may be irritating qualities in the secretions of
diseased parts, which may affect the parts to which they are applied,
without the existence of any* distinct morbid poison capable of gene-
rating a specific malady.  Unless, therefore, the exact identity of the
symptoms in the party which communicates and  the party  which
receives the infection  is fully shown, or unless the infection can be
traced through several successive individuals, some uncertainty affects
the conclusion.  But where the regular sequence of secondary on pri-
mary symptoms is undoubtedly established, it is difficult to avoid the
inference that there exists a distinct virus, which is received into the
circulating fluids, and carries the seeds of the disease to  the remoter
parts of the body.  It  is observable that the  passages which have been
so frequently quoted from Celsus and others, as proofs of the existence
of the venereal disease in Europe before the  close of the fifteenth cen-
tury, refer only to the  local injury sustained by those who come in con- 
PSEUDO-SYPHILIS.
521
tact with the diseased, and are entirely silent as to any constitutional
affection being the consequence of the local malady.1
  But wrhere the existence of a poison is proved, it may still be ques-
tioned whether this poison is the same with that of lues venerea; and
this question  can only be  answered by a comparison of the mode of
communication, the character of the symptoms, the course and progress
of the disease, and the mode of cure.   Where these are the same as
are found in syphilis, we can scarcely doubt the identity of the virus;
where there is a decided and uniform difference under similar circum-
stances, we must naturally infer a diversity.
  Hence, any error or inaccuracy in our notions  of the venereal dis-
ease itself will infallibly affect our discrimination of the diseases which
resemble it, and lead, according to the prepossessions and bias of the
individual, either to  the undue extension or  the  undue limitation of
the term.  Of late  years, the most frequent error seems to have been
the exclusion of cases which are manifestly syphilitic,  on account of
some difference  from the preconceived opinions  which have been
formed of lues venerea.  Writers on this subject seem scarcely to have
been  aware how various are  the appearances of venereal symptoms,
and how different at different times is  the effect of remedies.   A pri-
mary sore, in which the characters of a chancre as given by Mr. Hunter
are not  obviously visible, may nevertheless be venereal. It  may be
derived from  a venereal sore, and may produce constitutional symp-
toms which have  every character of genuine  syphilis.   In secondary
affections, the variety is still greater.  Symptoms of a  doubtful cha-
racter are frequently so intermixed with others, which it is impossible
to mistake, as to be certainly attributable to the same cause.
  Hence, when we  meet with deviations from those forms of the dis-
ease which are most peculiar and most characteristic, we are not war-
ranted in inferring a diversity of cause, or ascribing the symptoms to
the existence  of  a different virus from that  of genuine syphilis.  Yet
many histories have been  given to  the world as pseudo-syphilitic in
which the appearances exactly accord with  some  forms of the lues
venerea.
  Again, the notions which have prevailed as to the mode of cure have
been  a still more fertile source of error.  Mercury has been considered
as the only cure of syphilis, and its  action has been taken as the test
of the nature  of  the malady.  Where  on the one hand mercury has
disagreed, or where, on the other, the patient has recovered  without

  1 The relation between primary and secondary symptoms was formerly unknown.
With reference to this point, the history of syphilis may be divided into three periods :
The first, during which primary symptoms were the only ones known, is  anterior to
the epidemic of the fifteenth century ; in the second, commencing with this epidemic
and extending to the appearance of Fernel's work,* secondary or constitutional symp-
toms were more particularly noticed ; and, finally, in the third period, primary symp-
toms were  clearly distinguished  from constitutional  symptoms, which, in turn, and
especially  since  Hunter's time,  have  been divided into secondary and tertiary.—
Ricobd.
 * J. Fernel.—De Luis venerea curatione, &c.; Venice, 1046; Padua, 1580; Frankfort, 1581. Translated
into French by Michel Delong:  Paris, 1633.—Ed. 
522                   PSEUDO-SYPHILIS.
resorting to its use, it has been inferred that the disease has not been
venereal.
  Yet it has been fully established  by the experience of former ages,
confirmed as it has been  by a long series of experiments which have
been  recently instituted, that most, if  not all  venereal  symptoms,
whether primary  or secondary, may be  subdued without the use  of
mercury.   It is not necessary to refer to these experiments in detail.
They are well known;  and the conclusion which has been drawn from
them is irresistible,  or  at least there are no sources of error which can
materially impeach its  general truth.  On the other hand, the unfavor-
able action of mercury is no proof that the  disease is  not venereal.
Many circumstances may interfere with its effect as  an anti-syphilitic,
and  render it inert  or injurious in cases which are truly venereal.
When it produces  no sensible effect on the system, it frequently has
no action also on the venereal symptoms.  When it produces vomiting,
or dysentery, or erethismus  or  materially deranges in any way the
health, venereal symptoms will usually spread under its use.  Cases are
daily occurring in which  the subsequent progress  of the malady proves
the truth of this view; in which the ultimate cure is  effected by means
of mercury, though at one time it has seriously  aggravated the affec-
tions it was employed to cure.  In such cases, a practical knowledge
of the course and aspect of lues venerea can alone guide the judgment.
If the practitioner has not this knowledge, he will be staggered in his
belief as to the nature of the disease  on the occurrence of any unto
ward symptoms,  and  will usually abandon the  mercurial  treatment
altogether. If he has such an acquaintance with the  malady as to give
him confidence in the accuracy of his opinion, he will inquire whether
there has been no obstacle to the beneficial effects  of the remedy, which
will account  for its failure.  He will suspend it for a time, with the
intention of resorting to  it again at a subsequent period, when he can
employ it with greater precaution  and under more favorable circum-
stances.
  If then, the points of distinction on which reliance has been usually
placed are deceptive, it may be asked what other  grounds of discrimi-
nation can be substituted ?  The answer is plain.   Where there is a dif-
ference of virus, the difference of effects is not accidental or occasional,
but constant and uniform.  No doubt can arise  as to the diversity  of
measles and smallpox, though these diseases were formerly confounded,
because the distinction, when once pointed out, is confirmed by daily
experience.  The yaws of Africa and the West Indies, the sibbens  of
Scotland and  Canada, the scherlievo of the Illyrian coast,  the effects
of the poison of glanders on the human subject, cannot be confounded
with syphilis, because  the symptoms are  different; and this difference,
which may be traced uniformly through a series of individuals affected
by these maladies, prevents the possibility of attributing them to the
same cause.  The peculiarities which have been  supposed  to take the
cases described as pseudo-syphilitic out of the class of syphilitic dis-
eases are uncertain  and variable, and can never constitute the distinc-
tive characters of a separate and independent malady.—G. G. B.]
   Although the venereal disease keeps its specific properties distinct 
PSEUDO-SYPHILIS.                    523
in its  several forms, yet its symptoms are in appearance common to
many other diseases, and in that light it cannot be said to have  any
one symptom peculiar to itself.  For instance, every symptom of the
venereal disease, in form of a gonorrhoea, may be produced by  any
other visible irritating cause, and often without any cause that can be
assigned; even  buboes and swelled testicles, which are symptoms of
this  disease, have  followed  both stimulating injections and bougies,
when applied to the urethra of a sound person; and, indeed, these  two
symptoms, when they do arise from a venereal cause, in many cases are
only symptomatic,  not specific, but more especially the swelled testicle.
   Sores on the glans penis, prepuce, &c, in form of chancres, may, and
do arise without any venereal infection, although we may observe that
they are in general a consequence of former venereal sores which have
been perfectly cured.
   The symptoms produced from theinfection, when in the constitution,
are such as are common  to many other diseases, viz., blotches on the
skin are common to wrhat is called scorbutic habits; pains common to
rheumatism, swellings of the bones, periosteum, fascias, &c, to  many
bad habits, perhaps of the scrofulous and rheumatic kind.   Thus, most
of the symptoms of the venereal disease, in all its forms,  are to be found
in many other diseases; therefore, we are led back to the original  cause,
to a number of leading circumstances, as dates, and its effect upon others
from connection when only local, joined with the present appearances
and symptoms, before we can determine absolutely what the disease
truly is; for all these taken together may be such as can attend no other
disease.  However, with all our knowledge, and with all the application
of that knowledge  to suspicious symptoms of this disease, we are often
mistaken, often  calling it venereal when it is  not;  and sometimes sup-
posing it to be some other disease when it is  venereal.
   Rheumatism, in  many  of its symptoms, in some constitutions, resem-
bles the lues venerea; the nocturnal pains,  swelling of the tendons,
ligaments, and periosteum, and pain in those  swellings, are symptoms
both of rheumatism and the venerealdisease when it attacks those parts;
I do not know that  I ever saw the lues venerea attack the joints, though
many rheumatic complaints of those parts are cured by mercury,  and
therefore supposed to  be venereal.1
   Mercury, given without caution, often produces  the same symptoms
as rheumatism;  and I have seen even  such  supposed to be venereal,
and the medicine continued.

  1 The statement seems to be too general. Cases occasionally, though rarely, occur
where inflammation of  the synovial membrane of the joints shall take place in union
with secondary symptoms of lues venerea of an undoubted character; shall increase
in severity during the increase of the other symptoms  ; and shall subside as soon as
mercury is sufficiently used, and the eruption or sore throat are controlled by its exhi-
bition.  In such cases the synovial inflammation has an  acute character ; and is at-
tended with a degree of pain and tension and superficial redness, which sufficiently
distinguishes it from that languid form of the  same affection which  is common under
circumstances of general cachexia, whether that cachexia has been produced by mer-
cury acting as a poison, or  by the long duration of the  venereal disease itself, which
has been allowed to continue till every function necessary for  the  maintenance of nu-
trition and of health has become deranged, and the patient has been  reduced to a state
which closely resembles scrofula.—G. G. B. 
521
PSEUDO-SYPHILIS.
  Other diseases shall not only resemble the venereal in appearance,
but in the mode of contamination, proving themselves  to be poisons
by affecting the part of contact, and from thence producing immediate
consequences similar to buboes; also, remote consequences similar to
the lues venerea.
  As errors in forming a judgment of a disease lead to errors in the
cure, it becomes almost of as much consequence to avoid a mistake in
the one as in the other; for it is nearly as dangerous in many constitu-
tions to give mercury where the disease is not venereal, as to omit it in
those which are; for we may observe that  many of the constitutions
which put on some of the venereal symptoms, when the disease is not
present, are those with which mercury seldom agrees, and commonly
does harm.  I have seen mercury, given in a supposed venereal ulcer
of the tonsils, produce a mortification of those glands, and the patient
has been nearly destroyed.
  When treating of  the lues venerea, and giving the symptoms and
general appearances  of the disease,  I related some  cases which  ap-
peared to be venereal, though they really were not, and I  shall now
refer the reader to these, as it will be unnecessary to give them again
here, although, if they had not formerly been taken notice of, this would
have been a very proper place.
  As the diseases in question are various, and not to be reduced to any
system or order that I am acquainted with, I shall content myself with
relating the cases, and  thereby put in the power of others to judge for
themselves, if they should not be inclined to adopt  the conclusions I
have drawn from them.
  On the 28th of July, 1776, a gentleman, then  in  the West Indies,
scratched the end of  his finger with a thorn.  On the 31st, he opened
an abscess on the shoulder of a negro woman who had the  yaws, and
had been long subject to such abscesses in different parts of the body,
and to incurable ulcerations afterwards.   At the instant after the ope-
ration he perceived a  little of the matter upon  the scratch, and  ex-
claimed that he was inoculated.  On  the 2d of August, he amputated
a boy'» finger, of thirteen years of age,  for a sore resembling worm-
eaten wood.  The scratch  on his finger did not heal, but from time to
time threw off whitish scales;  this appearance alarmed him, and he
rubbed in mercurial ointment very freely.   Notwithstanding this, in
the month of September, a painful inflamed tumor appeared on  the
second joint of the finger, which was soon followed  by several others
on the back of the hand, in the course of the metacarpal  bone of  the
forefinger.  He still continued the mercurial friction, but without effect,
for the tumors daily multiplied, and  by the month of November  ex-
tended to within a small distance  of the  axilla.  They did not go on
to suppuration at this time.  About  the end of November, he began
to be affected with severe nocturnal pains in different parts of the body,
but especially along the tibia and fibula, with frequent severe headaches,
which continued to increase  to an almost  intolerable degree for five
months, though he used  mercurial friction, with decoction of sarsa-
parilla, every day in great quantity.
  In the month of May, 1777, a scabby eruption appeared in different 
PSEUDO-SYPHILIS.
525
parts of the body, especially the legs and thighs, and the before-men-
tioned tumors ulcerated; but this was followed by a remission of the
nocturnal pains.
  He could never bring on a  salivation, though his mouth was con-
stantly tender, even for months.  The ulcerations became daily worse,
and a voyage to England was thought the only resource.  He arrived
in London the first of August, and by the advice of Dr. William Hun-
ter  and  Sir John Pringle, he  began again a course of mercury and
sarsaparilla, with a milk diet.   I was called in, and judging that two-
thirds of a grain of mercurius  calcinatus, every day, was  too small a
dose if it were judged to be venereal, it was ordered to be gradually
increased to five grains; and he continued this course till November,
when all the sores were perfectly healed.
  He now discontinued the mercury, and remained free from all symp-
toms of the disorder, except some nodes on the tibia, and rheumatic
pains on exposure to cold, until about twelve months ago,1 when he
began  to have an uneasiness in swallowing, a rawness in the throat,
and  a  discharge of viscid mucus from that and the posterior nostrils,
all of which still continue.
  The following observations may be made on the above case:—
  There can be little doubt that the disease was the yaws.  The yaws
are a disease  that resembles the venereal  in several of its symptoms,
as well as in the manner in which it is most commonly communicated.
It differs, however, in some essential particulars.  The yaws have a
regular progress, after going through which they leave the constitution
in a healthy state, at least free from that disease, it being sufficient for
the cure that the patient be put in a state favorable to general health.
Thus, a negro laboring under the disease must do little or no work, be
kept clean, and have  a better diet than usual.  Under these eircum-.
stances, he commonly gets well in from four to nine months, although
the unfavorable cases will continue much longer.  Various medicines
are given for the cure, but it is not clear  that any of them do good.
Mercury has  considerable power over the disease, without  being a
specific for it.   If given early,  it will either check the progress of the
disease or perhaps even heal up all the sores on the skin; but nothing
is gained by this, for the disease soon breaks out anew.  Some practi-
tioners of medicine in  the West Indies are of opinion that interrupt-
ing the  course of the disease by mercury is productive of no other
evils than those of loss of time and an imperfect cure; others affirm
that it  is often the cause of what they call the boneache.  Towards
the end of the disease, it is generally allowed that mercury may be
given safely, and even with advantage.  It is probable the long con-
tinuance  of the  disease, being above  fourteen months, and  also  the
pains in the bones in the present case, were owing to the very early
and free use of mercury.   It may be allowable to add  that the yaws
do  not differ more  from the  venereal disease in  curing themselves

  1 The first edition of the work was published in 1786 ; consequently it would appear
that a considerable interval elapsed between the healing of the ulcerations and the
occurrence of the sore throat.—G. G.  B. 
526
PSEUDO-SYPHILIS.
than in this circumstance, that, like the smallpox, they affect none  a
second time.1
  A gentleman applied to me for the cure of chancres, seated on the
attachment of the prepuce to the penis, and also on the frasnum.  Mer-
cury was used chiefly by friction, in  order to affect the constitution;
it was also applied  to the  sores, in order to affect them locally.  The
cure of the chancres went on gradually and without interruption, and
in about five weeks they were perfectly  healed.  He  almost imme-
diately had connection with a woman, and long  before we could sup-
pose the mercury had all got out of his constitution.  In a very few
days after the first  connection, the prepuce began to be  chopped all
round on the edge of its reflection.   He continued his connection, and
upon its growing worse he applied to me, and I found the chops very
deep, and the prepuce there so tight and sore that he could not bring
it  back upon the  penis.  The question now was, whether this was
venereal or not.   The sores themselves did not appear to be so; but
more was to be taken into the account than simply appearances.  It
was first to be considered whether it might possibly be a return of his
former complaint.  This could not be the case, because the sores were
not in the same parts.  It was next to be questioned, was it possible
for this part of the' prepuce to have been contaminated at the same
time with the former, and the poison  not  to have come into action till
now, having been prevented by the course of mercury, which had not
cured  the  disposition ?  This  could  not be  well answered, although
not  probable, because  the poison  appeared to  come too  soon into
action  after leaving off  the medicine; for I did suppose there was still
a great deal of mercury in the constitution.  Was  it, then, possible
for him to have caught it from the woman ?   This, I supposed, could
•not have been the cause of these chops, whatever effect this connection
might  have to render them venereal hereafter;  for they appeared'too
soon after it, especially as  he had mercury in his constitution at the
time, and as the parts had been accustomed  to the  application of
venereal matter  but a little time before.   Although, from all circum-
stances taken together, I was convinced the case  was not venereal, yet
an apprehension arose in his mind concerning the possibility of having
given it to the lady, as he had connection after the first appearance of
the sores.  I was equally convinced of the impossibility of the one as
the other, therefore desired him to  rest easy on that head.  He went
immediately into the country, and nothing being done for those chops,
they got perfectly well.  In less than a fortnight after this connection,
the lady became a  little indisposed with a slight fever, and a swelling
came in one of her groins.   I watched the progress of this swelling,
which  was slow, and I  did not believe it to  be venereal.  It at last
formed matter and  broke, and  a poultice was applied to it.  Instead
of ulcerating or spreading, it rather had a healing disposition, and in
about six weeks, it was perfectly well.   While it was healing, scurfy

  1  The earliest and best description of the yaws is given  in the fifth volume of the
Edinburgh Medical Essays, and has been attributed to a gentleman of the name  of
Home.  The case related by Dr. Adams, in his work on morbid poisons, as occurring
at Madeira, seems not to have been a case of yaws at all.—Q. G. B. 
PSEUDO-SYPHILIS.
527
eruptions came out on the skin, some on the face and thighs, but more
especially  on the hands and feet, where the cuticle peeled off.  Upon
the first appearance of  these, I was a little staggered; but, as the sore
was healing, I was  unwilling  to give  credit  to  the  appearance, and
therefore begged that nothing might be done,  and they all got well.
  From the general outline of these cases, one would naturally have
said they  were venereal; but  the  particular  circumstances being all
investigated, and  the whole taken together, led  me  to suppose that
they were not, and the  event proved that to be the case.
  The following case was communicated by  Mr.  French,  of Harpur
Street.
  "June the 9th, 1782, a gentleman applied to me for an ulcer which
was seated on the glans penis, attended with excessive pain. Knowing
him to be  an intemperate man, and learning from himself that during
a state of  intoxication he had been connected  with a woman, I judged
the complaint to be venereal.  He was now  in a feverish state, and
unfit for the exhibition of mercury;  I therefore  prescribed for him
decoction  of bark, with elixir of vitriol and tinctura thebaica, pro-
portioned  to his pain.  I directed him to abstain from every kind of
fermented liquor, to live chiefly upon milk, and to wash the ulcer with
a liniment composed of equal parts of oil of almonds and aqua sap-
pharina.
   " About the 17th of the same month, some check having been given
to the fever, the sore looking  cleaner, and his pain having  abated, I
ordered him small doses of argentum vivum and extract of hemlock.
   " July the 4th, finding the  mercurial course to  disagree, I ordered
three  grains of the extract of hemlock to be taken two or three times
a day, and the decoction  of bark to be taken as  before, with twenty
drops of tinctura thebaica, which was gradually increased to sixty, at
bedtime.
   " The ulcer had spread very much during the mercurial course, and
had now destroyed half the glans penis.
   " October 1st, Mr. Hunter was consulted, and ordered the patient to
add the powder of sarsaparilla to the decoction of bark, to take lauda-
num  freely, and wash  the sores with tinctura thebaica.   Soon after
beginning this course  the remainder of the glans penis sloughed off,
the parts gradually healed, and health was restored.
   " There were two other symptoms in this case which deserve to be
taken notice of; a considerable enlargement of the scalp on the right
side of the os frontis, and on the left parietal  bone, attended with ex-
cessive pain, and vibices resembling the sea-scurvy on the  inside of
the left  tibia, both of which disappeared in the course of the cure.
   " Some  months after, the tumor  in  the head returned, and several
abscesses were formed, which were opened,  and the cranium found
carious  to a great extent.  On  account of the pain, he has for some
months  past taken two hundred and forty drops of laudanum and six
grains of  opium daily.   These sores healed up, and others broke out
in different parts of the head, which also got well; and in June, 1785,
there  was only one large ulcer in the angle of the right eye."
  A lady  was delivered  of a  child on the 30th of September, 1776. 
528
PSEUDO-SYPHILIS.
The infant being weakly, and the quantity of milk in the mother's
breasts abundant, it was judged proper to procure the child of a person
in the neighborhood to assist in keeping the breasts in a proper state.
It is worthy of remark that the lady kept her own child to the right
breast, the stranger to the left.  In about six weeks the nipple of the
left breast began to inflame, and the glands of  the axilla to swell.  A
few days after, several small ulcers were formed about the nipple, which
spreading rapidly, soon communicated  and became one ulcer, and at
last the whole nipple was destroyed.   The tumor in the axilla subsided,
and the ulcer in the breast healed in about three months from its first
appearance.   On  inquiry, about this time, the child  of the stranger
was found to be short-breathed, had the thrush, and died tabid, with
many sores on different parts of the body. The patient now complained
of shooting pains in  different parts of the body, which were succeeded
by an eruption on the arms, legs, and thighs, many of which became
ulcers.
   She was now put under a mercurial course, with a decoction of sarsa-
parilla.  Mercury was tried in a variety of forms; in solution, in pills
internally, and  externally  in the form of ointment.   It could  not be
continued above a few days at a time, as it always brought on fever or
purging, with extreme pain in  the bowels.  In this state she remained
till March 16,  1779, when she was delivered of another child  in a
diseased state.  This child was committed to the care of  a wet-nurse,
and lived about nine weeks; the cuticle peeling off in various parts,
and a scabby eruption covering the whole body.  The child died.
   Soon after the death of  the child the nurse complained of headache
and  sore throat, together  with  ulceration of  the  breasts.  Various
remedies were  given to her, but she  determined to go into a public
hospital,  where she was salivated, and after some months  she was dis-
charged,  but not  cured of the disease.  The  bones of the nose'and
palate exfoliated, and in a few months she also died tabid.
   Of the various remedies, tried by the lady herself, none succeeded
so well as sea-bathing.  About the month of May she began a course
of the Lisbon  diet-drink, and continued it with  regularity about a
month, dressing the sores with laudanum, by  which treatment the
sores healed up; and in September she was delivered of another child,
free from external marks of disease, but very sickly; and it died in
the course of the month.
   About a twelvemonth after the sores broke out again, and, although
mercurial dressings and internal medicines were  given, remained for a
twelvemonth, when they began again to heal up.
   [G. G. B.—The author is evidently of opinion that these  and similar
cases are not venereal, and he elsewhere denies it to be possible that
an infant can be contaminated by its parent before its birth.  Whether
he is right in this opinion must be judged by the following statement
of the facts, which are sufficiently frequent and  peculiar  to be given
With confidence in their truth.
r   When a mother suffers  during the period of pregnancy from a con-
stitutional venereal affection, she seems to be particularly disposed to
miscany.  The  abortion seems to be caused by the death of the infant, 
PSEUDO-SYPHILIS.
529
which  is very generally born dead, and  has usually ceased to show
signs of vitality for some days before its  ejection.
  If, however, miscarriage does not  take  place, it is most usual that
the infant at birth shows no signs of disease.  But at  a variable period,
generally from three to five weeks after birth, it becomes slightly indis-
posed.  Then eruptions appear about the thighs and the groins, between
the nates, or on the  pudenda.  They wear  the aspect of discolored
patches, generally affecting a  circular form,  with  a shining surface,
and some slight desquamation, but without the least  tubercular thicken-
ing. As the disease  proceeds these  patches enlarge, and eventually
occupy almost the whole body; and in the folds they sometimes slightly
excoriate, and even near the anus, at the umbilicus,  or on the female
pudenda, form small condylomatous excrescences. Then ulcers in many
cases take place in the interior of the mouth, and in the throat; the
nostrils are partially obstructed  by an increase of  their secretion, and
the voice  becomes weak and hoarse.  With all this  there is much
general indisposition.   From the first appearance of the symptoms the
child does not thrive, and as they continue it becomes very weak and
emaciated.  If the case be  neglected it  often terminates fatally, but
under the use of mercury all  the symptoms  are readily subdued, and
perfect health may be restored.
  Those who come into close contact with a child thus diseased may
be contaminated in consequence.  If such a child has sores in the inte-
rior of the mouth, and in this state sucks the breast of a healthy wo-
man, it is very common that the nipple should become ulcerated; and
the ulcer will not resemble the fissures which are so common on the
nipples of women who give suck, and which usually occasion no loss
of substance, but will  be a corroding ulcer,  and will destroy the whole
or the  greater part of the nipple before it is healed.  It also produces
in  general an enlarged gland in the axilla, which, however, rarely
passes  into suppuration.  At an interval of some weeks, sore throat,
eruptions, or nodes arise, which are in no respect distinguishable from
the common forms of lues venerea.
  If a woman who has been thus infected by a child which she has
suckled, suckles also another child, which is healthy, no infection will
be  communicated, provided the sound child is kept carefully to the
opposite breast, and is never allowed to take into its  mouth the nipple to
which the diseased child is applied.  But if this precaution is not taken,
and the children are applied  indiscriminately to either breast, the sound
child will  contract sores in  the  interior  of the lips,  and these will be
followed  by  scaly eruptions  on  the skin, exactly resembling those
which  are seen in an infant which has received the infection from its
mother.
  It would be easy to substantiate what has been stated by the recital
of cases.   The results are tolerably uniform; at least, the deviations
from the ordinary course are not greater than those which occur when
the venereal disease is communicated in the usual way, by sexual con-
nection.
  It is difficult in the face of these facts, to deny  that such cases are
the  effects of the venereal virus.   It is true that the symptoms  in chil-
       31 
530
PSEUDO-SYPHILIS.
 dren are  not  precisely the same, either in course or appearance, with
 the most usual symptoms of the venereal disease in adults.  Diseases
 of the bones or periosteum seem never to occur, nor are the eruptions
 tubercular.  Yet, as the symptoms in the adult from whom the disease
 is received  and the adult to whom it is communicated are exactly
 identical with those of common syphilis, it must be inferred that the
 difference is to be ascribed to the age and circumstances of an infant,
 and not to a diversity  of virus.
  It  is impossible to  admit the argument used by  the author, that
 secondary symptoms  never  contaminate, and, therefore, these cases
 must be mistaken.  The facts  are  so well  established that it is more
 easy to question the principle which has been laid down than to doubt
 the facts.—G.  G. B.]
  [Ricord.—I here share Mr. Babington's  opinion entirely;  only 1
 think that, up  to the present time, the absolute nature of the symptoms
 which may be communicated from infants to nurses, has not been accu
 rately determined, and that a given symptom, reputed a contagious
 secondary symptom, may at first have been primary; and also, in some
 cases, that a nurse who is said to have been infected by a child may
 have contracted syphilis otherwise.
  Be that as  it may,  though this explanation  is far from completely
 satisfying every mind, in the present state of science, there are very
 many incontestable cases of syphilis communicated  from infants to
 nurses, and  vice versa.
  With regard to tertiary symptoms,  which Mr. Babington believes
 do not exist in infants, they undergo  modifications dependent upon
 the peculiar conditions in which they are developed, and so readily
 assume the form of scrofula that their specific type is effaced, and their
 origin lost.]
  The following cases,  being all derived from one stock, show as much
 as possible  that new poisons are rising up every day, and those very
 similar to  the venereal in many respects, although not in all; therefore,
 it is the want of similarity that  becomes the criterion to judge by, and
 not the similarity.
  The parents of the child who is the subject of the following history
 were and are to all appearance healthy people.  The child was weakly
 when born;  and the mother having little or no milk, when it was three
 weeks old she gave it to a nurse whose milk was then seven months
 old, and was giving suck to her  own child. The foster  mother allowed
 her own to suck the right breast, while the other sucked the left.
  The nurse observed that the skin of the foster child began to peel
 off; but no  rawness or soreness took  place  except about the anus,
 where it looked as if scalded.  The same kind  of peeling took place
 on the lips, but they did not appear to be sore, although the people in
 the country said it was the thrush. The inner surface of the mouth
 and tongue  appeared sound.  In a fortnight after  her receiving the
 child  it died, and then she allowed her own child to suck both breasts
fqr three weeks; at the end of  which, she came to  town to nurse a
 gentleman's  child.
  She gave  suck to this second  child; but, after being in town about 
PSEUDO-SYPHILIS.
531
ten or eleven days, she did not feel herself perfectly well; which made
them suppose that the new mode  of life, confinement, in town, and
probably better living, might not  agree with her, and she went into
the country and took the gentleman's child with her.  About three or
four days after she went to the country, for instance, about a fortnight
after she took this  child,  and five weeks  after the  death of the first
child, her left nipple, which  the first-nursed child  had always sucked,
began to be sore, so  that she could  not let the child  suck it.  This
ulcer on the nipple  became extremely painful;  in a day or two erup-
tions came out on her face, and soon after all over her body, but most
on  her  legs and thighs.  They continued coming out for about a
fortnight, and had at first  very much  the appearance of the eruptions
of the smallpox, and on the  third day of their eruption were attended
with fever, universal uneasiness, and great pain.
  Two or three days after the eruption on  the  skin appeared, one of
the glands  of the arm-pit began to swell, and formed matter, and was
opened  within a fortnight after its first appearance, and healed almost
directly.  Some of the eruptions increased fast and became very broad
sores, nearly of the size of  a half-crown, especially on the legs and
thighs, and were  covered  with  a broad scab; many remained small,
and only appeared  like pimples.  About a fortnight  after  the first
appearance of the  eruption, some began to die  away; and  in four
weeks more after this appearance, a foul ulcer  attacked the left tonsil.
  The surgeon in the country, from  all these  circumstances, finding
he  could  not get any ground  by the before-mentioned treatment,
determined to  give her the solution  of the corrosive sublimate, of
which he gave half a grain in solution night  and morning;  in about
a week there seemed to be a stop put to the swelling of the ulcers, and
the discharge to be somewhat lessened, the  ulcer in the throat putting
on a better appearance.
  It was at this  period I first saw her, which was about six weeks
after the first appearance of the eruption, and a fortnight after the
appearance of the ulcer in the tonsil.   The eruptions were then very
much as before described, but  the  ulcer in the tonsil was clean and
healing.  From the history of the case I did  conceive it not  to be
venereal; I therefore  desired that all medicines might be  left off,
which medicines could only have been taken for a fortnight at most,
because it  was after the  appearance of the ulcer on  the tonsil the
mercury was given, which was only of a fortnight's standing when I
saw her.  She soon after recovered.
  After being well for some time she again applied to  the surgeon in
the country, an abscess having formed where the complaint first  began
in the breast, attended with  fresh eruptions on the face.
  The abscess was opened, and it healed  up in a  few days, and upon.
taking some cooling physic  the eruptions disappeared.  She has con-
tinued  very well ever  since, without any other bad effect  than the
total loss of her  nipple.  This case was certainly understood  to be
venereal.
  About five days after the appearance of the eruption on the  nurse,
the gentleman's child was taken away and given  to a healthy woman 
532
PSEUDO-SYPHILIS.
of a florid complexion, aged twenty-four years, and who had lain in
with her first child eleven months when she became wet-nurse to this
child.  After a few days  she observed eruptions on the child's  head,
not unlike those already described on the first nurse which it had
sucked.  Its mouth soon after became excoriated, so that it sucked
with difficulty. After a short time those eruptions on the head became
dry and peeled off, others appeared on the face, knees, and  feet, but
wholly unlike the former, as the first  maturated, while the latter ap-
peared only cutaneous, peeling off and leaving a circumscribed spot
of a light dun color, which continued increasing for five weeks.  These
eruptions continued nearly three  months  from their commencement,
at which period the child was extremely emaciated;  but no particular
treatment was indicated, so no medicine was  exhibited, and  in a few
weeks after it  came to London and got perfectly well.
  The second  nurse, a few days after  giving  suck to the child, had
blotches appear on her left breast, precisely the same with those on
the first nurse, with  this difference only, that they were fewer in
number, and attended with a greater degree of phlegmonous inflam-
mation.  They continued, and increased  in size for seven  or  eight
days; then the nipple of  the same breast became ulcerated, the ulcera-
tion spreading so much as to endanger the loss of it; her thighs now
became diseased, and afterwards her legs.
  She suckled this child about twelve weeks.   The disease seemed no
longer to increase, and in twelve or fourteen days after this entirely
disappeared, without her  taking any medicine, except a few ounces of
the decoction  of the bark.  The  only application  to the breast was
unguentum simplex.
  The milk at this time became so small  in  quantity that they were
under the necessity of providing a third wet-nurse  for the child, and
the second returned  to the country.  Her own child being weaned,
she had no farther occasion for the milk, and  in a few days it wholly
disappeared;  but by way of amusing the child when  peevish, she
allowed it to take the nipple which had been diseased in its mouth;
the consequence was, that in a few days this child also became diseased
in like manner with  the former.   She now applied to  an  eminent
surgeon for assistance, who, not being acquainted  with the history,
supposed it venereal, and ordered a colorless medicine, supposed, from
circumstances, to be the solution of sublimate, sixteen grains to half a
pint of water; the dose a tablespoonful.  She took this medicine as
directed, and also gave it  to her husband  and child; the child a tea-
spoonful only  at a time.   While taking this medicine she got well..
  The third wet-nurse, like the former, was  in a short time affected,
but the blotches in this case were still fewer in number, the disease
appearing to  lose considerably in its power, as each fresh  infection
became less malignant than the former.  She got well without taking
any medicine.
  [Home.—Added:  " The following case  shows the effect of the state
of the mind upon the body, and the bad  consequences attending the
patient's being indulged in his own opinions respecting the nature of
a disease.   It  is given as drawn up himself for my opinion. 
PSEUDO-SYPHILIS.
533
  " 'In May, 1789, when in London, I was  unhappy enough to  have
connection with a woman of the town.   Five days after, I took more
than usual exercise, and the  day being warm  I  perspired profusely.
This affected my head, more particularly my forehead.  In this situa-
tion I went into the country, and while  on  the road the  sweating in-
creased ;  when it went off it left a burning heat about the forehead, so
that I could  not wear my hat.  This heat continued all night, attended
with an external pain round the forehead.   The next day it  increased,
but the day  after its violence seemed to lessen; but it continued more
or less for several weeks.  On my return home, I was connected with
my wife.
  "'My mind became so much agitated that I found it impossible to
be at peace till I unfolded my  situation to a surgeon and apothecary.
  "' I began to fear that those affections of the head might arise from
disease.  The surgeon seemed to apprehend no danger. I pressed him
to give me some opening draughts, to carry off the inflammation about
the head, and flattered myself that they would also carry off any virus
that I had contracted.  Notwithstanding this, I  still, however, found
some of  these disagreeable sensations, together with an uneasiness in
the throat and teeth.
   '"All this time  there was nothing more  than  usual in the genital
parts, but a  degree of heat not felt or observed before.
   "' I now conceived that this heat was increasing.  By a constant and
minute inspection, I found the size of the penis at  times to diminish;
the nut assumed a pale yellowish color, and the glands behind the nut
seemed to be covered with mucus.  The heat about the head diminished;
the throat and teeth felt more uneasy.
   "' In  the  course of a fortnight after my return, I persuaded my
apothecary  to give me small doses of calomel.  For the first few days
they worked me  very violently.  The  quantity of calomel was then
lessened. All this time I felt no discharge of any kind, but after taking
those medicines a  few days I felt some heat and pain in the  groin, and
the penis seemed at times hot, and  I felt some shooting pains  about
the head.
   "' A fortnight completed this course,  and I now entered upon some
alteratives.   While taking them, my throat seemed to get worse and
worse, but more so towards night.
   "' Six weeks after the connection I was pronounced  well, and left
off all medicines.
   "' Soon after this, in the mornings, prior  to my making water, I per-
ceived a small quantity of a whitish discharge on the opening of the
lips of the urethra; never in quantity so large as a pea, and never but
in the morning.   I was induced to  try what stain this would give to
clean linen  ; it left a greenish spot.   This was immediately communi-
cated to the surgeon, who bid me think nothing of it, assuring me  it
was of no consequence.
   "' My mind was too unhappy to remain satisfied in this state, or with
those assurances;  I therefore  had the advice of a physician.
   "' He said if I was affected it was in a very small degree, and that
there was no possibility of my  injuring  my wife.   Notwithstanding 
531
PSEUDO-SYPHILIS.
which, he thought I had better take some medicines, which he would
prescribe, for a fortnight, and then go on with my strengthening reme-
dies.  I now began taking these medicines.  I took a large teaspoonful
of an electuary three times a day; my throat soon began to feel better;
after the  fortnight the strengthening plan was begun.
  '"These medicines being left off, my throat became uneasy, as before;
once or twice I discovered a discharge from the urethra, which was quite
clear,  and more glutinous  than my water.  This I always found was
after erections.
  "' The strengthening medicines were continued about a fortnight.
My throat felt very sore at night, and looked red all round.  A hard
reddish pimple now appeared in the roof of the mouth.   These cir-
cumstances made  me very unhappy.
  "'I now began taking an electuary, like the former, and drank a
pint of decoction of the woods every  day.  This  plan was  adhered to
for  six weeks.
  " 'I took strengthening medicines for  about a fortnight, and then left
them off".
  "'I used a variety of things for my mouth and throat; one time  an
electuary, and gargled with port wine;  another time I gargled with a
decoction of roses, honey, &c.
  "'I now  find myself in a much worse situation than ever; for  al-
though I have never been disabled from pursuing my business, I have
some  additional  disagreeable sensations; very unpleasant feelings in
the  shin bones, which affect me more after walking or standing, as if
pins were pricking me.  They are not violent, but disagreeable. My
legs sometimes seem uncommonly stiff;  there is a soreness in the knee,
and in the hollow under the knee;  a  pain in the small  of the  back,
sometimes in my arm.  I think my corns, which are often  troublesome,
have been more so, especially in damp weather.
  "'About three  months ago I discovered a spot on the inside of the
right thigh, the size of a shilling, which at times assumed a copper color,
but in common the color of the skin; but whenever heated it assumed
this color.   On the  other side several  more, of  a lighter  kind, have
appeared.  There are several small ones, of the  size of a large pin's
head,  about different parts of the body, rising above the skin.   There
is no particular pain attends them.
  '"Within this week  some very large  spots have appeared about the
neck, and the right side of the neck feels sore at times.  For some time
past my nose and forehead have felt different from what  they used to
do.   There  has been  a heat, attended  at times with a pricking and
throbbing pain, with a stiffness that I cannot describe.  The skin about
the  nose seems red.  This instant there  is a pain and stiffness felt in it.
My eyes  seem weaker than they used to be and sometimes look red.
My mouth has been affected;  the membrane appears pale and broken
in some places.   The saliva is very disagreeable; the breath is not  of-
fensive.  Whenever I have wind in the  stomach my throat is very sore
indeed.
  "' It is necessary that I should observe that I am of a scorbutic habit, 
PSEUDO-SYPHILIS.
535
which has always thrown out pimples betwixt my shoulders, down my
arms, and sometimes some few in my face.
  " 'When I returned home in May, I found  my wife looking  pale
and weak.  This I concluded to be the effect of breeding.  It appears
since, that on my return she must have been advanced about six weeks
in her pregnancy.   I prayed  the surgeon to tell me  if he thought
there was any danger  of my injuring her, and that, if there was, I
would fling myself at her feet and inform her of what had happened.
This I also  told the doctor; both assured  me  there was no danger.
Towards the latter end of June she seemed to have a slow fever.  The
apothecary attended her.   She appeared very weak.   By degrees she
got better.  In July she received a terrible fright, so that she became
very poorly again, was very weak, and complained of an unusual dis-
charge from  the vagina.   For this, through much  persuasion, I got
her to consent to have the doctor's advice.   This I pressed very much,
as he was acquainted with all the circumstances that had attended me.
I was very  apprehensive that her complaints were  now the effect  of
an  injury received from me.  I told the  doctor of  the discharge,
prayed him to give her symptoms due consideration, and pressed him
to prescribe such medicines as would effectually remove the complaint.
He attended her, and assured  me that  there was not the smallest ap-
pearanoe of her complaints arising from such a cause.  He said  they
were the effects of weakness and pregnancy.  She never complained
of any pain in the parts, nor  of any heat in making water.  At this
time she was  troubled with an almost  unremitting pain in  her teeth,
gums, &c.  The doctor prescribed some strengthening cordial medi-
cines, which she continued  to take for some time.  She  grew better,
but was almost  continually affected with pains in  her teeth.   This
discharge lessened by degrees.  Her habit was always disposed to be
costive,  but more so when  with child.  This the doctor accounted for
from her habit, her being with child, &c, and assured me that every-
thing was  perfectly  natural, and that there was not the  smallest
appearance of anything arising from disease.  About a month or more
before she was brought to bed, those complaints in her teeth, ears, and
head seemed to increase, a redness appeared over her eyebrows, where
there was great pain, &c.
  "'At this time I observed  some  little  spots about her  face, of a
yellowish color, one in her forehead, two or three less near her  ears,
&c, and some few on her arms.
  "'At length  she was brought to bed; had a fine  child, perfectly
healthy.  Her teeth were  still sore, the right  side of her cheek  so
much so, that she could not bear it to be touched.   Her left  breast
began now  to  be  very troublesome, and the more  so as  the  milk
advanced.  (In this breast she always  complained of a pain from her
first child, and  sometimes she fancied she  could feel a hard lump.)
Both her nipples were very sore, were surrounded with little ulcera-
tions ; but the left was by  far the worst.  It was very painful to her
to give  suck; she was obliged to have her breasts  drawn  now and
then.  Her nipples got better by degrees, and she now tells  me  they 
536
PSEUDO-SYPHILIS.
 are well.   There was early after  she had children a redness betwixt
 the breasts ;  but this also went off.
   " ' There now seems a little redness on each side of her nose near
 her eyes, and sometimes the tip and sides of her nostrils  appear  red.
 She says there is no pain.   Her pain is now in  the left gums, and
 extends through to the  cheek.   Her water is frequently very thick,
 and there is, very soon after it is discharged, an evident sediment in it.
   " ' The infant is free from  all appearances of disease, but at present
 is afflicted  with the snuffles  to a degree that exceeds anything of the
 kind that I ever saw in any of our other children.  I am  always  dis-
 posed to anticipate the worst, and it pains me very much, lest it should
 arise from  this general  source of evil.  The  child is hearty, thrives
 very well,  sleeps well.  Two children that are at home have now  and
 then been poorly; in the corners of their mouths there was, for weeks,
 an evident excoriation, assuming a whitish color.  This, I think, is
 now gone.   There seem some small pimples about  the  neck, very
 small, and  there are two or three of these small spots about each of
 them ; and sometimes their noses are red and sore.  Indeed, my mind
 has been afflicted with  an  idea  that I have  by this unguarded  act
 injured my whole house.  My situation is truly wretched.  I have
 made up my mind to take time by the forelock, to attack this disorder
 very early; but, alas 1 I am afraid I have fallen into bad hands.
   "' This business involves a great variety of questions  of the first
 importance to me.   The questions, with their answers, must be re-
 ferred  to your better judgment; I will  state two or three for  our
 satisfaction.
   " 'If my complaints arise  from lues, is it possible for  me to have
 injured my children by kissing them, sleeping, &c?
   " ' If my wife's discharge was  venereal,  would it not  most likely
 have produced a similar one in me ? or would not my having received
 the lues into  my habit prevent it ?
   " ' Are those pains in the head, teeth, ears, &c, likely to arise from
 this cause? If my wife's nipples had been affected from the complaint,
 would the  person that drew her  breast be infected ? and if so, how
 long, and in what manner would her infection appear?   Would  the
 nipples have  got well had this been the case ?  Can the child's snuffles
 arise from  this cause?   Can any part be injured by this complaint
 without manifest inflammation, swelling,  and discharge ?
   " ' I have only  to  add  that I pray you, sir, to be good enough to
 give this complex and unhappy case every  necessary attention.  I
should wish for effectual relief.' "—Home.]

§ 1.  Of Diseases supposed to be Venereal produced by Transplanted Teeth.

   Since the operation of transplanting teeth  has  been practised in
London, some cases have occurred in which the venereal infection has
been supposed to be communicated in this way, and they have been
treated accordingly;  nor has the method of cure tended to weaken
the suspicion; yet when all the circumstances attending them, both in
the mode of  catching the disease, and in  the cure, when they have 
PSEUDO-SYPHILIS.                   537
been treated as venereal, are considered, there is something in them
all which is not exactly similar to the usual appearance of the vene-
real disease when caught in the  common way; especially too when it
is considered that some of the cases were not  treated as venereal, and
yet were cured, and therefore the cure of the others, which appeared
to be from mercury, are not clear proofs  of their having  been vene-
real.1
  I believe that I have seen most, if not all, the cases of this kind which
have occurred, and have attended some of them.  In all of them the
time of local affection, after the insertion of the teeth, has been almost
regularly a month, which is too long for the venereal to take effect at
a medium;  and where they have produced constitutional  symptoms,
those again have either followed the local too close for the venereal, or
too regular as to  time.   But it may be advanced, that a disease has
been produced probably as bad in  its consequences as the venereal.
That a disease has been formed  in this way is certain.
   The first case of this kind which came under my care was a lady
who had one of the bicuspidati transplanted.   The transplanted tooth
fastened very well.  About a month after she danced  till five or six
o'clock in the morning, caught  cold, and  had a fever in consequence,
which lasted near six weeks.  In this time ulceration in the gum and
jaw took place, though it was then not known.  And  when she was
beginning to recover it was found  that not only the gum  and socket
of this tooth were diseased, but also those of the teeth next to it.  The
 two teeth were taken out, and the sockets of both afterwards exfoliated;
but the parts  were very backward in healing.
   This backwardness gave rise to various opinions, the principal of
 which was, that it was venereal.  In the mean time a rising appeared
 upon  one of the legs, which was of the indolent node kind;  this was
 also suspected by some to be venereal, or rather was a corroborating
 circumstance  of the former opinion;  but I gave it as my opinion that
 it was not.   I desired she might go to the sea and  bathe, which she
 did, and got perfectly well, both in the jaw and leg, and has continued
 so ever since.
   The second case of this kind I have  seen was also in a young lady.
 The transplanted tooth fastened extremely well, and continued so for
 about a month, when the gum began to ulcerate, leaving the tooth and
 socket bare.   The ulcer continued, and  blotches appeared upon  the
 skin,  and ulcers also in the throat.   The disease was treated as vene-
 real, the complaints gave way to this course, but they recurred several
 times after very severe courses of mercury;  however,  she  at last  got
 well.
   The only observation I can make on this case is,  that the symptoms
 recurred after continued courses of mercury much oftener than is usual

   1 It is to be remarked here that I do not, in the present case, lay any stress at all on
 my opinion of the lues venerea not having the power of contamination ; and I believe
 we must allow,  if the disease were venereal, it must have been contracted from a lues
 venerea in the person from whom the tooth was taken ; for chancres are not common
 in the mouth, and  they would be seen on examination.  I believe few discharges
 similar to gonorrhoea take place there. 
. 538                   PSEUDO-SYPHILIS.
in venereal cases, and I had my suspicions all along that it was scrofu-
lous.
  The third case was of a gentleman, where the transplanted tooth
remained without giving the least disturbance for about a month, when
the edge of the gum began to ulcerate, and the ulceration went on till
the tooth dropped out.  Some time after spots appeared almost every-
where on  the skin; they had not the truly venereal appearance, but
were redder or more  transparent, and more circumscribed.  He had
also a tendency to a hectic fever, sueh  as restlessness, want of sloop,
loss of appetite, and headache.  After trying several things, and  not
finding relief, he was put  under a course of mercury, and  all  disease
disappeared according to the common course of the cure of the venereal
disease, and we thought him well; but some time  after  the same ap-
pearances returned, with the addition of swelling in the  bones of the
metacarpus.  He was now put under another course of mercury more
severe than the former, and in the usual time all the symptoms again
disappeared.   Several months after the same eruptions came out again,
but not in so great a degree as before, and without any other attendant
symptoms.  He a third time took mercury, but it was only ten grains
of corrosive sublimate in the whole, and he got quite well.   The time
between his first taking mercury and his being cured was a space of
three years.
  Query: Could this case be venereal ?  The first two courses  of mer-
cury removing the eruptions would seem to prove it was;  but the third
course also removing them, which consisted of only ten grains of cor-
rosive sublimate, would seem to prove that  it could not be venereal;
for  if it had, the appearances which returned after  the second  course,
in which a considerable quantity of mercury had been  given, would
not have yielded to ten grains.
  The fourth case was that of a young lady who had a tooth trans-
planted, and about the same distance of time after it, as mentioned in
the former cases, the gum began to ulcerate, and the ulceration was
making considerable progress.  The surgeon who was first consulted
desired mercury to be given immediately. I was afterwards desired to
see  her, and advised that mercury should not be had recourse  to, that
we  might ascertain the nature of the case; for if she took mercury and
got well, it would be adding one more to the number of  the supposed
venereal cases  arising from such a cause.  I recommended drawing the
tooth, that we might see what effects would be produced by the removal
of the first cause. The tooth was drawn, and the gum healed up as fast
as any common ulcer,  and has ever since continued well.
  This case requires no comment.  I may, however, be allowed to ob-
serve, that if the lady had gone through a course of mercury, she would
have,  in all probability, also got well; for the tooth, in the  time neces-
sary for completing the course of mercury, would  have dropped out;
and if this had really happened, we need not hesitate in affirming that
it would have  been considered as venereal.
  The fifth case was that of a young lady, eighteen years of age, who
had one of the incisors transplanted, which fastened  very well;  but six
or seven weeks after the operation, an ulceration of the gum  took place, 
PSEUDO-SYPHILIS.                   539
the tooth was immediately ordered to be removed, and the bark was
given without any other medicine, and  she got well in a few weeks.
  The sixth case was that of a gentleman, aged twenty-three, a native
of one of the West India Islands, who had the two front incisors trans-
planted ;  and about the same time after the operation, as in the former
cases, an ulceration of the gums took place, which increased to a very
great degree, and the edges of the  gum sloughed off.  An eminent
surgeon was consulted, who ordered the bark; and the patient, with-
out taking any other medicine, got well in nearly the same time as the
ladies in cases four and five, who had the teeth taken out.  The gums
recovered themselves perfectly, but were considerably shorter.
  If we take some of the above cases, and consider them  as they at
first appeared, we shall almost pronounce them to  have been venereal.
If we take the others, we shall pronounce them absolutely not to be
venereal.  And if we consider every circumstance relating to those
probably venereal, we shall, as far as reasoning goes, conclude  that
they were not venereal.   The first case that appeared at the time to be
venereal is the second of those before related; but, as I did not attend
the lady through  the whole of the cure, I can say less upon it.   She
certainly had the symptoms  recur oftener than they do in venereal
cases in common, where the disease is  attended with  no  ambiguity,
and took more than the usual quantity of mercury.  There  is, there-
fore, in  this case, something  not  clearly understood, because it  does
not exactly agree with venereal cases in general in all its parts.
   The fourth case was similar in its recurring, and in the quantity of
mercury that appeared to be  necessary to remove  the symptoms.
   The most serious effects of transplanting a tooth  happened  to a
young lady, and are related, in the Medical Transactions, iii. 25, by the
late Sir William Watson.
   The dentist, being alarmed at the first appearance, desired me to
visit her upon his own account.  The edge of the gum had just  then
begun to ulcerate.  As I did not know well what was best to be done,
I desired him to make a strong solution of  corrosive  sublimate, and
let the mouth be often washed with it, and also  to  apply some  lint,
soaked in it, to the  part; but as this  did  not stop its progress, she
applied to Sir William  Watson, to whose account of  the case I  must
refer the reader, and from that account I must take my materials to
reason upon.  However, I may remark, that the case appears to  have
been supposed at last to be venereal, whatever might have been the
first opinion, and for the two following reasons : First, from the mode
of catching the disease being possible; and, secondly, from its not
giving way to medicines which are of no service  in the venereal dis-
ease ; and this opinion appears to have been  confirmed by the disease
giving way to mercury.  But the case itself, abstracted from the mode
of catching it, and even the mode of cure, does not perfectly agree with
the common attending circumstances  of the venereal; nor has that
attention been paid to the necessary circumstances sufficient to deter-
mine it to be venereal.
   The progress of the ulceration in the mouth, which was the first
symptom, was by much too rapid for a venereal ulcer  in common; for, 
540
PSEUDO-SYPHILIS.
it must be considered, if  venereal, simply as  a chancre or local affec-
tion.
  Now, let us trace the progress of the disease into the  constitution.
" About this time," viz., when the local disease was making such rapid
progress, "blotches appeared in her  face, neck, and various  parts of
the body; several of these became ulcerated painful sores." Now this
date of the constitutional affections following the local is by much too
soon to be venereal; we know if a lues venerea arises either from a
gonorrhoea or chancre, it does  not appear in common till about six
weeks, often much later, but  seldom  sooner.  I do not  count much
upon the circumstance of there being no swelling  of  the lymphatic
glands of the neck, forming buboes, as that is not a  constant symptom
attending the venereal matter getting into the circulation, although it
should be allowed to have some weight, especially where other circum-
stances do not perfectly agree.  The appearances from the constitution,
when they did take place, were much more violent  and rapid in their
progress than any venereal blotches I ever saw.  We  know in the
lues venerea that they are  months before they arrive at the stage of
scabs; also the pain attending those  sores did not  in the least corre-
spond with  the lues  venerea.   Venereal blotches hardly give any
sensation, or  at  least  very little; but, after  all, mercury cured this
disease, whatever it was.  Twenty-eight grains of  calomel, made into
fourteen pills, were taken, probably in ten or twelve days, for it was
directed she should take one  or two each  day, as the bowels would
allow; but,  although  tinctura thebaica  was given, they purged so
much as made it necessary to give no more in this way.  But  although
so little mercury was taken, and had also run off considerably by the
bowels, yet " the ulceration of her mouth and cheeks did not spread,
 but was less painful and of a milder  appearance; the blotches in her
face and body grew paler, and such  of them as had ulcerated healed
 apace and no new ones appeared.  Unguentum coeruleum fortius" was
therefore directed " to be well  rubbed into her legs and thighs twice
 a day, in small doses," lest it should be determined  to the bowels.  " In
 about ten or twelve  days her griping  and purging returned with
 violence, the ointment was  therefore discontinued.  At  this time the
 blotches were all gone;  the ulceration in her face and body were com-
 pletely healed, and those of her mouth nearly so."  [Op. cit., p. 328.]
   The only remark I  have to  make  on the cure is, that  the quantity
 of mercury was not sufficient to cure chancres  on the penis, making
 such rapid progress as those did in her mouth; nor could  the same
 quantity of mercury cure venereal sores on the skin, which had made
 such rapid progress as they did in  this  case; and if we take in the
 effect this had upon her health, with the termination of the whole, I
 think we should  pronounce it not venereal; for the specific circum-
 stances, if it  was venereal, were just as uncommon as the mode of
 catching it.
   Many of these cases, suspected of being venereal, I have seen occa-
 sionally ; and although the patients recovered while under a course of
 mercury, yet on account of the want of attention in the  practitioners 
PSEUDO-SYPHILIS.                    541
to the very circumstances  that would  decide the disease to be either
venereal or not, I pass them over unnoticed.
  After having considered the cases themselves of those who had the
teeth  transplanted, let us also consider the persons  from whom the
teeth were taken; for I cannot help thinking that this will throw some
light upon  the subject.  Let me suppose that the young girls from
whom the teeth were taken really had the lues venerea, and that the
teeth were  of course also  infected, which is a supposition most un-
favorable to my real opinion;  it  appears to  me that, even in this case,
there can be no difference between the gums of  the  girl from whom
the tooth was taken, and the gums of the person who received it.   If
the ulceration took place  in the last from  contamination, would not
the socket in the girl from whom the  tooth was  taken  likewise have
ulcerated?   But this  did  not happen in any  of them.  I have here
supposed the teeth capable of being contaminated;  although I believe
we  have never yet seen them have this disease primarily, but only  in
consequence of its breaking out somewhere else,  in the  mouth, throat,
or nose, and spreading to them. But still, if they are capable of having
the disease, and communicating it to others,  it becomes very extra-
ordinary that those people should have  hit upon  the  few teeth that
probably were ever so contaminated.
  When we consider that the girls from whom the teeth were taken
had not the least appearance of disease at the time, and had none when
the disease broke out  in the person who received the  teeth, it becomes
strange that it should break out  in the receivers and not in the giver.
  It is also singular  that  an ambiguity should follow this disease  in
all  its stages ; in the mode of its being caught, the appearance, and the
cure.
  Let us sum up all the arguments in favor of the disease not being
venereal.   First, two patients, whose cases  were  similar to the others
in their origin, recovered without medicine.  Secondly, they who seemed
to be cured by mercury had not a treatment exactly similar to those
who were indisputably poxed. Thirdly, I consider it  as impossible for
parts to have the power of contaminating which are not themselves dis-
eased.  Fourthly, the parts contaminating were never known to have
been contaminated themselves.  But it must be nearly the same thing
to those who want to have teeth transplanted, whether my reasoning is
just or not; for a disease in consequence of the operation most certainly
has taken place; and in some cases this has been worse, or cured with
more difficulty, than the lues venerea in common; and whatever the
disease may be, I yet know of no mode  of  prevention, except the
drawing of the tooth early, and  that has been  tried in  one case only,
and in that case was successful.
  From this account, many may be deterred from having this opera-
tion performed.   In that light no evil can arise,  except the mortifica-
tion which arises from a reflection that no relief is to be had in cases
of bad teeth.  But it is to be remembered that this is a publication of
all the unsuccessful cases, which is the very reverse of what is gene-
rally practised in medical books; and they are mentioned upon  no 
542                   PSEUDO-SYPHILIS.
other principle than that the disease, when it happens, may not be im-
properly managed.
  It may be asked, what is this disease ?  There is more difficulty in
answering what it is, than what it is not.  I should say that a sound
tooth transplanted may occasion such an irritation as shall produce a
species of disease which  may be followed by the local complaints above
mentioned.
  I cannot conclude without intimating that undescribed diseases, re-
sembling the venereal, are very numerous; and that what I have said
is rather to be considered as hints for others to prosecute this inquiry
farther, than as a complete account  of the subject. 
EXPLANATION  OF  THE  PLATES.
                            PLATE I.

  Fia. 1.  The penis slit open, showing a stricture in the urethra, about two
inches from the glans.   The stricture is but slight.  A A the cut surface of
the corpus spongiosum urethras.   B B the canal of the urethra, in which may
be observed the orifices of the lacunae.   C the stricture.
  Fig. 2.  The penis slit  open for about three inches, to show  the lacunas,
which become occasionally an obstruction to the passage of the bougie.  A A
the corpus spongiosum urethras.   B B the internal surface of the canal of the
urethra, pointing to the orifice of two of the lacunas.  C a bristle introduced
into a lacuna.  D the end of the bougie introduced into the remaining part
of the urethra.

                           PLATE II.

  The urethra opened in two different places, one before  the  stricture, the
other behind;  the  one  before is through the body of the penis, the other
behind is upon the anterior surface of the membranous part; and a bougie
passes from the one opening to the other.  A A the crura penis and bulbous part
of the urethra, all blended together by inflammation and suppuration, which
has taken place in many parts.   B B the prostate gland in a diseased state.
C C the cut edges of the bladder.  D the urethra behind the stricture, very
much enlarged; irregular on the surface in consequence of ulceration.  E E
the cut surfaces of the corpora cavernosa penis.   F F the cut surfaces of the
corpus spongiosum urethras.  GGa bougie passing from the sound to the
unsound part of the urethra.   H a small bougie in the new passage.
                           PLATE  III.

      Two Canulas for applying Caustic to Strictures in the Urethra.

  Fio. 1.  A straight silver canula, with the plug projecting beyond the ter-
mination of the canula, making a rounded end; at the other end of the wire
is a small port-crayon, in which is represented a piece of caustic.
  Fig. 2.  A flexible canula, for applying caustic to strictures in the bend of
the urethra.  The wire with the small port-crayon is pushed out beyond its end.
  Fig. 3.  A piece of silver wire  with the plug at the end, to be introduced
into the canula, as in Fig. 1. 
544              EXPLANATION  OF  THE  PLATES.
          M. Ricord's  Urethral Coarctotome and Porte-caustique.

  Fig. 4. Curved coarctotome, reduced to two-thirds the size of the original,
and broken in the centre.
  Fig. 5. Blade of the coarctotome, its stem bearing a slide  or graduator
(size of the original).
  Fig. 6. Conductor (size of the original).
  M. Ricord's coarctotome, consisting of only three pieces,  is  incontestably
the most simple  and solid instrument of the kind invented, and its mechanism
is such, that it acts like a bistoury directed with certainty upon the stricture,
by means of  a director.   The action of the instrument is  extremely simple.
The blade, Fig.  5, the  shape and  size of which may  be changed  at will, is
moved by means of a strong stem, and can be withdrawn and  entirely con-
cealed within the conductor, Fig.  6,  to allow  of the introduction  of the
instrument; a scale suitably graduated upon  the  latter, also enables us to
arrive exactly at the constricted part, the depth of which should be previously
measured by  an  ordinary explorator.
  The slide,  which, by  means of the screw, b,  Figs. 4 and 5, can be fixed to
any part of the  scale marked upon the stem at the  point c, indicates the pro-
jection of the blade when pushed forwards, as in Fig. 4.   The blade, in this
position, rises upon an inclined plane, which forms the termination  of the
groove of the conductor, and presents a cul-de-sac  superiorly, which receives
a little catch, a, placed at the extremity of the blade, Fig. 5, and in this way
prevents the  escape of the latter from the groove of the conductor, and allows
its cutting edge to be  directed with the greatest regularity.   By drawing
back the stem, the blade is made to re-enter  the conductor, and the instru-
ment may be withdrawn without fear of wounding the urethra.   It is no
small advantage in M. Ricord's instrument that it can be thoroughly cleansed
with the greatest ease, and thus preserved from rust, which, in all complicated
scarificators,  often impedes the motion of the  parts on each other, and what
is a much more  serious  inconvenience, corrodes them and makes them liable
to break during an operation.
  Fig.  7. Porte-caustique.—In a single instrument, M. Ricord has combined
all  the advantages of the best porte-caustiques.   A gum-elastic canula, fur-
nished at its  extremities with metallic  armatures, of which the  superior one
is surrounded by a small disk  presenting two  screws d d, to fix  the different
parts in  place, is designed to stop before the stricture and thus  determine its
anterior border.  Within the  outer tube or canula, is a second canula a a,
which is pushed forwards so as to pass through the  part that  it is designed
to cauterize:  this done, by a rotatory  movement the eccentric  kjiob termi-
nating the stylet b b' is made to project laterally.   This knob serves to grasp
the posterior border of the stricture, which  is then included between it and
the extremity of the external canula.   The instrument being thus arranged,
by  withdrawing the canula a a, the curette  b is exposed and the melted nitrate
of silver which it contains applied to the adjacent parts, or,  by giving a rota-
tory motion to the stylet supporting the curette, the whole  circumference of
the canal may be cauterized.


                             PLATE  IV.

  The bladder and penis of a person who  died of a mortification of the blad-
der in consequence of a stricture and stone in the urethra.    In this plate not
only the stricture is represented, but the thickened coats and fasciculated inner 
 
%  !•
T Sinclair's JjtK. ?h' 
 
 
 
 
T jir.clairs  lith.?bii 
 
 
 
?ldute  d
Del. 
'late 6.
kFnr.Le..
T. Sinclair's lithJJul 
Plate  r,
f;V" Ds!
T ,S in (. i j .Vs ^t}i.?hii. 
 
 
 
EXPLANATION  OF  THE PLATES.
545
surface of the bladder; as also the small stone, which acted as a valve or plug;
beside which a canula is introduced from  the  glans  down to the stricture,
showing the  practicability of destroying it with caustic.   A A the bladder,
cut open, showing its coats a little thickened, and its inner surface fascicu-
lated.   B the body of the penis.  C C the corpus spongiosum urethras cut
open, through its whole length, exposing the urethra.   D the prostate gland
divided.   E  a silver canula introduced into  the  urethra, through which the
caustic is passed on to the stricture.   F points  out the stricture, with the
stone lying above, so as entirely to prevent the passage of the urine.
                            PLATE  V.

  An enlarged prostate gland, particularly the valvular process, which has
increased inwards, into the  bladder, in form of a tumor; in consequence of
which the water passed with difficulty, which became the cause of the increased
thickness of the bladder.  A the prostate gland.  B the projecting part pass-
ing into the cavity of the bladder.  C C a bristle in the urethra, to show it is
above this  tumor.   D the cut edge of the bladder,  which shows its increased
thickness.

                             PLATE  VI.

  A, kidney; the ureter, pelvis, and infundibula of which are very considerably
enlarged in consequence of a stricture in the urethra.  A, the substance of the
kidney, which has  become  very thin.   B B the infundibula, much enlarged.
C the pelvis very much enlarged.  D the ureter increased more than ten times
its natural size.

                            PLATE VII.

   The valvular part of the bladder, so increased as to form a considerable tumor,
projecting into the cavity of the bladder.  The prostate is also enlarged.  This
tumor had been the occasion of several severe suppressions of urine, and had
often been the cause of a failure in drawing off the water with a  catheter, by
that instrument, most probably, passing into its substance so deep as to hinder
the urine entering its openings.  The dark line, passing along the tumor from
the urethra was probably made by this means,  but now collapsed.  A A the
cut surfaces of the prostate gland.  B B the inner  side of  the prostate gland
projecting inwards.  C the tumor.  D the cavity of the bladder.


                           PLATE  VIII.

Pathological Specimens presented by M. Ricord to the Academy of Medicine*

   r  - -pinsT —Boisseau, a draughtsman by profession, aged 52, entered the
tt*  -tal du Midi  April 2, 1836.  He had  had four attacks of  gonorrhoea,
vT°tP*niild  not state the exact time of their occurrence.   The first three affec-
?    disappeared readily, and  in a short time, under the use of cooling drinks;
w the discharge in  the last, though slight at first, gradually became very
  1   dant  and painful, and after continuing two months without treatment was

           i See the Bulletin de VAcadtmie de  Me'decine, 1838, t.  ii. p. 506.
        35 
546
EXPLANATION OF THE PLATES.
complicated with epididymitis of the right testicle, which had lasted a week
at the time of his entrance to the hospital, when he was found to have a hy-
drocele in the acute stage, which was punctured.
  Leeches were  twice applied over the course of the spermatic cord, and the
scrotum covered with poultices.  A slight diminution took place in the volume
of the tumor; but the pain, which had disappeared almost immediately after
puncturing, the testicle having been thus relieved from the pressure exercised
by the liquid inclosed in the tunica vaginalis, returned on the third day in con-
sequence of afresh effusion, which was also evacuated ;  finally, the fluid having
accumulated a third time, M. Ricord, notwithstanding the acute stage, injected
the  sac with a vinous  infusion of'roses of Provins, and  a cure resulted as  in
the  most simple  cases.
  The gonorrhoea, which had been  very painful from the  first, furnished a
greenish pus, mixed with a few streaks of blood,  and, on  being inoculated
upon the patient's left  thigh, gave  the characteristic pustule of a chancre.
Finally, on the 14th of  June, the epididymitis  and hydrocele were perfectly
cured, but the discharge continued much the same, in spite of the use of cubebs
and copaiba.  Boisseau was obliged to leave the hospital, on business of his
own, but returned June 21, with epididymitis on  the  left  side,  complicated
with hydrocele.   The tunica vaginalis  was very tense, and severe pain was
felt in the testicle.  M.  Ricord evacuated the fluid by puncture, and the pain
disappeared ; he afterwards introduced a mesh within the sac, in order to pre-
vent a new effusion.   In spite of antiblennorrhagics, and astringents, the use
of which was resumed, the discharge became more and more abundant; the
patient  appeared very much depressed, and night-sweats, rapid and general
marasmus, and constipation followed.  A light  purgative was given, and fol-
lowed by a fetid  evacuation; the urine became thick, and contained shreds of
pus; the prostration increased, and finally death ensued August 4.
  Fig. 1. (Autopsy.)—The urethral, and the bladder c, having been opened
on their  superior surfaces, the canal was found to be destroyed throughout its
membranous and prostatic portions, and hollowed out by deep ulcerations ddd,
having all the characters of primary phagedenic ulcers; the prostate e was
deeply involved; in front, a fragment of the urethra/, adherent at its base,
but detached from the subjacent parts and  rounded and  hypertrophied, was
floating  in the pus;  behind, there was also a wider fragment, g, hard and
thickened.  Within the  bladder were found several rounded ulcerations, hhh,
with their edges  cut perpendicularly, and presenting the characters of primary
syphilitic ulcers, which had destroyed the whole thickness of the mucous mem-
brane.  Among  these ulcerations, most of which were in the progressive stage,
there were some which were almost cicatrized, and towards the vesicle trigone
several slight depressions with smooth whitish surfaces indicated the presence
of cicatrices.
  The left vesicula seminalis inclosed a collection of pus, which had destroyed
its central portion, and communicated with  the surrounding cellular tissue by
rounded openings, the edges of which were clearly cut.  On the same side, the
vas efferens and vas deferens, ulcerated and filled with pus, communicated with
the disorganized epididymis, of which the envelop, as it were, alone remained.
The presence of  the pus had even affected the testicle, on the surface of which
several bands of false membrane were seen forming adhesions with the  corre-
sponding parts of the tunica vaginalis ;  no operation, however, had been per-
formed here, as above stated, except  a simple puncture to relieve the pressure.
The right vesicula seminalis was sound, and also the  corresponding testicle,
in which the vinous injection had produced complete adhesion of the two folds
of the tunica vaginalis. 
EXPLANATION  OF  THE PLATES.
547
  In concluding this observation, we believe it important to call attention to
the fact that nothing  but antiphlogistic balsams  and astringents were ever
employed in Boisseau's gonorrhoeal affection, and that he had never made use
of injections, and had never been sounded.

  Case Second.—Bourdon (Adolphe), aged eighteen years, a gilder by trade,
entered the hospital August  16, 1836.   A few days after a suspicious con-
nection, this patient perceived a chancre situated  on the corona glandis, near
the fraenum; no treatment was opposed to the progress of the ulcer, which
extended to the neighboring  tissues.  The meatus was red and swollen, and
there escaped from it at  first a little bloody matter, and afterwards pus, the
quantity of which  gradually augmented, till at last it had the  appearance of
a copious urethral discharge.  The emission of urine excited pain of some
severity.   After some necessary labor and certain excesses in which Bourdon
engaged, his prepuce, which  was previously narrow, became cedematous, and
a phimosis ensued, which  compelled the patient to present himself to the
hospital.   It was  designed to  perform an operation on the inferior  surface
of the prepuce, but the incision encroached upon the side; the edges of the
wound, inoculated by the virulent pus, became ulcerated, hard, and thickened.
   The disease progressed with considerable rapidity.  In spite of the various
means which were used, the whole of the corona glandis ulcerated, and the
lips of the meatus urinarius were destroyed by a chancre.  Finding no relief,
Bourdon returned  home ;  but a few days after he presented himself at the
consultation of M. Ricord. Being admitted to the hospital, Bourdon appears
very feeble, in consequence of excessive  emaciation.  His digestive functions,
however, go on regularly; he has  a little cough, and his  chest  presents a
slight dulness towards the upper part of the right lung; his respiration  is
free; no trace of a syphilitic eruption is noticed on the skin.  The corona
glandis and meatus urinarius, and the edges of the wound resulting from the
operation for phimosis are ulcerated, and present the external characters of
a chancre in the period of progress. The discharge is abundant and slightly
sanious; the emission of urine is very painful, especially towards its close,
and the last  drops of this  fluid  bring away some  shreds of blood.   The
passage of the feces excites  pain  in the  region of the  neck of the bladder.
On inoculating the matter of the urethral discharge upon the left thigh, on
the third day a pustule has formed, which is deeply cauterized with nitrate
of  silver, and  the  ulcerations are  dressed with  a concentrated  solution  of
opium.
   September  4, the acute stage continues,  attended with much pain.   The
pustule  on the thigh was  destroyed by the cauterization.   A pomade  of
calomel  and opium is  used for the dressing.   September 20, the  patient
complains of incontinence of urine ; the vesical tenesmus, which he  has ex-
perienced for some time, is a little less severe.   His emaciation constantly
increases, and his debility is  extreme.   During  the  months of October and
November, the morbid  symptoms are aggravated;  the urine  oozes  away
incessantly, and an obstinate  diarrhoea supervenes.  M. Ricord  attributes
the incontinence of urine to  the ulcerations having involved the neck of the
bladder.   In the early days of December, the condition of the patient  appears
beyond relief;  his marasmus makes rapid progress, and finally death occurs,
December 20.
   Fig.  2. (Autopsy.)—The urethra c, and  the bladder  b, having been
divided  superiorly, it is found that the ulceration of  the meatus  urinarius,/
extends  within the urethra to a distance of four lines; an inch farther back,
another oblong ulceration g, eight lines in length and four in width, has 
548
EXPLANATION OF THE PLATES.
destroyed the whole thickness of the mucous membrane.   The membranous
and prostatic portions of the urethra, the neck of the bladder, and  the pros-
tate itself, are the seat  of a large ulceration, having  all the characters of a
serpiginous phagedenic chancre, and presenting here and  there rounded de-
pressions h, i,j, with perpendicularly cut edges.  Scarcely any traces remain
of the neck of the bladder;  the lateral lobes of the prostate are replaced by
two large irregular excavations k, I, communicating with each other beneath
a ribbon m, formed by a fragment of hypertrophied mucous membrane.  The
capacity of the bladder is diminished one-half;  its mucous membrane  has
disappeared, and is replaced by a mammillated surface, resulting from hyper-
trophy of the granulations upon an ulceration in the reparative stage ; the
edges of the incision d d, which divides the organ perpendicularly,  are twice
as thick as in the normal state.
  Fig. 3. On the corona glandis a is seen a circular ulceration, some parts
of which are in the reparative stage; the prepuce is  hypertrophied, and the
edges b c of the wound made in the operation for  phimosis, are ulcerated;
the chancre at the meatus urinarius, d, is everywhere healing. 
.INDEX.
Abortion, influence of mercury upon, 502.
                      syphilis in produc-
                        ing, 451, 529.
Absorption  of  syphilitic virus,  363, 370,
  395.
Albuginitis, 455.
            treatment of, 506.
Alopecia, period of occurrence, 437.
          treatment of, 506.
Animals, communication of syphilis to, 42,
  61, 302.
Antiblennorrhagics, 128-, 135.

                   B.
Balanitis and balano-posthitis, 80.
                            treatment of,
                              136.
                           ulcerations in,
                              80.
Belloste's pills, 337.
Bell's experiments, 52.
Biniqui's method of dilating strictures,178.
Bladder, affections of, 240.
         fall of a bougie into, 181.
         irritability of, 158, 254.
         paralysis of, 242.
                     treatment, 245.
         puncture of, in strictures, 194.
Blennorrhagia, 68.
Blood, chemical analysis  of, in syphilis,
  437.
Bones, syphilitic affections of, 435, 460.
Bougies, 197.
         different forms of, 200.
         inconveniences of, 198.
         influence  of, in producing  false
          passages, 206.
Bromfield's  treatment of swelled testicle,
  142.
Bubo, 361,369.
      benignant, 369.
      gonorrhceal, 97.
                  in women, 107.
      indurated, 371.
      non-consecutive, 372.
      simple, 369.
      sympathetic, 369.
      treatment of. 377,  387.
                  Malapert's method, 388.
      virulent, 370.
                   C.
 Capsules of copaiba, 135.
 Caries, treatment of syphilitic, 507.
 Cauterization of chancres, 320.
                strictures, 182, 188.
 Cellular tissue, syphilitic affections of, 460.
                          treatment, 507.
 Chancre, 283.
         concealed, 55, 325.
         dependent on virulent pus, 44,46.
         development of, 46, 284, 293.
         diagnosis of, 298, 300, 302.
         duration of, 295, 300, 304.
         indurated, 295, 302.
         infecting, 302.
         inflammatory,  298.
         in women, 303, 313.
         necessary condition of the tissues
            for, 291.
         parchemini,  303.
         phagedenic, 297, 304.
         regular, 294.
         serpiginous, 297.
         simple, 299.
         superficial, 303, 326.
         transmission of, 301, 307.
         treatment of,  general  observa-
                         tions on, 315.
                  cauterization, 318.
                  constitutional, 340,342.
                      duration of, 497.
                      rules  for, 498.
                          when required,
                            343.
                  in women, 346.
                  local  applications, 322.
                     when sufficient, 325,
                        344.
         two stages of, 294.
         variations in reparative stage of,
           298, 300, 304.
         varieties of,  295, 299.
Chlorate of potassa in mercurial salivation,
  502.
Chordee, 87.
         Ricord's pills for, 326.
         treatment of, 140.
Circumcision, 338.
Concealed chancre, 55.
                  cases of, 545.
                  treatment of, 325. 
550
INDEX.
Condoms, 517.
Constitutional syphilis, 393.
                     attacks a person but
                       once, 305.
                     Hunter's division in-
                       to two stages, 418.
                     order of appearance
                       of the symptoms
                       in, 420.
                     premonitory symp-
                       toms of, 437.
                     treatment  of, gene-
                     ral remarks on, 465.
                     use of mercury in,
                       467, 496.
Contagion of venereal diseases, 516.
Copaiba, 128.
Copper color of syphilitic eruptions, 439.
Cubebs,  135.

                  D.
Dilatation of strictures, 178.
Discharge, gonorrhoeal, 68, 84.
                     effect of, when taken
                       internally, 398.
                     in females, 106.
Dupuytren's  pomade for the hair, 506.

                  E.
Ecthyma, 445.
Emery's tar  ointment, 505.
Epididymis, obliteration of, 239.
            persistent induration of, 159.
Epididymitis, 90.
             causes of, 93.
             complications of, 94.
             effect of,  upon the gonor-
                rhceal discharge, 95.
             treatment of, 141.
Epilepsy, dependent on syphilis, 37.
Erections, avoidance of, 326.
Exanthematous syphilitic eruptions, 440.
Exploration of  the urethra, 166.
Eyes, syphilitic affection of, 448.
                       treatment of, 505.

                  F.
False passages, 202.
               causes of, 206.
               parts of urethra most sub-
                 ject to, 206.
               prognosis of, 208.
               symptoms of, 207.
               treatment of, 208.
Female, gonorrhoea in the, 101, 105.
Fistula?, urinary, 221, 225.
                 treatment of, 226.
Foetus, syphilis in the, 451.

                  G.
Gleet, 150,156.
      prophylaxis as  applied to, 516.
      relation  of, to gonorrhoea, 146.
      treatment of, 153, 156.
Gonocele, 275.
Gonorrhoea, 67.
           are there two kinds of? 56, /->•
           causes of, 78.
           difference between  gonorrhoea
             and chancre:—
                theory of Hunter, 50.
                         Hufeland, 57.
                         Rose, 57.
                         Swe'diaur, 57.
                         Lagneau, 57.
           effect of habit upon, 78.
           facility of curing, compared
             with that of chancre, 465,495.
           identity of, with chancre, 48,
             51, 54, 57.
           incubation of, 69.
           in women, 101, 105.
           relapses in, 74.
           results of experimental inocu-
             lation upon, 52, 55,432,452.
           seat of, 79, 86, 88.
           symptoms of, 82.
                     discharge,  68, 84.
                     pain, 88.
           synonymous terms with, 68.
           treatment of, 109, 125.
                      abortive, 125.
                      antiblennorrhagics,
                        128.
                      astringents,   112,
                        136.
                      constitutional, 120.
                      direct, 126.
                      evacuants, 112,136.
                      indirect, 128.
                      injections, 114,126.
                      in women, 119,136.
                      mercurials,    113,
                        122, 137.
                      palliative, 126.
 Gonorrhceal ophthalmia, 268.
                     causes of, 269.
                     diagnosis of, 272.
                     from contagion, 269.
                     metastatic, 274.
                     symptoms of, 270.
                     treatment  of,  272.
           rheumatism, 275.
                     causes of, 276.
                     diagnosis of, 280.
                     seat of, 277.
                     symptoms of, 278.
                     treatment of,  281.
 Guaiacum, use of, in syphilis, 493.
 Gummata, 461.

                   H.
 Habit, effect  of, in gonorrhoea, 48.
 Hemorrhage  from the urethra, 139.
 Hernia humoralis,  90.
 Herpetic syphilitic eruptions, 444.
 Hydrocele, complicating Epididymitis, 94.
 Hypospadias, cases of, 129, 227. 
INDEX.
551
                   i.
Impotence, 258.
Incompatibility of morbid actions, 34.
Incubation of syphilis, 69.
Induration of the base of a chancre, 283,303.
              Babington's remarks on, 288.
              Ricord's remarks on, 295.
              microscopical characters of,
                297.
              power of contagion of, 46.
              prognostic value of, 305,318.
Indurated  chancre, 302.
                   treatment of, 326.
Infantile syphilis, 451.
Infants, prophylaxis applied to, 518.
Infiltration of urine, 218.
Inflammation, 38.
              in neighborhood of urethra,
                215.
Inflammatory chancre, 298.
                       treatment of,  331.
Injections  in gonorrhoea, 126.
                        formula for, 126.
                        objections to, met,
                          127, 172.
Inoculation, experimental, 55,405,432,452.
                        results of, 55.
Iodide of potassium, 498, 503.
Iodized oil, 390.
Iritis, syphilitic, 428.
                treatment of, 505.
                   L.
Lagneau's treatment of gonorrhoea, 137.
Lallemand's porte-caustiques, 191.
Lepra, 426, 444.
Lichen, 425, 443.
Liver, syphilitic affections of, 463.
Lues venerea, 893.
            divisible into two periods, 411.
            general observations on  the
              treatment of, 465.
Lungs, syphilitic affections of, 462.
Lymphatics, inflammation of, 99.

                   M.
Malapert's and Reynaud's treatment of bu-
  boes, 388.
Mercury, action of, 476, 496.
         ill effects of, 499.
         influence of, in producing abor-
          tion, 502.
         internal  administration  of,  467,
          478.
         local application of, to chancres,
          324.
         necessary quantity of, to be given,
          343, 497.
         presence of, in the secretions, 472.
         rules for use of, 496.
         salivation from, 499.
Mercurial cachexia, 502.
          frictions, 479, 496.
          treatment, duration of, 343,f497. I
                    when required, 343. |
 Mercurial tremor, 502.
 Meshes, 156.
 Metastatic ophthalmia, 273.
 Mortification, 39.
 Mouth, treatment of syphilitic affections
   of, 505.
 Mucous membranes, syphilitic affections
           of, 447.
         papules and tubercles, 441.
 Muscles, syphilitic tubercles in, 459.

                   N.
 Nails, syphilitic affections of, 440.
                            treatment of,
                              506.
 Neuralgic pains in the urethra, 149.
 Nitrate of silver injections, 126.
 Nurses, communication of syphilis by, 62,
   530.

                   O.
 Onychia, syphilitic, 440.
 Ophthalmia, gonorrhoeal, 268.
 Opiated cerate, 325.
 Orchitis, 455.
 Osteocopic pains, 459.
                  treatment of, 506.
 Ostitis, syphilitic, treatment of, 507.
 Ovary, affection of, in gonorrhoea, 106.

                   P.
 Papular syphilitic eruptions, 441.
 Paraphimosis, 308, 313.
               treatment of, 338.
 Pemphigus neonatorum, 451.
 Periostitis, syphilitic, 459.
           treatment of 506.
 Phagedenic chancre, 297
                     Babington's  remarks
                       on, 349.
                     effects of mercury on,
                       352.
                     treatment of, 327.
 Phimosis, 308, 311.
           treatment of, 331, 336.
 Powers, comparative, of different  parts of
   the body, 36.
 Primary syphilitic symptoms,  295.
 Prophylaxis of syphilis, 514.
 Prostate gland, affections of, 233.
                            treatment of,
                              238.
                anomalies of, 237.
 Prostitutes, prophylaxis with regard to, 516.
 Psoriasis, 426, 443.
 Pustular syphilitic eruptions, 445.

                   R.
 Rectum, treatment of chancres in, 326.
 Relapses in gonorrhoea, 74.
 Rheumatism, gonorrhoeal, 275.
 Ricord's porte-caustique and urethrotome, 191.
 Rousselot's arsenical powder, 329.
 Rubeola, 440.
| Rupia, 426, 446. 
552                                INDEX.
 Salivation, mercurial, 499.
                      treatment of, 501.
            from the use of iodide of potas^
              sium, 503.
 Sarcocele, tubercular, 159.
 Scarification of strictures, 192.
 Secondary symptoms, 418, 437.
                     definition of, 396,411.
                     nature of, 396, 399.
                     period  of  develop-
                       ment, 396.
                     pus  from, not inocu-
                       lable, 400.
                     treatment of, 465.
 Seminal emissions, 256.
 Serpiginous chancre, 297.
                     treatment of, 327.
 Seutin's forceps, 340.
 Skin, secondary affections of, 421,438.
                         characters   of,
                            439.
                         division of, 438.
                         local treatment
                            of, 504.
 Spermatic passages, lesions  of, 238.
 Spermatorrhoea, 256.
 Squamous syphilitic eruptions, 443.
                            local  treat-
                            ment of, 504.
 Strictures, 161.
           causes of, 162,  170.
           exploration of,  166.
           from external causes, 164.
           in women,  194.
           number of, 168.
           organic, 163.
           seat of, 168.
           spasmodic, 162.
                     distinguishing cha-
                      racteristics of, 230.
                     treatment of, 178.
          symptoms of, 165.
          treatment of, 173, 177.
                     bougies, 197.
                     cauterization,  182,
                       188.
                     dilatation, 174,178.
                     forced  injections,
                       193.
                     puncture, 192.
                     resolvents, 178.
                     ruptures, 193.
                     scarifications, 192.
Successive symptoms, 439.
Superficial chancres, 303,  326.
Syme's operation, 194,  211.
Sympathy, 33.
Syphilis, three periods of, 396.
         historical  notice of, 521.
Tartrate of iron and potash, 324.
Teeth, transplanted, 536.
Tertiary symptoms, 434, 453.
                  definition of, 396.
                  constitutional treatment
                    of, 503.
                  local treatment of, 506.
Testicles, affection of, in gonorrhcea, 90.
          syphilitic  affection of, 455.
          atrophy of, 265.
Throat, syphilitic  affections of, 427.
                            treatment of,
                               505.
Thymus gland, syphilitic affection of, 462.
Tubercular syphilitic eruptions, 424,446.
                            local  treat-
                            ment of, 507.
Tunica albuginea, incisions of, 144.
 Ulcus elevatum, 298.
 Urethra, strictures of, 161.
         enlargement of, 209.
 Urethral chancre, 56.
 Urethrotomy, 193.
 Urinary abscess, 218.
 Urine, suppression of, 246.
       infiltration of, 218.

                   V.
 Vaginitis, 105.
 Vegetations, 355.
          microscopical characters of, 357.
          treatment of, 358.
          in the urethra, 163, 232.
 Vesiculae seminales, lesions of, 239.
 Vesicular syphilitic eruptions, 444.
 Vienna paste, formula for, 321.
 Vidal's incisions of the tunica albuginea,
  144.
 Virus, syphilitic, 41, 520.
      absorption of, 395.
      can be propagated only by matter,
        43, 46.
      identity of in gonorrhcea and chancre,
        Hunter's belief in, 48.
        Babington's remarks on, 51.
        Ricord's remarks on, 54.
      is no respecter of persons, 395.
      nature of, 42.
      origin of, 41.
      retains its contagious property after
        a length of time, 292.
      unity or plurality of, 308.
Vital organs, susceptibility of, 37.
Warts, 355.
W.
THE END. 
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      HABERSHON ON DISEASES  OF THE ALIMENTARY CANAL
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                                 Addre«      BLAN HARD & LEA, Philadelphia. 
AND SCIENTIFIC PUBLICATIONS.                   3
                             ALLEN  (J.  M.),  M. D.,
                  Professor of Anatomy in the Pennsylvania Medical College, Ac.

THE  PRACTICAL  ANATOMIST;  or, The  Student's  Guide hi the Dissecting.
  ROOM.  With 266 illustrations.  In one handsome royal 12mo. volume, of over 600 pages, lea-
  ther.  $2 25.
  In the arrangement of this work, the author has endeavored to present a complete and thorough
course of dissections in a clearer and more available form for practical use, than  has as yet been
accomplished.  The chapters follow each other in the order in which dissections  are usually con-
ducted in this country, and as each region is taken up, every detail  regarding it is fully described
and illustrated, so that the student is not interrupted in his labors, by the necessity of referring from
one portion of the volume to another.
  However valuable  may be  the  " Dissector's
Guides" which we, of late, have had occasion to
notice, we feel confident that the work of Dr. Allen
is superior to any of them.  We believe with the
author, that none is so fully illustrated as this, and
the arrangement of the work is such as to facilitate
the labors of the student in acquiring a thorough
practical knowledge of Anatomy.  We most cordi-
ally recommend it to their attention.—Western Lan-
cet,Dee. 1856.
  We believe it to be one  of the most useful works
upon the subject ever written.  It is handsomely
illustrated, well printed, and will be found of con-
venient size for use in the dissecting-room.—Med.
Examiner, Dec. 1856.
    From Prof. J. S. Davis, University of Va.

  I am not acquainted with any work that attains so
fully the object which it proposes.

From  C. P. Fanner, M. D., Demonstrator, Uni-
             versity of Michigan.

  I  have examined the work briefly, but even this
examination has convinced me that it is an excelltnt
guide for the Dissector.  Its illustrations are beau-
tiful, and more than I have seen in a work  of this
kind.  I shall take great pleasure in recommending
it to my classes as the text-book of the dissecting-
room.
                         ANALYTICAL  COMPENDIUM
OF  MEDICAL  SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery,
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  1000 pages, with 374 illustrations. *3 00.  EF" See Neill, p. 24.


                ABEL (F. A.), F.C.S.  AND  C.  L. BLOXAM.

HANDBOOK OF   CHEMISTRY, Theoretical,  Practical, and Technical j  with  a
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                          ASHWELL  (SAMUEL),  M.D.,
                   Obstetric Physician and Lecturer to Guy's Hospital, London.

A PRACTICAL TREATISE ON  THE DISEASES  PECULIAR TO WOMEN.
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  and revised Loudon edition.  In one octavo volume,  extra cloth, of 528 pages.  $3 00.
                                               The  most able, and certainly the most standard
                                             ami practical, work on female diseases that we have
                                             yet seen.—Medico-Chirurgical Review.
  The most useful practical work on the subject in
the  English language. — Boston Med. and Surg.
Journal.
                            ARNOTT (NEILL), M. D.
ELEMENTS   OF  PHYSICS;  or  Natural Philosophy,  General and  Medical.
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  M. D.  Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra-
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                        BUDD (GEORGE), M. D., F. R. S.,
                      Professor of Medicine in King's College, London.

ON  DISEASES OF  THE  LIVER.    Third American, from  the  third  and
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  Has fairlv established for itself a place among the  is not perceptibly changed, the history of hver dis
classical  medical literature of England .-British  eases is made more compete, and is ke»t upon a leve
and Foreign Medico-Chir. Review, July, 1857.
  Dr. Budd'g Treatise on Diseases of the  Liver is
now a standard work in Medical literature, and dur-
in* the intervals which have elapsed between the
eases is made more complete, and is kept upon a level
with the progress of modern science.  It is the best
work on Diseases of the Liver in any language.—
London Med. Times and Gazette, June 27, 1857.
  This work, now the standard book of reference on
successive editions th«^author ™£™{£™  cha.  reviBed, and many new illustrations of the views of
the text the most striking nomtiesw^nicnna^^^^^^  the learned author added in the present eUition.-

LnaTa^^^
                                  BY THE SAME AUTHOR.

ON  THE  ORGANIC  DISEASES  AND  FUNCTIONAL  DISORDERS  OF
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' ^heV.^L^ut^^^Y^^  the character of a thoujhtful and experienced  phy-
^SS^T^S^^^H^ ."nan easy I sician._*.o»«/o« Med. times and Gazette. 
A
BLANCHARD & LEA'S MEDICAL
                          BUCKNILL  (J. C),  M.  D.,
              Medical Superintendent of the Devon County Lunatic Asylum; and
                          DANIEL  H.  TUKE,  M.  D.,
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A MANUAL OF PSYCHOLOGICAL  MEDICINE;  containing the  History,
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modern in its views and explicit in its teaching to suffice for the demands of the practitioner."
               BENNETT (J.  HUGHES), M. D.,  F. R. 8. E.,
              Professor of Clinical Medicine in the University of Edinburgh, tee.

THE PATHOLOGY AND  TREATMENT OF  PULMONARY  TUBERCU-
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                         BENNETT  (HENRY), M. D.
A PRACTICAL  TREATISE  ON INFLAMMATION OF THE UTERUS,
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  much enlarged edition, preparing by the author for publication in 1859.
  We are firmly of opinion that in proportion as a
knowledge of uterine diseases becomes more appre-
ciated, this work will be proportionably established
as a text-book in the profession.—The Lancet.
 When, a few years back, the first edition of the
present work was published, the subject was one al-
most entirely unknown to the obstetrical celebrities
of the day : and even now we have reason to know
that the bulk of the profession are not fully alive to
the importance and frequency of the disease of wbich
it takes cognizance.  The present edition is so much
enlarged, altered, and improved, that it can scarcely
be considered the same work.—Dr. Ranlcing's Ab-
stract.
BY THE SAME AUTHOR.
A REVIEW  OF THE  PRESENT  STATE OF UTERINE  PATHOLOGY.
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                    BIRD (GOLDING), A. M.f M. D., Ac.

URINARY   DEPOSITS:   THEIR   DIAGNOSIS,  PATHOLOGY,  AND
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                                         extension and satisfactory employment of our thera-
                                         peutic resources. In the preparation of this new
                                         edition of his work, it is obvious that Dr. Oolding
                                         Bird has spared no pains to render it a faithful repre-
                                         sentation of the present state of scientific knowledge
                                         on the subject it embraces.— The British and Foreign
                                         Medico-Chirurgical Review.
  It can scarcely be necessary for us to say anything
of the merits of this well-known Treatise, which so
admirably brings into practical application the re-
sults of those microscopical and chemical researches
regarding the physiology and pathology of the uri-
nary secretion, which have contributed so much to
the increase of our diagnostic powers, and to the
                         BOWMAN (JOHN E.), M.D.
PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY   Second  Ame
  rican, from the third and revised English Edition.  In one neat vnlnm.     no J3econa  Amf
  with numerous illustrations, pp. 288.  $1 25                   *' r°yal 12m°-'eXtra cIoth'

                                BY THE SAME AUTHOR.

INTRODUCTION  TO  PRACTICAL   CHEMISTRY   INCLTTDTNP   ANA
  LYSIS.  Second American, from the second and revised Londnn^i,     ™  u    **     ,,
  trations.  In one neat vol, royal 12mo., extra cloth  pp 35fJ  £i 25 °a-  Wlth numerous lllu8"
BEALE ON THE LAWS OF HEALTH IN RE-
  LATION TO MIND AND BODY.  A Series of
  Letters from an old Practitioner to a Patient.  In
  one volume, royal 12mo., extra cloth,  pp. 296
  80 cents.

BUSHNAN'S PHYSIOLOGY OF ANIMAL AND
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  Functions and Phenomena of Organic Lite.  In
  one handsome royal 12mo. volume, extra cloth
  with over 100 illustrations,  pp.234.  80 cents
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  onefl™^RHEUMATIC  PNEUMONIA.   In
  one 8vo. volume, extra cloth,  pp. 150. »1 25.

Bj8Sn ^Vt URINE (MANUALS ON).  BY
  RFP^P  1lLnI^InGRIFF1TH-  G.  OWEN
  thfck ^.AND  AL?RED MARKWICK.  One

  Plateks.VOp1pUT6'0.r°ff25lamO-' e*tra clwth> with

BR?RIv'S, CIfINICAL LECTURES ON  SUR-
  UfcKY.  1 vol. 8vo.  cloth.  350 pp.  8125. 
AND  SCIENTIFIC PUBLICATIONS.                    5
                              BARCLAY (A. W.)   M. D.,
                        Assistant Physician to St. George's Hospital, Ac.

A MANUAL OF  MEDICAL  DIAGNOSIS; being  an  Analysis  of the  Signs
  and Symptoms of Disease.  In one neat octavo volume, extra cloth, of 424 pages.  $2 00.  (A new
  work, now ready.)
  Of works exclusively devoted to this important
branch, our profession has at command, compara-
tively, but few, and< therefore, in the publication of
the present work, Messrs. Blanchard &  Lea have
conferred a great favor upon us.  Dr. Barclay, from
having occupied, for a long period, the position of
Medical Registrar at St.  George's Hospital, pos-
sessed advantages for correct observation and reli-
able conclusions, as to the significance of symptoms,
which have fallen to the  lot  of but few, either in
his own  or any  other country.  He has  carefully
systematized  the results of his observation of over
twelve thousand patients, and by his diligence and
judicious  classification, the  profession  has been
presented with the  most  convenient  and reliable
work on the subject of Diagnosis that it has been
our good fortune ever to  examine; we can, there-
fore, say of L)r. Barclay's work, that, from his sys-
tematic manner of arrangement, his work is one of
tne best works " for reference" in the daily emer-
gencies of the practitioner, with which we are ac-
quainted ; but, at the same time, we would recom-
mend our readers, especially  the younger ones, to
read thoroughly and study diligently the whole work,
and the " emergencies" will not occur so often.—
Southern Med. and Surg. Journ., March, 1858.
   To give this information, to supply this admitted
deficiency, is the object of Dr. Barclay's Manual.
The task of composing such a work is neither an
easy nor a light one; but Dr. Barclay has performed
it in a manner which meets our most unqualified
approbation.  He is no mere theorist; he knows his
work  thoroughly, and in attempting to perform it,
has not exceeded his powers.—British Med. Journal,
Dec. 5, 1857.
  We venture to predict that the work will be de-
servedly  popular, and soon become, like Watson's
Practice, an indispensable necessity to the practi-
tioner.—N. A. Med. Journal, April, 1858.
  An inestimable work of reference for the young
practitioner and student.—Nashville Med. Journal,
May,  1858.
  We hope the volume will have an extensive cir-
culation, not among students of medicine only, but
practitioners also.  They will never regret a faith-
ful study of its pages.—Cincinnati Lancet, Mar. '58.
  This Manual  of Medical Diagnosis is one of the
most  scientific,  useful, and instructive works of its
kind  that we  have ever  read, and Dr. Barclay has
done good service to medical science in collecting,
arranging, and  analyzing the signs and symptoms
of so many diseases. — N. J. Med. and Surg. Re-
porter, March, 1858.
                          BARLOW  (GEORGE H.), M. D.
                           Physician to Guy's Hospital, London, &c.
A MANUAL OF THE  PRACTICE OF MEDICINE.   With Additions by D.
  F. Condie, M. D., author of " A Practical Treatise on Diseases of Children," &c.  In one hand-
  some octavo volume, leather, of over 600 pages.  $2 75.
  We recommendDr. Barlow'sManual in the warm-
est manner as a most valuable vade-mecum.  We
have had frequent  occasion to consult it, and have
found it clear, concise, practical, and sound.  It is
eminently  a practical work, containing all that is
essential, and avoiding useless theoretical discus-
sion.  The work supplies what has been for some
time wanting, a manual of practice based upon mo-
dern discoveries in pathology and rational views of
treatment  of disease.  It is especially intended for
the UBe of students and junior practitioners, but it
will be found hardly less useful to the experienced
physician.  The American editor has added to the
work three chapters—on Cholera Infantum, Yellow
Fever, and Cerebro-spinal Meningitis. These addi-
tions, the two first of which are indispensable to a
work on practice destined for the profession  in this
country, are executed with great judgment  and  fi-
delity, by Dr. Condie, who has also succeeded  hap-
pily in imitating the conciseness  and clearness of
style which are such agreeable characteristics of
the original book.—Boston Med. and Surg. Journal.
                            BARTLETT (ELISHA), M. D.
THE  HISTORY,  DIAGNOSIS,  AND TREATMENT OF  THE FEVERS
  OF THE UNITED STATES.  A new and revised edition.  By Alonzo Clark, M. D., Prof.
  of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c.  In
  one octavo volume, of six hundred pages, extra cloth.  Price $3  00.
  It is the best work on fevers which has emanated
from the American press; and the present editor has
carefully availed himself of all information exist-
ing upon the subject in the Old und New World, so
that the doctrines advanced are brought down to the
latest date  in  the progress of this department of
Medical Science.—London Med. Times and Gazette,
May 2, 1857.
  This excellent monograph on febrile disease, has
stood deservedly high since its first publication.  It
will be seen that it has now reached its fourth edi-
tion under the supervision of Prof. A. Clark, a gen-
tleman who, from the nature of his studies and pur-
suits, is well calculated to appreciate and discuss
the many intricate and difficult questions in patho-
logy.  His annotations add much to the interest of
the work, and have brought it well up to the condi-
tion of the science as  it exists at the present day
in regard to this class of diseases.—Southern Med.
and Surg. Journal, Mar. 1857.
  It is a work of great practical value and interest,
containing much that is new relative to the several
diseases of which it treats, and, with the  additions
of the editor, is fully up to the times.  The distinct-
ive features of the different forms of fever are plainly
and forcibly portrayed, and the lines of demarcation
carefully and accurately drawn, and to the Ameri-
can practitioner is a  more valuable and safe guide
than any work  on fever extant.—Ohio Med. and
Surg Journal, May, 1857.
                             BROWN  (ISAAC  BAKER),
                         Surgeon-Accoucheur to St. Mary's Hospital, &c.

ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT
  MENT.   With handsome illustrations.   One vol. 8vo., extra cloth, pp. 276
  Mr. Brown has earned for himself a high/eputa-
$1 60.
tion in the operative treatment of sundry diseases
and injuries to which females are peculiarly subject.
We can truly say of his work that it is an important
addition to obstetrical literature  The operative
suggestions and contrivances which Mr. Brown de-
scrioeB, exhibit much practical  sagacity  and skill,
and merit the careful attention  of every surgeon-
accoucheur.—Association Journal.

  We have no hesitation in recommending this book
to the careful attention of all surgeons  who make
female complaints a part of their study and practice.
—Dublin Quarterly Journal. 
6
BLANCHARD & LEA'S  MEDICAL
             CARPENTER (WILLIAM B.), M. D., F.  R. S.,  &.C.,
           Examiner in Physiology and Comparative Anatomy in the University of London.

PRINCIPLES OF HUMAN  PHYSIOLOGY; with  their chief applications to
  Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine.  A new American, from
  the la*t and revised London edition.  With nearly three hundred illustrations.  Edited, with addi-
  tions, by Francis Gtjrney Smith, M. D., Professor of the Institutes ot Medicine in the Pennsyl-
  vania Medical College, &c. In one very large and beautiful octavo volume, of about  nine hundred
  large pages, handsomely printed and strongly bound in leather, with raised bands.  $4 25.

  In the preparation of this new edition, the author ha* spared no labor to render it, as heretofore,
a complete and lucid exposition of the most  advanced condition of its important subject.  The
amount of the additions required to effect this object thoroughly, joined to the former  large size of
the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all
those portions not bearing directly upon  Human Physiology, designing  to  incorporate  them in
his forthcoming Treatise on General Physiology.  As a full and accurate text-book on the Phy-
siology of Man, the  work in its present  condition therefore  presents even  greater  claims upon
the student and physician than those which have heretofore  won  for it the very wide and distin-
guished favor which it has so long enjoyed.  The additions of Prof. Smith will be found to supply
whatever may have been wanting to the American student, while the introduction of many new
illustrations, and the most careful mechanical execution, render the volume one of the most at-
tractive as yet issued.

  For upwards of thirteen  years  Dr. Carpenter's I   To eulogize this great work would be superfluous
work has been considered by the profession gene- | We should observe, however, that in this edition
rally, both in this country and England, as the most j the  author has remodelled a large portion of the
valuable compendium on the subject of physiology | former, and the editor has added much  matter of in-
in our language. This distinction it owes to the high
attainments and unwearied industry of its accom-
plished author.  The present edition (which, like the
last American one, was prepared by the author him-
self), is the result of such extensive revision, that it
may almost be considered a new work.  We need
hardly say, in concluding this brief notice, that while
the work is indispensable to every student of medi-
cine in this country, it will amply repay the practi-
tioner for its perusal by the interest and value of its
contents.—Boston Med. and Surg. Journal.

  This is a standard work—the text-book used by all
medical students who read the English language.
It has passed  through several editions in  order to
keep pace with the rapidly growing science of Phy-
siology. Nothing need be said in its praise, for its
merits are universally known; we have  nothing to
say of its defects, for they only appear where the
science of which it  treats is incomplete.—Western
Lancet.
  The most complete exposition of physiology which
any language can at present give.—Brit, and For.
Med.-Chirurg. Review.
terest, especially in the form of illustrations. We
may confidently recommend it as the most complete
work on Human Physiology in our language.—
Southern Med. and Surg. Journal, December, 1855.
  The most  complete work on the science in our
language.—Am. Med. Journal.
  The most complete work now extant in our lan-
guage.—JV. O. Med. Register.
  The best text-book in the  language on this ex-
tensive subject.—London Med. Times.
  A complete cyclopaedia of this branch of science.
—N. Y.  Med. Times.
                                                The profession of this country, and perhaps also
                                               of Europe, have anxiously and for some time awaited
                                               the announcement of this new edition of Carpenter's
                                               Human Physiology.  His former editions have for
                                               many years been almost  the only text-book on Phy-
                                               siology in all our medical schools, and its circula-
                                               tion among the profession has been unsurpassed by
                                               any work in any department of medical science.
                                                It is  quite  unnecessary for us to  speak of this
                                               work as its merits would justify.  The mere an-
                                             ,  nounceinent of its appearance will afford the highest
  The greatest, the most reliable, and the best book j  pleasure to every student of  Physiolojrv  while its
on the subject which we know of in  the English  perusal will  be of  infinite  service  in  advancin*
language.-S»e«Ao«op«.                         |  physiological science.-OAio Med. and Surg. Jour*.


                          by the same author.  (Lately Issued.)

PRINCIPLES OF  COMPARATIVE  PHYSIOLOGY.   New American, from
  the Fourth and Revised London edition.  In one large  and handsome octavo volume, with  over
  three hundred beautiful illustrations,  pp.752.  Extra cloth,  $4 80; leather, raised bands, $5 25.

  The delay which has existed in the appearance of this work has been caused  by the very thorough
revision and remodelling which it has undergone at the hands of the author, an* the large number
of new illustrations which have been prepared for it.   It will, therefore, be found almos a  new
work,  and fu ly up to the day in  every department of the subject, rendering it a reliable t«*bS)k
for all students engaged in this branch of science.   Every effort has been made to render St^o-

mescal S c^TSS^ ^^ WOrth" °f **  eXahed r^™> «* cre^tabJeVoTe
  This book should not only be read but thoroughly
 studied by every member of the profession.  None
 are too wise or old, to be benefited thereby.  But
 especially to the younger class would we cordially
 commend it as best fitted of any work in the Englisn
 language to qualify them for the reception and com-
 prehension of those truths which are daily being de-
 veloped in physiology.—Medical Counsellor.
  Without pretending to it, it is an encyclopedia of
 the subject, accurate and complete in all respects—
 a truthful reflection of the advanced state at which
 the science has now arrived.—Dublin Quarterly
 Journal of Medical Science.

  A truly magnificent work—in itself a perfect phy-
siological study.—Ranking's Abstract.
  This work stands without its fellow.  It is one
few men in Europe could have undertaken; it is one j
no man, we believe, could have brought to so suc-
cessful an issue as Dr. Carpenter,  ft required foT
its production a physiologist at once deeply read in
the labors of others,  capable of taking  a general,
critical, and unprejudiced view of those labors, and
of combining the varied, heterogeneous materials at
his disposal, so as to form an harmonious whole.
We feel that this abstract can give the reader a very
imperfect idea of the fulness of  this work, and no
idea of its unity, of the admirable manner in which
material has been brought, from the most various
sources, to conduce to its completeness, of the lucid-
ity of the reasoning it contains, or of the clearness
of language in which the whole is clothed.  Not the
profession only, but the scientific world at large,
must feel deeply indebted to Dr. Carpenter for tnis
great work.  It  must, indeed, add largely even to
his high reputation.—Medical Times. 
AND  SCIENTIFIC  PUBLICATIONS.                   1
                CARPENTER (WILLIAM B.),  M. D., F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

THE  MICROSCOPE AND ITS  REVELATIONS.   With an  Appendix  con-
  taining the Applications of the Microscope to Clinical Medicine, &c.   By F. G. Smith, M. D.
  Illustrated by four hundred and thirty-four beautiful engravings on wood.  In one large and very
  handsome octavo volume, of 724 pages, extra cloth, $4 00; leather, $4  50.

  Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher
 eminently qualify him to produce what has long been wanted—a good text-book on the  practical
 use of the microscope.  In the present volume his object has been, as stated in his Preface, " to
 combine, within  a moderate compass, that information with regard to the use of his 'tools,' which
 is most essential to the working microscopist, with such an account of the objects best fitted for
 his study, as might qualify him to comprehend what he observes, and might thus prepare him to
 benefit science, whilst expanding and refreshing his own mind "  That he  has succeeded in accom-
 plishing this, no one acquainted with his previous labors can doubt.
   The great importance of the microscope as a means of diagnosis, and the number of  microsco-
 nists wno are also physicians, have induced the American publishers, with the author's approval, to
 add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to
 clinical medicine, together with an account of American Microscopes, their modifications  and
 accessories   This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is
 honed, will adapt the volume  more particularly to the use of the American student.
   Every care lias been taken  in the mechanical execution of the work, which is confidently pre-
 sented as in no  respect  inferior to the choicest productions ol the London press.
   The mode in  which the author has executed his intentions may be gathered from the following
 condensed synopsis of the
                                       CONTENTS.

  INTRODUCTION-History of the  Microscope.   Chap. I. Optical Principles of the Microscope.
    Chap U  Construction of the Microscope.  Chap.  Ill  Accessory Apparatus.  Chap.  iv.
    M^nLemenYof the Microscope  Chap. V.  Preparation, Mounting, and Collection of Objects.
    Chap^ VI  Microscopic Formfof Vegetable Life-Protophytes.  Chap. VII. Higher Cryptoga-
    m?a   Chap  VIII. Phanerogamic Plants.  Chap. IX. Microscopic Forms of Ammal  Life-Pro-
    ^xoa-Animalcules.   Chap*X. Foraminifera, Polycystina and Sponges   Chap. XL Zoophytes.
    loaoa Aiuuiui^m^n           c     XIII  p0ivzoa and Compound Tumcala.  Chap. XIV.





    Those who are acquainted with Dr. Carpenter's
  previous writings on Animal and Vegetable Physio-
 FreviouB wiuiukb *«* «».».-..-- ——  -o      _. -
 o*v will fully understand how vast a store of know-
ledge he is able to bring to bear upon so comprehen-
sive a subject as the revelations of the microscope;
and even those who have no previous acquaintance
with the construction or uses of this ins rument,
will find abundance of information conveyed in clear
Tnd simple  language.-Med.  Times and Gazette.
  Although  originally not  intended  as  a  strictly

                                 BY THE SAME AUTHOR
medical work, the additions by Prof. Smith give it
a positive claim upon the profession, for which we
doubt not he will receive their sincere thanks.  In-
deed we know not where the student of medicine
will find such a complete and satisfactory collection
of microscopic facts bearing upon physiology and
practical medicine as is contained in Prof. Smith's
appendix; and this of itself, it seems to us, is fully
worth the cost of the volume.—Louisville Medical
Review, Nov. 1856.
ELEMENTS  (OB^MANUAL;.OF™=2=G  HY^
  To sav that it is the best manual of Physiology
now before the public, would notdo sufficient justice
?o tne author .-Buffalo Medical Journal.
  In his former works it would seem that he had
e Aausted thTsubject of Physiology  I n 'hepresent,
Kves theessence, as it were, ofthe whole.-N. Y.
be gives —
Journal of Medicine
  Those who have occasion for an elementary trea-
tise on Physiology, cannot do better than to possess
themselves ofthe manual of Dr. Carpenter.—Medica I
Examiner.
  The best and most complete expose of modern
Physiology, in one volume, extant in the English
language.—St. Louis Medical Journal.
                           BY THE same author.  (Preparing.)

      ™™t^o nw  n?NTFRAL  PHYSIOLOGY,  INCLUDING  ORGANIC
PRINCIPLES OF  ^ENERAL  ^iwuw  ^ ^ ^
  CHEMISTRY AND HISTOLOGY.^  w ua^a           wJth ^^ hundred lllustratlons.
  Kingdom.  In one large and very handsome ociav         ,                         u ^^

  The subject of general f^^Si^TSl^ ^i^ * prepare a volume which
«pres^Tmo?rthaolgSyUrd fuliy* thaSs yet been attempted, and which may be regarded
Sanrntroduction to his other works.
                                 BY THE SAME ATITHOR.

A PRIZE ESSAY ON THE USEI OF ALCOHOLIC|I^J»™|«™ 
8                     BLANCHARD & LEA'S MEDICAL
                           CONDIE (D.  F.),  M. D., &c.

A  PRACTICAL TREATISE ON THE DISEASES OF CHILDREN.   Fifth
  edition, revised and augmented.  In one large volume, 8vo., leather, of over 750 pages. $3 25.
  [Now Ready, December, 1858.)
  In presenting a new and revised edition of this favorite work, the publishers have only to state
that the author has endeavored to render it in every respect "a complete and faithful exposition of
the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full
and exact account ofthe diseases of infancy and childhood."   To accomplish this he has subjected
fhe whole work to a careful and thorough revision, rewriting a considerable portion, and  adding
several new chapters. In this manner it is hoped that any deficiencies which may have previously
existed have been supplied, that the recent labors  of practitioners and  observers have been tho-
roughly incorporated, and that  in every point the work will be found to maintain the high reputation
it has enjoyed as a complete and thoroughly practical book of reierence in infantile affections.
  A few notices of previous editions are subjoined.
                                             We pronounced the first edition to be the best
                                           work on the diseases of children in the English
                                           language, and, notwithstanding all  that has been
                                           published, we still regard it in that light.—Medical
  Dr. Condie's scholarship, acumen, industry, and
 practical sense are manifested in this, as in all his
 numerous contributions to science.—Dr. Holmes's
 Report to the American Medical Association.
  Taken as a whole, in our judgment. Dr. Condie's
 Treatise  is the one from the perusal of which the
 practitioner in this country will rise with the great-
 est satisfaction—Western Journal of Medicine and
 Surgery.

  One of the best works upon the Diseases of Chil-
 dren in the English  language.—Western Lancet.
  We feel assured from actual experience that nc
 physician's library can be complete without a copy
 of this work.—N. Y. Journal of Medicine.
  A veritable pediatric encyclopaedia, and an honor
 to American medical literature.—Ohio Medical and
Surgical Journal.
  We feel persuaded that the American medical pro-
fession will soon regard it not only as a very good.
 Examiner.
  The value of works by native authors on the dis-
 eases which the physician is called upon to combat,
 will be appreciated by all; and the work of Dr. Con-
 die has gained for itself the character of a safe guide
 for students, and a useful work for consultation by
 those engaged in practice.—N. Y. Med. Times.
  This is the fourth edition of this deservedly popu-
 lar treatise. During the interval since the last edi-
 tion, it has been subjected to a thorough  revision
 by  the author; and all new observations in the
 pathology and therapeutics of children have been
 included in the present volume.  As we said before,
 we do not know of a better book on diseases of chil-
 dren, and to a large part of its recommendations we
yield an unhesitating concurrence.—Buffalo Med.
     ----------„—- .. Uv„ umj u a very eouu,  yieiu an
but as the toy hn "Practical Treatise on the \ Journal
Diseases of Children."—American Medical Journal    p„,i.„„„ «,     ±e ,,  *
  i. tu rf.™,(m..t „/ • r  .-,  .   " >"«^rnu.t. i  Perhaps the mostfull and complete work now be-
work of D? fi ?/ J2?^,le Hth«aPe«««. the  '»« the profession ofthe United Itatei^ indeed! we
Whi„i. h,  k  Condie.1? considered one of the best  may say in the English language  It is vastlvsun*

-TKSutkoToF!'11** m ^ E"gli8h IangUa*e- ;J^»-tof it-p?edece^r.*!i^iaiSJ£
             CHRISTISON  (ROBERT), M. D., V. P. R. S.  E.  8tc

 A»r?t?SS^?,?RY; 0T>. Commentary  on the PharrnacopieiaL'of Great Britain







                        COOPER  (BRANSBY B )   F  B  S

 LECTURES ON  THE  PRINCIPLES  AND'PRACTICE  OF SURGERY
  In one very large octavo volume, extra cloth, of 750 pages.   $3  00               UlUxMir.

 COOPER  ON DISLOCATIONS  AND FRAC-
  TURES OF THE JOINTS.-Edited by BranIby
  B. Cooper, F. R. S., &c.  With additional Ob-
  servations by Prof. J. C. Warren.  A new Ame-
  rican edition.  In one handsome octavo volume
  extra cloth, of about 500 pages, with numerous
  illustrations on wood. $3 25.

° OFPTHp0BIr?P?IVAN^0MY A?D LEASES
  OF THE BREAST, with twenty-five Miscellane-
  ous and Surgical Papers.  One large volume, im-

  ptaS. ta'fiof        ' with 252 fi&ure,»on 3«
COOPER ON  THE STRUCTURE AND Tim
  EASES OF  THE  TESTIS, AND  ON  THE
  THYMUS GLAND.  One vol', imperial 8vo,e^
  tra cloth, with 177 figures on 29 plates. $2 00.
COPLAND ON THE CAUSES  NATTTRF  amti
  TREATMENT OF PALSY^NdAWpl'ex™

  80 cTnU     C' T°M 1'im°i CXtra c,oth-  PP- ™-


CpI¥H5LOPVEy^S^T,HEIR DIAGNOSIS,
  rATHOLOGY, AND  TREATMENT  In om
  octavo volume, leather, of 600 pages.  *1 50
                           CARSON (JOSEPH)  M  D
           Professor of Materia Medica and Pharmaev in ti,I tt„7   '!   -
SYNOPSIS OF  THE  COURSE OFISS^^SVT^^'
  AND PHARMACY, deliverediulhe University ol£™L,0N M™A  MEDICA
  tion.  In one very neat octavo voluine^e^V«te?^W^ *nd  revised •*

                          CURLING  (T.   B.)   F R S
             Surgeon to the London Hospital President nftkln' . '•
A PRACTICAL TREATISE  ON DISEASF^Off t SS ^ *0'    '
  TIC  CORD, AND KROTUltt  s^^^,?^ ™ TESTIS, SPERMA-
  Uon.   <-nehandsomeoctavovo,„me,e^^^ 
AND  SCIENTIFIC  PUBLICATIONS.                     9
               CHURCHILL  (FLEETWOOD), M.  D., M. R. I.  A.
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.   Edited, with
  Notes and Additions, by D.  Francis Condie, M. D., author of a "Practical Treatise on the
  Diseases  of Children," &c.  With  139  illustrations.  In one very handsome octavo volume,
  leather,   pp.510.   $3 00.
  To bestow praise on a book that has received such
marked approbation would be superfluous. We need
Uiai HCU U(IJIlUU<tttUU WUU1U UC BUJJCI UUUUB. » V C UC^U
only  say, therefore, that if the first edition was
thought worthy  of a  favorable reception  by the
medical public, we can confidently affirm that this
will  be found much more  so.  The lecturer, the
practitioner, and the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction in everything relating to theo-
retical and practical midwifery.—Dublin Quarterly
Journal of Medical Science.

  A work of very great merit, and  such as we can
confidently recommend to the  study of every obste-
tric practitioner.—London Medical Gazette.

  This is certainly the most perfect system extant.
It is the best adapted for the purposes of a text-
book, and that which  he whose necessities confine
him to one book, should select in preference  to all
others.—Southern Medical and Surgical Journal.

   The most popular work on midwifery ever issued
from the American press.—Charleston Med. Journal.

   Were we reduced to the  necessity of having but
 one  work on midwifery, and permitted to choose,
 we  would unhesitatingly take Churchill.—Western
 Med. and Surg. Journal.
   It is  impossible  to conceive a more useful and
 elegant  manual than Dr.  Churchill's  Practice of
 Midwifery.—Provincial Medical Journal.

   Certainly, in our opinion, the very best work on
 the subject which exists.—N. Y. Annalist.
                             BY  THE SAME AUTHOR.  (Just Issued.)
 ON THE  DISEASES OF INFANTS  AND  CHILDREN.   Second  American
   Edition revved and enlarged by the author.  Edited, with Notes, by W. V. Keating, M D  In
   Se laSeand handsome vdume, extra cloth, of over 700 pages.  $3 00, or in leather, $3 25
   t      „,.;„<, thU work a  second time for the  American profession, the author  has spared no
 l«£rOTvta! t ^v^rv thorough region? introducing several new chapters, and rewritmg other,
 labor in giving n a very luuiuuguc      ,    ,.   °.  .    «evere scrutiny.  The efforts ofthe
 while every•por-tionjrf £~»|^^o^^^^0rSSEa" lati^. to  matters peculiar
 American editor have ^n directed to buppiy  g                           whole       there.

 to  this country as might haJeofe^P«J5 ^omXte°works on the subject accessible to  the Ame-
  ^$2STT£^^^?™^ thceveiyextensive  additions have
  Sa^mm^ated without unduly Rasing the^ of the wor^ ^^^^ ^  ^   ^

                                                 material thus derived hasbeen used with consummate
                                                 skill, and the result has been a work creditable alike
                                                 to the author and his country.—N. A. Medtco-Chir.
  No work holds a higher position, or is more de-
serving of being placed in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiner.

  Previous editions, under the editorial supervision
of Prof R.  M. Huston,  have been  received with
marked favor,  and they deserved it; but this, re-
printed from a very late Dublin edition, carefully
revised and brought up by the author to the present
time, does present an unusually accurate and able
exposition of every important particular embraced
in the department of midwifery. * * The clearness,
directness, and precision of its teachings, together
with the great amount of statistical research which
its text exhibits, have served to  place it already in
the foremost rank of works in this department of re-
medial science.—N. O. Med. and Surg. Journal.

   In our opinion, it forms one of the best if not the
very best text-book and epitome of obstetric science
 which we at  present possess in the English lan-
guage.— Monthly Journal of Medical Science.

   The clearness and precision of style in which it is
 written, and the great amount of statistical research
 which it contains, have served to place it in the first
 rankof works in this departmentof medical science.
 —N. Y. Journal of Medicine.
  Few treatises will be found better adapted aa a
text-book for the student, or as a manual  for the
frequent consultation of the  young practitioner.—
American Medical Journal.
  This work contains a vast amount of interesting
matter which is so well ananged and so curtly
worded tlat the book may be regarded as an ency-
elop^iia of information upon the subject, of which
it treats   It is certainly also a monument of Dr.
Churchfll's untiring industry, in-much as there ,.
not a ainslework upon thediseases of children witn
which we areacquainted that is not fully referred
£hand quoted from  in its pages, art1 scarcely a>Con-
tribution of the least  importance to any British  or
Foreign Medical Journal, for some years P^wh"*
is not daly noticed.-London Lancet, Feb. 20,1858.
  A vailine himself of every fresh source of informa-
tio\,D  (Chill endeavored with h.s accustomed
industry and perseverance, to br.ng his work up to
the nresent state of medical knowledge in all the
^hiectsof which it treats; and in this endeavor he
h««J we feel bound to say/been em.nently success-
fnl ' besides he addition of more than one hundred
and tbirfy Pages of matter, we observe that some
ana tnirr.y pigco____^__► „i,„„t,.ranreintroduced,
entirely ntw;
viz : on para



 Journal, Feb. 1858.
Review, May, 1858.
  After this meagre, and we know, very imperfect
notice of Dr. Churchill's work, we shall conclude
bv saying;, that it is one that cannot fail from its co-
piousness'extensive research, and general accuracy,
to exalt still higher the reputation of the author in
this country.  The American reader will be particu-
larly pleased to find that Dr. Churchill has done full
justice throughout his work to the various American
authors on this subject.  The  names of Dewees,
Eberle, Condie,  and Stewart, occur on nearly every
paee, and these authors are constantly referred toby
thl author in terms ofthe highest praise, and with
the most liberal courtesy.—The Medical Examiner.

  We recommend the work  of Dr. Churchill most
cordially, both to students and practitioners, as a
   ,  . . J l _ j>_.i:„ui«.n;<)i. in fli*. ti-Antmpnt of the Q1S-
                                     Sciences.
ages of matter, we observe tnat some    rdially  both to students and practitioners,
 Ind important chapters are introduced,  valuabl^nd;reHableguide in the treatment of th
ilyiis, syphilis, phthisis, sclerema, &c.  eagegof children.—Am.Journ.ofthe Med. Scie:
 work now stands, it is, we believe, the               ^ work Qn thU department of t
  We know of no work on this department of Prac-
tical Medicine which presents so candid and unpre-
judiced a  statement or posting up of our actual
knowledge as this.—N. Y. Journal of Medicine.
  Its claims to merit both as a scientific and practi-
cal work, are of the  highest  order   Whilst we
would not elevate it above every other treatise on
the same subject, wecertainly believe  that very few
are equal to it, and none superior.—Southern Med.
and Surgical Journal.
~~~" ™ nv m™  PTTFRPERAL FEVEKAND OTHER DISEASES  PE- 
BLANCHARD  &  LEA'S  MEDICAL
           CHURCHILL  (FLEETWOOD),  M. D., M.  R.  I. A.,  Sec.

ON THE  DISEASES  OF  WOMEN; including  those of Pregnancy  and Child-
  bed.  A new American edition, revised by the Author.  With Notes and Additions, by D_ Fran-
  cis Condie, M. D., author ot "A Practical Treatise on the Diseases of Children."  With nume-
  rous illustrations.  In one large and handsome octavo volume, leather, of 768 pages. (Just Issued,
  1857.)  $3 00.
  This edition of Dr.  Churchill's very popular treatise  may almost be termed  a new work, so
thoroughly has he revised it in every portion.  It will be found greatly enlarged, and thoroughly
brought up to the most recent condition of the subjeet, while the very handsome series of illustra-
tions introduced, representing such pathological conditions as can be  accurately portrayed, present
a novel feature, and afford valuable  assistance to  the  young practitioner.  Such additions as ap-
peared desirable  for the American  student have  been  made by the editor, Dr. Condie, while a
marked improvement in  the mechanical execution keeps pace with the advance in all other respects
which the volume has  undergone, while the price has been kept at the former very moderate  rate.
                                               extent that Dr. Churchill does.   His, indeed, is the
                                               only thorough  treatise we  know of on the subject;
                                               and it may lie commended  to practitioners and  stu-
  It comprises, unquestionably, one of the most ex-
act and comprehensive expositions of the present
state of medical knowledge in respect to the diseases
of women that has yet been published.—Am. Journ.
Med. Sciences, July, 1857.
  We hail with much pleasure the volume before
us, thoroughly revised, corrected, and brought up
to the latest  date, by Dr. Churchill himself, and
rendered still more valuable by notes, from the ex-
perienced and able pen of Dr. D. F. Condie, of Phil-
adelphia.— Southern Med. and  Surg. Journal, Oct.
1857.
  This work is the most reliable which we possess
on this subject; and is deservedly popular with the
profession.—Charleston Med. Journal, July, 1857.
  Dr. Churchill's treatise on the Diseases of Women
is, perhaps, the most popular of his works with the
profession in  this  country. It has been very gene-
rally received both as a text-book and  manual  of
practice.   The present edition has undergone the
most elaborate revision, and additions of an import-
ant character have been  made, to render it a com-
plete exponent of the present state of our knowledge
of these diseases.—N. Y. Journ. of Med., Sept. 1857.
  We now regretfully take leave of Dr. Churchill's
book.  Had our typographical  limits permitted, we
should gladly have borrowed  more from its richly
stored  pages.  In  conclusion, we heartily recom-
mend it to the profession, and would at the  same
time express our firm conviction that it will not only
add to the reputation of its author, but will prove a
work of great and extensive utility to obstetric
practitioners.—Dublin Medical Press.
  We know of no  uuthor who deserves that appro-
bation, on "the diseases of females," to the  same
dents as a masterpiece in its particular department.
The former editions of this work have been com-
mended strongly in this journal, and they have won
'■heir wav to an extended, and a well-deserved popu-
larity.  This fifth edition, before us, is well calcu-
lated to maintain  Dr.  Churchill's  high reputation.
It was  revised and enlarged by the author, for his
American publishers, and it seems to us that there is
scarcely any species of desirable information on its
subjects that may not  be found in this work.—The
Western Journal of Medicine and Surgery.

  We are  gratified to announce a  new and revised
edition of Dr. Churchill's valuable work on the dis-
eases of females   We have ever regarded it as one
of the  very  best  works on the subjects embraced
within its scope, in the English language;  and the
present edition, enlarged and revised by the author,
renders it still more entitled to the confidence ofthe
profession.  The  valuable notes of Prof. Huston
have been retained, and contribute, in no small de-
gree, to enhance  the  value of the work.   It is a
source of  congratulation  that the publishers  have
permitted  the author  to be,  in this instance, his
own editor, thus  securing all the revision which
an author alone is capable of making.—The Western
Lancet.
  Asa comprehensive manual for students,  or a
work of reference for  practitioners, we only speak
with common justice when we say that it surpasses
any other that has ever issued on the  same sub-
ject from the British press.—The Dublin Quarterly
Journal.
                              DICKSON  (S.  H.)f  M. D.,
           Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia.

ELEMENTS OF  MEDICINE;  a Compendious View of Pathology  and Thera-
  peutics, or the History and Treatment of Diseases.  In one large and handsome octavo volume,
  of 750 pages, leather.  $3 75.
  As an American text-book on the Practice of Medicine for the student, and as a condensed work
of reference for the practitioner, this volume will have strong claims on the attention ofthe profession.
Few physicians have had wider opportunities than the author for observation and  experience, and
few perhaps have used them better.  As the result of a life of study and practice, therefore, the
present volume will doubtless be received with the welcome it deserves
  This book is eminently what it professes to be; a
distinguished merit in these days.  Designed  for
" Teachers and Students of Medicine," and admira-
bly suited to their wants, we th ink it will be recei ved,
on its own merits, with a hearty welcome.—Boston
Med. and Surg. Journal.

  Indited by one of the most accomplished writers
of our country, as well as by one who has long held
a high position among teachers and practitioners of
medicine, this work is entitled to patronage and
careful study.  The learned  author has endeavored
to condense in this volume most of the practical
matter contained in his former productions, so as to
adapt it to the use of those who have not  time to
devote to more extensive works.—Southern Med. and
Surg. Journal.

  Prof. Dickson's work supplies, to a great  extent,
a desideratum long felt in American medicine.—N
O. Med. and Surg. Journal.

  Estimating this work according to the purpose for
which  it is designed, we must think highly of  its
  merits, and we have no hesitation in predicting for
  it a favorable reception by both students and teachers.
   Not professing to be a complete and comprehensive
  treatise, it will not be found full in detail, nor filled
  with discussions of theories and opinions, but  em-
  bracing all that is essential in theory and practice,
  it is admirably adapted to the wants of the American
  student.   Avoiding all that is uncertain, it presents
  more clearly to the mind ofthe reader that which is
  established and verified by experience.  The varied
  and extensive reading of the author is conspicuously
  apparent,  and all the recent improvements and  dis-
  coveries in therapeutics and pathology are chroni-
  cled in its pages—Charleston Med.  Journal.
   In the first part of the work the subject of gene-
  ral pathology is presented in outline, giving a beau-
  tiful  picture of  its distinguishing  features,  and
  throughout the succeeding chapters we find that he
  has kept  scrupulously within  the bounds of sound
  reasoning  and  legitimate  deduction.   Upon  the
  whole, we do not hesitate to pronounce it a superior
  work m its class, and that Dr. Dickson merits  a
  place in the first rank of American writers.—Western
I Lancet. 
AND SCIENTIFIC  PUBLICATIONS.
11
                      DRUITT (ROBERT),  M.R.C.S.,  &c.
THE PRINCIPLES  AND PRACTICE  OF  MODERN SURGERY.   Edited
  by F. W. Sargent, M. D., author of " Minor Surgery," &c.  Illustrated with one hundred and
  ninety-three wood-engravings.  In one very handsomely printed octavo volume, leather, of 576
  large pages.  $3 00.
  Dr. Druitt's researches into the  literature of his i ments of theoretical and practical Surgery—that it
subject have been not only extensive, but well di-  is found to contain reliable and authentic informa-
rected; the most discordant authors are fairly and | tion on the nature and treatment of nearly all surgi-
impartially quoted, and, while due credit is given j cal affections—is a sufficient reason for the liberal
to each, their respective merits are weighed with  patronage  it has obtained.  The editor, Dr. F. W.
an unprejudiced hand.  The grain  of wheat is pre- I Sargent, has contributed much to enhance the value
served, and the chaff is  unmercifully stripped off.
The arrangement is  simple and philosophical, and
the style, though clear and interesting, is so precise.
that the book contains more information condensed
into a few words than any other surgical work with
which we  are acquainted.—London  Medical Times
and Gazette.
  Druitt's Surgery is too well known to the Ameri-
can medical profession to require its announcement
anywhere. Probably no work of the kind has ever
been more cordially  received and extensively circu-
of the work, by such American improvements as are
salculated  more  perfectly to adapt  it to our own
views and practice in this  country. It abounds
everywhere with spirited and life-like illustrations,
which to the young surgeon, especially, are of no
minor consideration. Every medical man  frequently
ae/eds just such a work as this, for immediate refer-
ence in moments of sudden emergency, when he has
not time to consult  more elaborate treatises.—The
Ohio Medical and Surgical Journal.
  No work, in our. opinion, equals it in  presenting
ueen more curuiany receiveu anu extensively circu-   r*u mvin., m uii>u|iiuivu. ^uai. i> ... K.^=^^j....B
lated than this.  The fact that it comprehends in a , so  much valuable surgical  matter  in so small a
comparatively small compass, all the essential ele- \ compass.—St. Louis Med. and Surgical Journal.

                            DALTON,  JR. (J.  C), M.  D.
                 Professor of Physiology in the College of Physicians, New York.
A  TREATISE ON HUMAN  PHYSIOLOGY, designed for the use of Students
  and Practitioners of Medicine.  With two hundred and fifty-four illustrations on wood.  In one
  very beautiful octavo volume, of over 600 pages, extra cloth, $4 00; leather,  raised bands, $4 25.
  (Now  ready, Jan. 1859.)
  The object of the  author has been to present a condensed view of the present condition of his
-Mibiect divested of mere  theoretical views and hypothetical reasonings, but  comprehending all
important details which may be received as de6nitely settled.  His long experience as an investi-
gator and as a teacher has given him peculiar advantages in this, and he has endeavored wherever
practicable to show  the means by which results have been reached, so as to afford  the student the
means of pursuing original research, as well as a complete text-book of  the science in  its most ad-
vanced condition.  Of the numerous illustrations, all are original with the exception of eleven, so
that the whole possesses a completeness  and authority not otherwise  attainable, and m the me-
chanical execution every care has been taken to present  one of the handsomest volumes as yet
produced by the American press.
  To our mind  fulfils in a most admirable manner I pressed into  a reasonable compass, embracing like-
fk  1;!L »!„ .Tn »tfH hv the author  The broad   wise the results of recent laborers in this department
KfThys^                             vLr «*«•-*"■and Su*e-Reporur'Jan 29'
mination, and its most valuable acquisitions com- | 1859.__

            DUNGLISON,  FORBES,  TVVEEDlE,  AND  CONOLLY.
TFTF  CYCLOPAEDIA  OF PRACTICAL  MEDICINE: comprising Treatises on
  theN*   a^

  ^Cdoubt^                                                         »12 °K°-   „h
  * * This work contains no less than tour hundred and eighteen distinct treatises, contributed by
six^eilhtdiTunguTshed physicians, rendering it a complete  library of reference  for  the  country

 practitioner.                 Pm-tieal Medicine ! titioner.  This estimate of it has not been formed
  The moat complete work on *^™ZbMo i from a hasty examination, but after an intimate ac
 extant;  or, at least, in  our language.  b»m    quaintance derived from  frequent consultation of i
Medical and Surgical Journal
  For reference, it is above all price to every prac-
titioner.— Western Lancet.
  One of the most valuable medical publications of
theday-as a work of reference it is invaluable—
Western Journal of Medicine and Surgery.
  It has been to us, both as learner and  teacher, a
work for ready and frequent reference, one in which
modern  English medicine is exhibited in the most
advantageous light—Medical Examiner.

  We rejoice that this work  is to be placed within
  we 'cji'iy-_______.   .   ...  „mlntPV.  ,t heme
quaintance derived from frequent consultation of it
during the past nine or ten years.  The editors are
practitioners of established reputation, and the list
of contributors embraces many of the most eminen
professors and teachers of London, Edinburgh, Dub-
lin, and Glasgow.  It is, indeed, the great merit of
this work that the principal articles have been fur-
nished by practitioners who have not only devoted
especial attention to the diseases about which  they
have written, but have also enjoyed  opportunities
for an extensive practical acquaintance with them,
and whose reputation carries the assurance of  their
competency  justly to appreciate the opinions of
>hWC Sft."profession n XtoeVn't"^!"being I =s^.e i^mpslheir own doctrines with
unquesuoimbly one of very great value J the prac-1 high and just authority .-American Medical Journ.

     „..Q,a nnMPBPHPNSIVE SYSTEM OF  DANA ON ZOOPHYTES AND CORALS.  In one
D^WnBvvfFFRYIHuKS by occasional cases    volume, imperial quarto extra cloth, with wood-
  MIrfD™iv^JavinKS  Twelfth edition, with the    cuts. 815 00.  Also, AN ATLAS, in one volume.
  and many engrdvingsiw      correc'tionll  In    imperial folio, with sixty-one magnificent colored
  "^Lv^^^                                Plate8-  Bound in half morocco.  830 00.
^r^TREA^SE  ON THE  PHYSICAL I DE LA  BECHE'S  GEOLOGICAL OBSERVER
DEWEES'S  IK^Aiinc.  «_.           CHILD-i   Inone very largeand handsome octavo volume, ex
  AND MEDICAL  TREATMENT  OF  CHILD
  REN   The last edition.  In one volume, octavo,
  extra cloth, 548 pages.  82 80.
DEWEES'S TREATISE  ON THE DISEASES
  OF FEMALES.   Tenth edition  In one> volume,
  octavo   xtra cloth, 532 pages, with plates. 83 00.
  In one very largeand handsome octavo volume, ex-
  tra cloth, of 700 pages, with 300 wood-cuts. $4 00.
FRICK ON RENAL AFFECTIONS; their Diag-
  nosis and Pathology.  With illustrations.  One
  volume, royal 12mo., extra cloth.  75 cents. 
12                     BLANCHARD  &  LEA'S  MEDICAL
                          DUNGLISON  (ROBLEY),  M. D.,
           Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

             NEW AND ENLARGED  EDITION, Now Ready, 1858.

 MEDICAL  LEXICON;  a Dictionary of Medical Science, containing  a concise
   Explanation ofthe various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene
   Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry'
   &c.  Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic
   Preparations, &c.  With French and other Synonymes.  Fifteenth edition, revised and very
   greatly enlarged.  In one very large and handsome octavo volume, of 992 double-columned pages
   in small type; strongly bound in leather, with raised bands.  Price $4 00.

   Especial care has been devoted in  the  preparation of this edition to render it in every respect
 worthy a  continuance of the very remarkable favor which it has hitherto enjoyed.   The rapid
 sale of Fifteen large editions, and the constantly increasing demand, show that "it is regarded by
 the profession as the standard authority.  Stimulated by this fact, the author  has endeavored in the
 present revision to introduce whatever might be necessary " to make it a satisfactory and desira-
 ble—if not indispensable—lexicon, in which the  student may search  without disappointment for
 every term that has been legitimated  in the nomenclature of the science."  To accomplish this
 large additions have been found requisite,  and the extent of the author's labors may be estimated
 from the fact that about Six Thousand subjects and terms have been introduced throughout  ren-
 dering the whole number of definitions about Sixty Thousand, to accommodate which, the 'num-
 ber of  pages has been increased by nearly a hundred, notwithstanding an enlargement in the size
 ofthe pase.  The medical press, both in this country and in England, has pronounced the work in-
 dispensable to all medical students and practitioners, and the present improved edition will not lose
 that enviable repufafion.                                                                  usc
  The publishers have endeavored to render the mechanical execution worthy of a volume of such
 universal use in daily reference    The greatest care hns been exercised to obtain the typographical
 accuracy so necessary in a work ot the kind.  By the small but exceedingly clear type employed
an immense amount  of matter condensed in its thousand ample pages, while the binding will be
found strong and durable.   With all these improvements and enlargements, the price has been kenl
at the former very moderate rate,  placing it within the reach of all.                           P
    This work, the appearance of the fifteenth edition
  of which, it has become our duty and pleasure to
  announce, is perhaps the most stupendous monument
  of labor and erudilion in medical literature.  One
  would hardly suppose after constant use of the pre-
  ceding editions, where we have never failed to find
  a sufficiently full explanation of ever) medical term,
  that in this edition "about six thousand subjects
  and terms have been added," with a careful revision
  and correction of the entire work.  It is only neces-
  sary to announce the advent of this edition to make
  it occupy the place ofthe preceding one on the table
  of every medical man, as it is withoutdoubt the best
  and most comprehensive work of the kind which has
  ever appeared—Buffalo Med. Journ., Jan. 1858.

   The work is  a monument of patient  research,
  skilful judgment, and vast physical labor, that will
  perpetuate the name of the author more effectually
  than any possible device of stone or metal   Dr
  JJunglison deserves the thanks not only ofthe Ame-
  rican profession, but of the whole medical world —
  North Am. Medico-Chir. Review, Jan. 1858.
   A Medical Dictionary better adapted for the wants
  ot the profession than any other with which we are
  acquainted, and  of a character which  places it far
  above comparison and competition.—Am. Journ
  Med. Sciences, Jan. 1858.

   We need only say, that the addition of 6,000 new
 terms, with their accompanying definitions, may be
 said to constitute a new work, by itself.  We have
 examined the Dictionary attentively, and are most
 Happy to pronounce it unrivalled of its kind  The
 erudition displayed, and the extraordinary industry
 which mus have been demanded, in its preparation
 and  perfection, redound  to the lasting credit of its
 author and have furnished us with a volume■ indis*
 pensable at the present day, to all who would find
 themselves au niveau with the highest standards o°
 med.ca information.-i?^™ Medical and Surgical
 Journal, Dec. 31, 1857.                "■omrgieai

  Good lexicons and encyclopedic works irenerallv
 are the most labor-saving contrivance  whTcnH£.'
 rary men enjoy; and the labor which is required to
produce them in the perfect manner of this examDle
is something appalling to contemplate.  The auThor
  tells us in his preface that he has added about six
  thousand terms and subjects to this edition, which
  before, was considered universally as the best work
  Marcn 1858'" aDy ,anSuaSe— SMiman's Journal,

   He has razed his gigantic structure to the founda-
  tions, and remodelled and reconstructed the entire
  pile   No less than six thousand additional subjects
  and terms are illustrated and analyzed in this new
  ■fx Iv0?h„nf?H?*.J!ie  gra"?  "IWregate to  beyond
  Bixty thousand !  Thus is placed before the  profes-
  tSermf„oWl>leterd.thoro,u^h «P«™ent of medical
  terminology without rival or possibility of rivalry.
  —Nashville Journ. of Med. and Surg., Jan. 1858.
   It is universally acknowledged, we believe  that
  n^rW8 in7mPrably thegbest and ™«'com-
  plete Medical  Lexicon in  the  English language.
  The amount of labor which the distinguished  f urtfor
  kainin8t°We,d Up°n lt iB Uu]y wonderful, and the
 irt« gnnd resercJ? d'sP'ayed in  its preparat on
 tionT.  V remarkable- Comment and commenaa-
  MnlfB f,r nneCuSSary' as no  one at the Preient day
 than t.h. P"£haslD? anJ ?ther Medical Dictionary
 than this.-Si.  Louis Med. and  Surg. Journ., Jan





  A very perfect work of the kind,  undoubtedly the
 most perfect ,n the English language -Med. and
 Surg. Reporter, Jan. 1868.

 thl'tj* n.°T f mPnat'eally the Medical Dictionary of

 asB^iaaK?, %*&? - - ■»»•«•
  It is scarcely necessary to remark that any medi-




IMS." ""  ™U-r>"™«'«'M.Z!VjZlZ',
BY THE SAME AUTHOR. 
AND SCIENTIFIC  PUBLICATIONS.
13
                         DUNGLISON (ROBLEY),  M. D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN   PHYSIOLOGY.   Eighth edition.    Thoroughly revised  and exten-
  sively modified and enlarged, with five hundred and thirty-two illustrations.  In two large and
  handsomely printed octavo volumes, leather, of about 1500 pages.  $7 00.
  In revising this work for its eighth appearance, the author has spared no labor to render it worthy
a continuance ofthe very great favor which has been extended to it by the profession.  The whole
contents have been rearranged, and to a great extent  remodelled; the investigations which of late
years have been so numerous and so important, have been carefully examined  and incorporated,
and the work in every respect has been brought  up to a level with the  present state of the subject.
The object of the author has been to render it a concise but comprehensive treatise, containing the
whole body of physiological science, to which the student and man of science can at all times refer
with the certainty of finding whatever they are in search of, fully presented  in all its aspects; and
on no former edition has the author bestowed more labor to secure this result.
  We believe that it can truly be said, no more com-
plete repertory of facts upon the subject treated,
can anywhere be found.  The author has, moreover,
that enviable  tact at description and that facility
and ease of expression which render him peculiarly
acceptable to the casual, or the studious reader.
This faculty, so requisite in  setting forth many
graver and less attractive subjects,  lends additional
charms to one always fascinating.—Boston Med.
and Surg. Journal, Sept. 1856.

  The most complete  and satisfactory system of
Physiology in the English language.—Amer. Med
Journal.
                                                The best work of the kind in the English lan-
                                              guage.—Silliman's Journal.
                                                The present edition the author has made a perfect
                                              mirror of the science as it is at the present hour.
                                              As a work upon physiology proper, the science of
                                              the functions performed by the body, thestudent will
                                              find it  all he wishes.—Nashville Journ. of Med.
                                              Sept. 1856.
                                                That he has succeeded, most admirably succeeded
                                              in his purpose, is apparent from the appearance of
                                              an eighth edition.  It is now the great encyclopaedia
                                              on the subject,  and worthy of a place iu every phy-
                                              sician's library.—Western Lancet, Sept. 1656.

                           BY THE SAME author.   (Now Ready.)

GENERAL   THERAPEUTICS  AND   MATERIA MEDICA;  adapted  for a
  Medical Text-book.  With Indexes of Remedies and  of Diseases and their Remedies.   Sixth
  Edition, revised and improved.   With one hundred and ninety-three illustrations.  In two large
  and handsomely printed octavo vols., leather, of about 1100 pages.  $6 00.

                                 From the Author's Preface.
  " Another edition of this work being called for, the author has subjected it to a thorough and careful
revision. It has been gratifying to him that it has been found so extensively useful by those for whom
it was especially intended, as to require that & sixth edition should be issued in so short a time after
the publication of a fifth.   Grateful for the favorable reception of the work by the profession, he has
bestowed on the preparation of the  present edition all those cares which were demanded  by the
former editions, and has spared no pains to  render it a faithful  epitome of General Therapeutics
and Materia M*»dica.  The copious  Indexes of Remedies and of Diseases  and their Remedies can-
not fail, the author conceives, to add materially to the value of the work."
  This work is too widely and too favorably known to require more than the assurance that the
author has revised it with his customary industry,  introducing whatever has  been found necessary
to bring it on a level with the most advanced condition ofthe subject.   The number ol illustrations
has been somewhat enlarged, and the mechanical execution of the volumes will be found to have
undergone a decided improvement.
  In announcing a new edition of Dr. Dunglison's
  The work will, we have little doubt, be bought
and read by the majority of medical students j  its
size, arrangement, and reliability  recommend it to
all;  no one, we venture to predict, will study it
without profit, and there are  few  to whom it will
not be in some measure useful us a work of reft-r-
ence. The young practitioner, more especially, will
find the copious indexes appended to this  edition of
great assistance in the selection and preparation of
suitable formuhe.—Charleston Med. Journ. and Re-
view, Jan. 1858.
General Therapeutics and Materia Medica, we have
no words of commendation to bestow upon a work
whose merits have been heretofore so often and so
justly extolled.  It must not be supposed, however,
that the present is a mere reprint of the previous
edition; the character of  the author for laborious
research, judicious analysis, and clearness of ex-
pression  is fully sustained by the numerous addi-
tions he has made to  the work, and the careful re-
Vision to which he has subjected the whole.—N. A.
Medico-Chir. Review, Jan. 1858.
                        BY THE same author.  (A new Edition.)

NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND
  ADMINISTRATION. Seventh edition, with extensive Additions.  In one very large octavo
  volume, leather, of 770 pages.   $3  75.
   Another edition of the « New Remedies"  having been called for, the author has endeavored to
  Another edition oiine^.c             d since ,he publicat on of the last edition.
add every thing'of moment.that has^«MJ*™ ; ^in ^^  to have undergone considerable *x-
  ^^^^^JZ^vSorm^b^  enabled to introduce, as far as practicable, the
r^^f^^^^^^^ox^u^A as of his own observation and reflection;


^t&ZX^^B^ basing thfbulk of *e volume.^*.

  One of the most useful  of the author's works.-
Southem Medical and Surgical Journal.
  This elaborate and  useful volume   ■hould  be
found in every medical library, for as a book.of re-
I^n J  for Dhvsieians, it is  unsurpassed by  any
other^0* if/x Bte^ce,  and  the double index for
diseases  and for remedies, will be found greatly to
Sc" it. viae.-*.- York Med. Gazette.
  The great learning of the author, and his remark-
able industry in pushing his researches into every
source whence information is derivable,have enabled
him to throw together an extensive mass of facts
and statements, accompanied  by full  reference to
authorities; which  last feature renders the  work
practically valuable to investigators who desire te
examine the original papers—The American Journal
of Pharmacy. 
11
BLANCHARD  <fc  LEA'S  MEDICAL
                                ERICHSEN  (JOHN),
                    Professor of Surgery in University College, London, Ac.

THE  SCIENCE  AND ART OF SURGERY; being a Treatise on Surgical
  Injuries, Diseases, and Operations.  New and improved American, from the second enlarged
  and carefully revised London edition.   Illustrated with over four hundred engravings on wood.
  In one large and  handsome octavo volume,  of one  thousand  closely printed pages, leather,
  raised bands.   $4 SO.  (Now Ready, January, 1859.)
  The very distinguished favor with which this work has been received on both sides of the Atlan-
tic has stimulated the author to render it even more worthy of the position which il has so rapidly
attained as a standard authority.  Every portion has been carefully revised, numerous additions
have been made, and the most watchful care has been exercised to render it a complete exponent
ofthe most advanced condition of surgical science.   In this manner the work has been enlarged by
about a hundred pages, while the series of engravings has been increased by more than a hundred,
rendering it one of the most thoroughly illustrated volumes before the profession.  The additions of
the author having rendered unnecessary most of the notes of the former American editor, but little
has been added in this country; some  few notes and occasional illustrations have, however, been
introduced to elucidate American modes of practice.
                                             rarely encounter cases  requiring surgical manage-
                                             ment .—Stethoscope.
                                               Embracing, as will be perceived, the whole surgi-
                                             cal domain, and each division of iiself almost com-
                                             plete and perfect, each chapter full and explicit, each
                                             subject faithfully exhibited, we can only express ouj
                                             estimate of it in the aggregate. We consider ii an
                                             excellent contribution  to  surgery, as probably the
                                             best single volume now extant on the subject, and
                                             with great pleasure we  add it  to our text-books.—
                                             Nashville. Journal of Medicine and Surgery.
                                              Prof. Erichsen's work, for its size, has not been
                                             surpassed; his nine hundred and eight pages,  pro-
                                             fusely illustrated, are rich  in  physiological, patholo-
                                             gical, and operative suggestions, doctrines, details,
                                             and processes; and will prove a reliable resource
                                             for information, both to physician and sureeon, in the
                                             hour of peril.— N. O. Med. and Surg. Journal.
  It is, in our humble judgment, decidedly the best
biok of the kind in the  Knglish language. Strange
that just such books are notoflener produced by pub-
lic teach'TS of surgery in this country and Greal
Britain  Indeed, it is a matter of great astonishment.
but no less true than astonishing, that ofthe many
works on surgery republished in this country within
th»- last  fifteen  or twenty years as  text-books for
medical students, this is the only one that even ap-
proximates to the fulfilment ofthe peculiar wants of
young men just entenngupon the study of this branch
ofthe profession.— Western Jour, of Med. an/ Surgery.
  Its value is greatly enhanced by a very copious
well-arranged index.  We regard this as one of the
most valuable contributions to modern surgery.  To
one entering hi.-* novitiate of practice, we regard it
the most serviceable guide which he can consult.  He
will find  a fulness of detail leadinghim through every
step ofthe operation, and not deserting him until the
final is«ne ofthe ease is decided  For the same rea-
son we recommend it to those whose routine of prac-
tice lies in such parts of the country that they musi
  We are acquainted with no other work wherein
so much good sense, sound principle, and practical
inferences, stamp every page.—American Lancet.
                           ELLIS (BENJAMIN), M.D.
THE  MEDTCAL FORMULARY: being a Collection of Prescriptions, derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.  To which is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.  The
  whole accompanied with a few  brief Pharmaceutic and Medical Observations.  Tenth edition,
  di.V-?  j iau- ^n exte?£?d by Robe*t  P- Thomas, M. D., Professor of Materia Medica in the
  Philadelphia College of Pharmacy.  In one neat octavo volume, extra cloth, of 296 pages.  $1 75.

                       FOWNES  (GEORGE),  PH. D., &.C.
ELEMENTARY  CHEMISTRY;  Theoretical and  Practical.  With  numerous
     strahons   E^ed, wth^Addkions, by Robert Bridges, M.D.  In one large  royal 12mo.
  volume, of over 550 pages, with 181 wood-cuts
  We know of no better text-book, especially in the
difficult  department of organic  chemistry, upon
which it is particularly full and satisfactory. We
would recommend it to  preceptors as a  capital
" office book" for their  students who are beginners
in Chemistry.  It is copiously illustrated with ex-
cellent wood-cuts, and altogether admirably "got
up."—N. J. Medical Reporter.
  A standard manual, which has long enjoyed  the
reputation of embodying much knowledge in a small
space.  The author hasachieved the difficult task of
condensation with masterly tact.  His book is con-
cise without being dry, and brief without being too
dogmatical or general.— Virginia Med. and Surgical
Journal.
  In leather, $1 50; extra cloth, $1  35.
  The work of Dr. Fownes has long been before
the public, and its merits have been fully appreci-
ated as  the best text-book on chemistry now in
existence.  We do not, of course, place it in a rank
superior to the works of Brande, Graham,  Turner,
Gregory, or Gmelin, but we say that, as  a work
for students, it is preferable to any of  them.—Lon-
don Journal of Medicine.
  A work well adapted to the wants of the student
It is an excellent exposition of the chief doctrines
and facts of modern chemistry. The size ofthe work.
and still more the condensed yet perspicuous style
in which it is written, absolve it from the charges
very properly urged against most manuals termed
popular— Edinburgh Journal of Medical Science.
  __                    FISKE  FUND PRIZE  ESSAYS

THE EFFECTS OF CLIMATE ON TUBERCULOUS  DISEASE.   By Edwin
  MENT 0RF TUBERCLE^Vv^ INFLUU?NCE OF PREGNANCY ON THE DEVELOP
  M£.tsi  uf lUJJt,KOLES.  By Ldward Warren, M. D., of Edenton  N f!   Tnw»ih»,Tn
  one neat octavo volume, extra cloth.  $1 00.   (Juet Ready.)     ™eaton> W" u  Together in

                       FERGUSSON  (VvTlLIAM), F. R. S
                     Professor of Surgery in King's College, London, &c

A  SYSTEM OF PRACTICAL SURGERY.   Fourth ArnprW  a.„   ,v  a.- a
  and enlarged London edition.  In one large and beamifullv mSLln^     n,' fr°m *he third
  pages, with 393 handsome illustrations, leather   $31 00    P           ° V°lume' °f aboUt 700
  No work was ever written which more nearly I   The uriiliH™. „r „
r-omorehended the necessities  of the student  ana  more thanever iml^»y ".T pa^8 make8 thi» ™>rk
practitioner, and was more carefully arranged to  dtioner   aSIkJ-iiP ?Jfableto ""^tudentand prac-
that single purpose than this.-iV. Y.  Med. Journal   tltlon"—Ra"><™g's Abstract. 
AND SCIENTIFIC  PUBLICATIONS                    15
                             FLINT  (AUSTIN), M. D.,
        Professor of the Theory and Practice of Medicine in the University of Louisville, &e.
                                (An Important New Work.)
PHYSICAL EXPLORATION AND DIAGNOSIS  OF  DISEASES AFFECT-
  ING THE RESPIRATORY ORGANS.  In  one large and handsome octavo volume,  extra
  cloth, 636 pages.  $3 00.
  We can only state our general impression of the ' lungs, with which we are acquainted in the English
bigh value  of this work, and cordially recommend I language.—Boston Med. and Surg. Journal.
it to all.  We regard it, in point both of irrangement    ^ work of original observation ofthe highest merit.
and of the marked ability of its treatment of the sub-  \ye recommend the treatise to every one who wishes
jects, as destined to take the first rank in works of  to become a correct auscultator.  Based to a very
this class.  So far asour information extends, it has  inr?e extent upon cases numerically examined, it
at present no equal.  To the practitioner, as well as  carrjes tlieevidtnce of careful stud\ and discrimina-
the student, it will be invaluable in clearing up the  t[on u,lf)n every page  It does credit to tue author,
diagnosis of doubtful cases, and in shedding light  | iintij through him, to the profession in this  country.
upon difficult phenomena.—Buffalo Med. Journal,  jt is, what we cannot call every hook upon anscul-
   This  is the most elaborate work devoted exclu-  tation, a readable book.—Am. Jour. Med. Sciences.
sively to the physical exploration of diseases of the I

                                   NOW COMPLETE,
                          GRAHAM (THOMAS),  F. R. S.f
 THE  ELEMENTS  OF INORGANIC  CHEMISTRY,  including  the Applica-
   tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert
   Bridges, M. D.  Complete in  one large  and handsome octavo volume, of over 800 very iar„e
   pages, with two hundred and thirty-two wood-cuts, extra cloth.  $4 00.
    *** Part II., completing the  work from p. 431 to end, with Index, Title Matter, &c, may be
  had separate, cloth backs and paper sides.  Price $2 50.               nnrt;nn nf this work has
    The long delay which has intervened since the appearance of the  first portion of this work, has
  rendered  necessary an Appendix, embodying the numerous  and  important mvest.gations and dis-
  coveries of the rasyt few years in the subjects  contained in Part  I.  This occupies a large port on
  of pTrtll  and will bTfound to  present a complete abstract of the most recent  researches in the
  general prmcTpleTof £e Sco?as well as all details necessary to bring the whole work thoroughly
  ud to the Dresent time in all departments of Inorganic Chemistry.
   Gentlemen^desirous of completing their copies  of the work are requested toapply for Part II.
  without delay.  It will be sent by  mail, prepaid, on receipt^ofthe amount, $2 80.
  It is a very acceptable addition to the library of
standard books of eveTy chemical student. No reader
of English works on this science can afford to be
without this edition of Prof. Graham's Elements.—
Silliman's Journal, March, 1858.

From Prof. J L. Crawcour,  New Orleans School
           of Medicine, May 9, 1858.
  It is beyond all question the best systematic work
on  Chemistry  in the English language, and I am
eratifiedto find that an American edition at a mo-
derate price has been issued, so as to place it within
tLTmeLs of students  It will be the only text-book
I shall now recommend to my class.________
 From Prof. Wolco't Gihbs, N. Y. Free Academy,
                May 25, 1858.
  The work is an admirable one in all respects,and
its republication here cannot fiil to exert a positive
influence upon the progress of science in this country.

From Prof. E- N. Horsford. Harvard College, April
                  27, 1859.

  It has, in its earlier and less perfect editions, been
familiar to me, and  the excellence of its plan and
the clearness and completeness of its discussions,
have long been uiy admiration.
                     GRIFFITH (ROBERT  E.),  M. D.,«tc.
&  ttxttvPT^ \L FORMULARY, containing the methods of Preparing and Ad-
A UNIVERbALi *"nf>"Y£f. •  »    The wh°ole adapted to Physicians and Pharmaoeu-
  ministering Officinal ™d ^'^i^tad  withTumorous additions, by Robert P  Thomas
  lists.   Second Edition, thoroughly ^^vJJ^E College of Pharmacy.  In one large and

  LSsome^                                    cXnn8'  $3 °°: °r ^^ ^ ^^

  fwata work requiring much per^ance, and | nisteritig me^cines that can^desire^by the pays.-

when P^'-Jlndrat hallined"from'me'African    The amoun.of useful,everyday matter.for a prac-

P  n I. «hHpH o this Formulary, and has rendered it  and Surg. Journal.
**!.'"„„„ deservine of the confidence of pharma-    w    dict a „eM 8a)e forthis woTk. and we espe-
ceSaK                                                  "> a» medieal »«»»"-*«*-
  «r  .„unnv to announce  a new and improved \mond Stethoscope.
",1;,' 11(:«>fiilnes< to practiuoners of medicine, u is
uetteKptdr.h^rPPurPoses than the u.spensato
Acs-Southern Med. and Surg. Journal.
  It is one ofthe most useful book, a ~«ntrjr pra«i
  lhiseuuionoi w «"»»■;----—- ,.;.-„"  f n;
improved by the revision and ample additions of Dr.
Thomas, and is now, we  believe, one of the  most
complete works of its kind in any language.  The
additions amount to about seventy  pages and  no
effort has been spared to include in them all the  re-
  Itisoaeofthemostu^^
lioner can possibly have  in his possession.          meaiciai o^        ^ ^ indwpeIwable ,? the physi-
ChronieU.                                      » l  ana lh#.& j, none «ve can more cordially recom-


                           GLUGE (GOTTLIEB), M. D.,


AN  ATLAS  OF  PAraOI^IOM^lbiu^ fa ^ Un      ,

  nradAKenvotJe°,S"
  SJT'twelve copperplates.   $5 00. 
10                   BLANCHARD & LEA'S  MEDICAL
                         GROSS (SAMUEL D.),  M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, &c.
                            New Edition (Now Ready.)
ELEMENTS  OF PATHOLOGICAL ANATOMY.   Third edition, thoroughly
  revised and greatly improved.  In one large and very handsome octavo volume, with about three
  hundred and fifty beautiful  illustrations, of which a large number are from original drawings.
  Price in extra cloth, $4 75;  leather, raised bands, $5 25.
  The very rapid advances in  the Science of Pathological Anatomy during the last few years have
rendered essential a thorough modification  of this work, with a view of making it a correct expo-
nent of the present state of the subject.  The very careful manner in which this task has been
executed, and the amount of alteration which it has undergone, have enabled the author to say that
" with the many changes and improvements now introduced, the work may be regarded almost as
a new treatise," while the efforts ofthe author  have been seconded as regards the mechanical
execution of the volume, rendering it one of the  handsomest productions of the American press.
A very large number of new and beautiful original illustrations have been introduced, and the work
it is hoped, will fully maintain the reputation hitherto enjoyed by it of a complete and practical ex-
position of its difficult and important subject.
  We have been favorably impressed with the gene-
ral manner in which Dr. Gross has executed bis task
of affording a comprehensive digest of the present
state ofthe literature of Pathological Anatomy, and
have much pleasure in recommending his work to
our  readers, as we believe one  well deserving  ot
diligent perusal and careful study__Montreal Med
Chron., Sept. 1857.
  We most sincerely congratulate the author on the
 successful manner in which he has accomplished his
 proposed object.  His book is most admirably cal-
 culated to fill up a blank which has  long been felt to
 exist in this department of medical literature, and
 as such must become very widely circulated amongst
 all classes of  the profession. — Dublin Quarterly
 Journ. of Med. Science, Nov. 1857.

                                 BY THE SAME AUTHOR.

 A  PRACTICAL  TREATISE  ON  THE   DISEASES,  INJURIES, AND

  Mm5r«,°F TS5-  URINARY, BLADDER, THE PROSTATE GLAND,  AND
  fn«,In..*,  ,•      r      ,nd Ed,t'on> rev;ised, and mueh enlarged, with one hundred and eighty-
  £ iJ.,h    ?  j KInJ°neJ-f1f  and Very, handsome octav» volume, of over nine hundred pages
  In leather, raised bands, $5 25; extra cloth, $4 75.                                 F«HP»-
  A volume replete with truths and principles ofthe
 utmost value in the investigation of these diseases.—
 American Medical Journal.
  On the appearance of the first edition of this work,
 the leading English medical review predicted that it
 would have a " permanent place in the literature of
 surgery worthy to rank with the  best works of the
present age."  This prediction has been amply ful-
filled.  Dr. Gross's treatise has been found to sup-
ply completely the want which has been  felt ever
since the elevationof surgery to the rank of a science,
of a good practical treatise on the  diseases of the
bladder and its accessory organs.  Philosophical in
its design, methodical in its arrangement, ample and
                                             sound in its practical details, it may in truth be said
                                             to leave scarcely anything to be desired on so im-
                                             portant a subject, and with the additions and modi-
                                             fications  resulting  from future discoveries and im-
                                             provements, it will probably remain one of the most
                                             valuable works on this subject so long as the science
                                             of medicine shall  exist.—Boston Med. and Sur*
                                             Journal.                                   ""

                                              Whoever will peruse the vast amount of valuable
                                             practical  information  it contains, and which we
                                             have been unable  even to notice, will, we think,
                                             agree with us, that there is no work  in the Enirlish
                                             language which can make any just pretensions  to
                                             be its equal.—N. Y. Journal of Medicine.
  »  TVT» * /^mx« . -r ™____         BY THK SAMK AUTHOR.
   sf(?4CTTICA^ ™1ATISE  ON  FOREIGN  BODIES  IN THE  AIR-PAS-
   SAGES.  In one handsome octavo volume, extra cloth, with illustrations.  p?468  $2 75


 A SYSTEM OF SDMB^S^^p^l^ .^p^ and 0pera
   tive.  With very numerous engravings of wood/ In two lafge oCvoCes!'        P

                          GIBSON (WILLIAM).  M. D.,
 TVnmTmT      Late Pr°fessor of Surgery in the University of Pennsylvania &c
 INSTITUTES  AND  PRACTICE OF  SURGERY-  }JZ  n tr      *    n
   of Lectures.  Eighth edition, improved arTdalterecT^thThirty fouf oSST/* I ^
   octavo volumes, containing about 1000 pages, leather, raised barms? $6 50?        ° handsome

                           GRAY (HENRY),  F. R. S..
                   Lecturer on Anatomy at St. George's Hosrjital  i™j™ , „

 ANATOMY, DESCRIPTIVE AND SURGICAT    tk  'it   •     v    „  ,
  Carter M  D.,la«e DemonstratorlA^lny^fst. Getr^s nStaM^D g"  ^  ^  Y"
  by the Author and Dr.  Cartee.  In  one mai-nifWnt  ;™   • 8,ilosPltal > ,ne Dissections joint y
  and elaborate engravings on wood.  (Atpre™?         Penal  °C,aV0 Volurae> with 363 large

  The author has endeavored in this work to  cover a more pxi^ua  .      r  t-
r-uMomary in the ordinary  text-books, bv givine notonW ?Za ?X.,ended  ran&e of subjects than is
also the applica.ion  of those details in the oracfice of Z  v     ''f necessaT for the student, but
-n.y a guide for the learner, but"? admiral"i^k rf^'S^'for th?!'?' ,h"9 ^"^^ ft n°'
engravings form a special feature in the work manvofS L     ..   C-We Practl"°ner.  The

"7A^ ha.™*,he names of the vario'rpam prU'd oT^X S "J" °'™V". "^ a11
GARDNER'S  MEDICAL CHEMISTRY, for  the
  use of Students and the Profession.  In one royal
  Jjmo. vol., ex. cloth, pp. 386, with illustrations

HUGHES'  CLINICAL  INTRODUCTION  TO
St£ePr^odpsEo°/p^1?ultation and


 voi. royal limo., ex. cloth, pp. 304.  $1 00. 
AND  SCIENTIFIC-PUBLICATIONS.
17
                        HOBLYN  (RICHARD  D.),  M. D.

A DICTIONARY  OF  THE  TERMS  USED  IN MEDICINE  AND  THE
  COLLATERAL SCIENCES.  A new American edition.  Revised, with numerous Additions,
  by Isaac Hays, M. D., editcr of the " American Journal ofthe Medical Sciences."  In one large
  royal 12mo. volume, leather, of over 500 double columned pages.  $1 50.
  If the frequency with which we have referred to
this volume since its reception from the publisher,
two or  three  weeks ago, be  any criterion for the
future, the binding will soon have to be renewed, even
with careful handling.  We find that Dr. Hays has
done the profession great service by his careful and
industrious labors.  The Dictionary has thus become
eminently suited to our  medical brethren in this
country.  The additions by Dr. Hays are in brackets,
and we believe there is not a  single page but bears
these insignia; in every instance which we have thus
far noticed, the additions are really needed and ex-
ceedingly valuable. We heartily commend the work
to all who wish to be au courant in medical termi-
nology.—Boston Med. and Surg. Journal.

  To both practitioner  and student, we  recommend
this dictionary as being convenient  in size, accurate
  Hoblyn has always been a favorite dictionary, and
in its present enlarged and improved form will give
greater satisfaction than ever. The American editor,
Dr. Hays, has made many very valuable additions.
—N.J. Med. Reporter.
  To supply the want of the medical reader arising
from this cause, we know of no dictionary  better
arranged and adapted than the one bearing the above
title.  It is not encumbered with the obsolete terms
of a bygone age, but it contains all that are now in
use; embracing every department of medical science
down to the very latest date. The volume is of a
convenient size to be used by the medical student,
and yet large enough to make a respectable appear-
ance in the library of a physician.—Western Lancet.
  Hoblyn's Dictionary has long been a favorite with
     It is the best book of definitions we have, and
in definition, and sufficiently full and complete for ought always  to be upon the  student's table.—
ordinary consultation.—Charles ton Med. Journ. and Southern Med. and Surg. Journal.
Review.                                   I
                     HUNTER (JOHN).
(See " Ricord," page 26, for Ricord's edition of Hunter on Venereal.)
             HOLLAND (SIR  HENRY),  BART.,  M.D..F. R. S.,
                     Physician in Ordinary to the Queen of England, &c.

MEDICAL NOTES  AND  REFLECTIONS.  From the  third  London edition.
  In one handsome octavo volume, extra cloth. $3 00.
                          HABERSHON <S.  O.),  M. D.,
   Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c.

PATHOLOGICAL  AND  PRACTICAL  OBSERVATIONS  ON  DISEASES
  OF THE ALIMENTArV CANAL, (ESOPHAGUS, STOMACH  CECUM  AND INTES-
  TTNES.  With illustrations on wood.  In one handsome octavo volume.  (Publishing %n tht
  Medical News and Library for 1858 and 1859.)

                       HORNER (WILLIAM E.), M. D.,
                   Professor of Anatomy in the University of Pennsylvania.
SPECIAL  ANATOMY   AND  HISTOLOGY.  Eighth edition   Extensively
  revised and modified.  In two large octavo volumes extra cloth of more than one thousand
  pages,handsomely printed, with over three hundred illustrations.  $6 00.
BY THE SAME AUTHOR.
ANATOMICAL ATLAS.
  page 28.
By Professors  Horner and Smith.    See Smith,
In
                       HAMILTON (FRANK H.), M. D.,
                     Professor of Surgery, in Buffalo Medical College, Ac.
A COMPLETE TREATISE ON FRACTURES AND  DISLOCATIONS.
  one handsome octavo volume, with several hundred illustrations.  (Preparing.)

                       JONES (T. WHARTON), F.  R.  S.,
         Professor of Ophthalmic Medicine and Surgery in University College, London, &c.

TTTF  PRINCIPLES  AND  PRACTICE OF   OPHTHALMIC  MEDICINE
  Tvn SURGERY  With one hundred and ten illustrations.  Second American from the second
  AND SUttOriitti.  vvuu mc in     .   w KnwARD Hartshorne, M. D., Surgeon to Wills
  We are confident that the reader will find  on
perusal, that the execut on of the work amply fulfils
th* nromise of the preface, and sustains, in every
the promise oi u  j      i      f he author ag
lv wrought up, and digested in the author's mind,
as to come forth with the freshness and impressive-
ness of an original production.  We entertain little
doubt that this book will become what its author
hoped it might become, a manual for daily reference
and consultation by the student and the general prac-
titioner.  The. work is marked by that correctness,
clearness, and precision of style which distinguish
all the productions of the learned author.—British
and For. Med. Review. 
IS
B  .ANCHARD  &  LEA'S  MEDICAL
JONES (C.  HANDFIELD),  F. R. S., 81  EDWARD H. SIEVEKING,  M. D.,
                Assistant Physicians and Lecturers in St. Mary's Hospital, London.

A MANUAL OF PATHOLOGICAL  ANATOMY.   First  American Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.  In one large and
  beautiful octavo volume of nearly 750 pages, leather.  $3 75.
                                              present condition of pathological anatomy. In this
                                              they have been completely successful.  The work is
                                              one of the best compilations which we have ever
  Asa concise text-book, containing, in a condensed
form, a complete outline of what is known in the
domain of Pathological Anatomy, it is perhaps the
best work in the English language.  Its great merit
consists in its completeness and brevity, and in this
respect it supplies a great  desideratum in our lite-
rature.  Heretofore the student of pathology was
obliged to glean from a great number of monographs,
and the field was so extensive that but few cultivated
it with any degree of success.  As a simple work
of reference, therefore, it  is of great value  to the
student of pathological anatomy, and should be in
every physician's library.— Western Lancet.
  Tn offering the above titled work to the public, the
authors have not attempted to intrude new views on
their professional brethren, hut simply to lay before
them, what has long been wanted, an outline of the
perused.—Charleston Medical Journal and Review.
  We urge upon our readers and the profession gene-
rally the importance of informing themselves in re-
gard to modern views of pathology, and recommend
to them to procure the work before us as the best
means of obtaining this information.—Stethoscope.
  From the casual examination  we have given we
are  inclined to regard it as a text-book, plain, ra-
tional, and intelligible, such a book as the practical
man needs for daily reference.  For this reason it
will be likely to be largely useful, as it suits itself
to those busy men who have little  time for minute
investigation, and prefer a summary to an elaborate
tieatise.—Buffalo Medical Journal.
                    KIRKES (WILLIAM SENHOUSE),  M.D.,
               Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c.

A  MANUAL  OF  PHYSIOLOGY.    A new American, from  the  third  and
  improved London edition.  With two hundred illustrations.   In  one large and handsome royal
  12mo. volume, leather,  pp.586.  $2 00.  (Just Issued, 1857.)
  In again passing this work through his hands, the author has endeavored to render it a correct
exposition of the present condition of the science, making such alterations and additions as have
been dictated by further experience, or as the progress of investigation has rendered desirable.  In
every point of mechanical execution the publishers have  sought to make it superior to former edi-
tions, and at the very low price at which it is offered, it will  be found one of the handsomest and
cheapest volumes before the profession.
  In making these improvements, care has been exercised not  unduly to increase its  size, thus
maintaining its distinctive characteristic of presenting within a moderate compass a clear and con-
nected view of its subjects, sufficient for the wants of the student.

                                                One of the very best handbooks of Physiology we
                                              possess—presenting just such an outline of the sci-
                                              ence, comprising an account of its leading facts and
                                              generally admitted principles, as the student requires
                                              during  his attendance upon a course of lectures, or
                                              for reference whilst preparing for examination —
                                              Am. Medical Journal.
  This is a new and very much improved edition of
Dr. Kirkes' well-known Handbook of Physiology.
Originally constructed on the basis of the admirable
treatise of Muller, it has in successive editions de-
veloped itself into an almost original work, though
no change has been made in the plan or arrangement.
It combines conciseness with completeness, and is,
therefore, admirably adapted for consultation by the
busy practitioner.—Dublin Quarterly Journal, Feb.

  Its excellence is in its compactness, its clearness,
and its carefully cited authorities.  It is the most
convenient of text-books. These gentlemen, Messrs
Kirkes and Paget, have reallyan immense talent for
silence, which is not so common or so cheap as prat-
ing people fancy.   They have the gift of telling us
what we want to know, without thinking it neces-
sary  to tell  us all they know.—Boston Med  and
Surg. Journal, May 14, 1857.
  We need only say, that, without entering into dis-
cussions of unsettled questions, it contains  all the
recent improvements in this department of medical
science.  For the student beginning this study, and
the practitioner who has but leisure to refresh his
memory, this book is invaluable, as it contains all
that it is important to know, without special details,
which are  read with interest only by those who
would make a specialty, or desire to possess a criti-
cal knowledge of the subject__Charleston Medical
Journal.
KNAPP'S TECHNOLOGY ; or, Chemistry applied
  to the Arts and to Manufactures.  Edited, with
  numerous Notes and Additions, by Dr. Edmund
  Ronalds and Dr. Thomas Richardson.  First
American edition, with Notes and Additions, by
Prof.  Walter R. Johnson.   In two handsome
octavo volumes, extra cloth, with about 500 wood-
engravings.  86 00.
                               LUDLOW (J.  L.),  M. D.

A  MANUAL  OF  EXAMINATIONS  upon  Anatomy,  Physiology,  Suroerv



  over 800 closely printed pages.   (Just Issued.)  $2 50                      ^oiume, teatner, ol












frett, at • K]anc, his memory of the vuiou. topic.  M.y™ies7   c°m<>'!lled '» laM^-w.ium L....I, 
AND SCIENTIFIC PUBLICATIONS.                   19
it treats.—Edinburgh Monthly Journal of Medical
Science.
  Already well known and appreciated by the scien-
tific world, Professor Lehmann's great work re-
quires no laudatory sentences, as, under a new garb,
it is now presented to us.  The little space at our
command would ill suffice to set forth even a. small
portion of its excellences.—Boston Med. and Surg.
Journal, Dec. 1855.
                               LEHMANN (C.  G.)
PHYSIOLOGICAL  CHEMISTRY.   Translated  from  the  second  edition  by
  George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry
  in the Medical  Department of the University of Pennsylvania, with  illustrations selected from
  Funke's Atlas of Physiological Chemistry, and an Appendix of plates.  Complete in  two large
  and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus-
  trations.   $6 00.
  This great work, universally acknowledged as the most complete and authoritative exposition of
 the principles and details of Zoochemistry, in its passage  through the press, has received from
 Professor Rogers such care as was necessary to present it in a correct and reliable form.   To such
 a work additions were deemed superfluous, but several years having  elapsed between the appear-
 and in Germany of the first and last volume, the latter contained  a supplement, embodying nume-
 rous corrections and additions resulting from the advance of the science.   These have all been incor-
 porated in the text in their appropriate places, while the subjects have been still further elucidated by
 the insertion of illustrations from the Atlas of Dr. Otto Funke. With the view of supplying the stu<Jent
 with the means of convenient comparison, a  large number of wood-cuts, from works on kindred
 subjects, have also been added in the form of  an Appendix  of Plates.  The work is, therefore, pre-
 sented as in every way worthy the attention  of all who desire to be familiar with the modern facts
 and doctrines of Physiological Science.
   The most important contribution  as yet made to
 Physiological Chemistry.—Am. Journal Med. Sci-
 ences, Jan. 1856.
   The present volumes belong to  the small class of
 medical literature which comprises elaborate works
 of the highest order of merit.—Montreal Med. Chron-
 icle, Jan. 1856.
   The work of Lehmann stands unrivalled as the
  most comprehensive book of reference and informa-
  tion extant on every branch of the subject on which
                            BY THE SAME AUTHOR.  (Just Issued.)
  MANUAL OF  CHEMICAL  PHYSIOLOGY.   Translated from  the  German,
    with Notes and Additions, by J. Cheston xMorris, M. D.,  with an Introductory■ Esaay on Jita
    Force, by Samuel Jackson/M. D., Professor of the Institutes of  Medicine ,n the U^iversi y of
    PennsVlvania. With illustrations on wood.   In one  very handsome octavo volume, extra cloth,
    of 336 pages.   $2 25.
                           Frotr. Prof. Ja-ckson's Introductory Essay.
    In adopting the handbook of Dr. Lehmann as * manual* Organic  C^
  students of the University, and in recommending his original work  of Phys"^ic*l V u^utho-
  for their more mature studies, the high value of his researches,  and the great weight of his autho
  rity in that important department of medical science are fully recognized.

                           LAWRENCE (W.), F.  R.S., &c.
   a  ipppATTqiu   ON  DISEASES  OF   THE  EYE.  A  new  edition,  edited,






   the reach of the profession.-S^Aoseoj*.           octavo pa«s-has enabled both author and editor to

     This  standard text-book on the department of  ^^^^^ftSfZ
   which it treats, ha. not been f.»Pe"^e^^gunJect  knowledge o The whole science in this department,

   neUf*^^^^
   ments of Dr. Hays, the American editor, is it at all I Y. Med. t*az.






     SeKToneTvery neat royal ^mo^ume^extra^loth. Price $1 00.


              ™™t  TREATISEFMAOND  THE  "aUOT8,  SYMPTOMS,  AND
    A PRACTICAL  S^i^oRHffiA  By M. Lallemand.  Translated and edited  by
      TREATMENT  OF SpE£^TS?a7editiony  To  which  is  added----ON DISEASES
      Henhy J McDougall.   Third American edition    x           organs.  With special rcfer-
      OF THE VESICULA SEMINALES^j^ their  associ^ ^^ ^^   By Marris
      ence to the Morbid ^^^^^rfSXrt 400 pp., extra cloth. $2 00. (Now Ready.)
      Wilson, M. D.   In one neat octavo voiu   ,                  unquestionably exercised a very
      Although the views of M. Lallemand on Sp"™'™» n      generally adopted, still, a num-
    greaUnfluenJe, and the treatment-dialed byg^^KoHdftL publishers have thought that
    berofvears having elapsed since his work ^a. |iven       addititm of  .he little treatise of Dr.
    rte value of the present  edition woulc1 be g^^.rfSpermatorrhasiare investigated with
    Marris Wilson.   In it the causpsof theditterem                       experience of the pro-
    "caidoModern pathology, from J^^S^Xm of curative treatment.  Whatever defi-
     essfon, the attempt i. ^"Itf^&TlJeavid by the progress of medical science, will,
    ciencies may have been caused'■"JJ*JrorK
    it is hoped, be in this manner supplied. 
•20
BLANCHARD & LEA'S MEDICAL
                            LA  ROCHE  (R.),  M. D., &c.
YELLOW FEVER,  considered  in its  Historical,  Pathological,  Etiological,  and
  Therapeutical Relations.  Including a Sketch of the Disease as it has occurred in Philadelphia
  from 1699 to 1854, with an examination ofthe connections between it and the fevers known under
  the same name in other  parts of temperate as well as in tropical regions.   In two  large and
  handsome octavo volumes of nearly 1500 pages, extra cloth.  $7 00.
                                              arduous research and careful study, and the result
                                              is such as will reflect the  highest honor upon the
                                              author and our country.—Southern Med.  and Surg.
  From Professor S. H. Dickson, Charleston, S. C,
               September 18, 1855.
   A monument of intelligent and well applied re-
 search, almost without example.  It is,  indeed, in
 itself, a lar<re library, and is destined to constitute
 the special  resort as a book of reference,  in the
 subject of which it treats, to all future time.
   We have not time at present, engaged as we are,
 by day and by night, in the work of combating this
 very disease, now prevailing in oui city, to do more
 than give this cursory notice of what we consider
 as undoubtedly the most able and erudite medical
 publication our country has yet produced.  But in
 view of the startling fact, that this, the most malig-
 nant and unmanageable disease of modern  times,
 has for several years been prevailing in our country
 to a greater  extent than ever before:  that it is no
 longer confined to either large or small cities, but
 penetrates country villages, plantations, and farm-
 houses; that it is  treated with scarcely better suc-
 cess now than thirty or  forty years ago; that there
 is vast mischief done by ignorant pretenders to know-
 ledge in regard to the disease, and inviewof the pro-
 bability that a majority  of southern physicians will
 be called upon to treat the disease, we trust that this
 able and comprehensive treatise will be very gene-
 rally read in  the south.—Memphis Med. Recorder.
  This is decidedly the great American medical work
of the day—a full, complete, and systematic treatise,
unequalled by any other upon the all-important sub-
ject of \ ellow Fever.  The laborious, indefatigable,
and learned author has devoted to it many years of
 Journal.

   The genius and scholarship of this great physician
 could not have been better  employed than in the
 erection of this towering monument to his own fame
 and to the glory of the medical literature of his own
 country. It is destined to remain the great autho-
 rity upon the subject of Yellow Fever.   The student
 and physician will  find in these volumes a risumi
 ofthe sum total ofthe knowledge ofthe world upon
 the awful scourge which they so elaborately discuss.
 The style is so soft and so pure as to refresh and in-
 vigorate the  mind while absorbing  the thoughts of
 the gifted author, while the publishers have suc-
 ceeded in bringing the externals into a most felicitous
 harmony with  the inspiration that dwells within.
 Take it all in all, it is a book we have often dreamed
 of, but dreamed not that it  would ever  meet our
 waking eye as a tangible reality .—Nashville Journal
 of Medicine.

  We deem it fortunate that  the splendid work of
 Dr. La Roche should have been issued from the press
 at this particular time. The want of a reliable di-
 gest of all that is known in relation to this frightful
 malady has long been felt—a want very satisfactorily
 met in the work  before us.  We deem it but faint
 praise to say that Dr. La Rcche has succeeded in
 presenting the profession with an able and complete
 monograph, one which will find its way into every
well ordered library.—Fa. Stethoscope.
 T>xn?TT\/ir\-KTT a    •    «           BY THE SAME author.
   ttmnalfSS  iL^  Sn^^ Connection, Pathological  and  Etiological, with An.



      p  ,      ,_          MILLErMHENRY),  m. d.,

 princ&lesTn^^I^


   tavo volume, of over 600 pages!   (Nol R^y!" $3 75      W°°d'  In °nB VCry hands°me °°-

 tJXStota .%S?l^u>0^^JLT!^ygpK^  to require the  attention of
 practice.  The very *vo^^                                            and extensive
 some years since, is an earnest that  the present work"will fulfil  he ■?„?  ™ ? ^.""^.n," issued
 within a moderate compass a complete aiiHir ^rtu,  . u  ,r ut,or s intentlon of providing
 ference for the practitioner?  Baled to a^erta"nexSf VrZtTf  ** the Tt^ and  book  of re"
 than double its size,  and almost wnoHvYewrnmn  i? I P  ,the/°!™er work, but enlarged to more
 the author, the mos  recen™ 10^00^^2^ %TY' ^u^ ,-he matured 4>erience of
 Cazeaux, Simpson, TylebS^th? &r ?E               °hTUC  Writers' such^ DuBOIS>
 but also ofthe Paris', the London and fhe Edinburgh^oStefnc schooNtS Th °"  £  °f  the Amer-ican'
 many years as a teacher of his favorite branch  has *£I„ Id  f■   ... The au  hor * P«w«ion for so
dents and a  facility of conveyine instructZ wh,Vhg^   ^7 a familiar«y with the wants of stu-
adapted to its purposes     *  g instructlon> whlcn <*nnot fail to  render the volume eminently
 w^Jf„COng!a!ulatLethe author ***** the task is done.
 c^l DuhlfnraBUlatlhl'?thuat he haa *iven t0 the medi:
 cat public a work which will secure for him a hish

 ntiesornm|h:nnP0Siti?n am?nS the standard "tho.
 S?"  \e. Pri«"'»Ples and practice of obstetrics.
 ftSS? r"i1™" are n0t less due t0 the medical Pro-
 ff«^K°f.thlS c"untrv' »•» the acquisition of a trea-
 tise embodying the results of the studies, reflections
 i^thTf Snnere °f Prof- Mi,ler-  Few ">en, if any
 on th\l£n*K7' T more,c™Petent than he to write
 on this department of medicine. Engaged for thirty-
 five years in an extended practice of Sbstetrics. for
 M/of ThS .eaCher  °rf thi8.bra"<* «f instruction
 L?„h-^   the largest  of our institutions, a diligent
 student as well as a careful observer, an original and
 independent  thinker,  wedded to no hobbies ever
 ready to consider without prejudice new views and

 and withal a clear, agreeable writer, a  practica
 S86 pT hlS pen could not ^11 to possess grea
 ""■ *ftaJaiaS to  Prof. Miller's work we We
 only to add that we hope most sincerely it will be In
the hands of every reading and thinking practitioner
of this country .-Buffalo Med Journll, Mar 1858
 ■JnH»,H*.J  »'   ."mf must take its P,ace araonS th«
 tionfow^8|temat,Ctreatiseson obstetrics; a posi-
 s suchTM."' merfts.J«"ly entitle it.  The style
 ec"is dt the descriptions are clear, and each sub-
 ito nraPH.-i'h"1  -nd  eluc'dated with due regard to
 accent    •"■"."IS"!, which cannot fail to make it
 ait?oner« 6 "w va,uable to both students and prac-
 notte? witi.^? Can°0t' ,h°wever, close this brief
 nrof«.Wlthout congratulating the author and  the
 t«Sl.  t?  the,kProduction of such an excellent
 feel irn,,HThe author «s a western man of whom we
 Will finH m'^ W! CanDOt bUt think that  his book
 obs etr^efi, 7 "Si!""T* warm ^mirers wherever
 obstetrics is taught and studied as a science and an
an.—1 He Cincinnati Lancet and Observer, Feb. 1858.

 hotemml-eSpe|!t.able  and  val"ahle addition to our
alike on th.n1  ^"""/"i  and one  ^fleeting credit
ttsa«achii  ^0randthe in"titution to which he
mostuLf^l1,1,THef8tKdentW;in find in thi8 work a
"hmner  ,„5 , det°hl8 "'"dies ; the country prac-
oTesaV.irV? m h18 reading' c™ obtain  from its
sSe  »nJ  ™T °f the mndern literature of the
 tion -'„.,"f, weh"Petosee  this American produc-

Sw.5s^Perai?by the  P"«»i«-^ 
AND SCIENTIFIC  PUBLICATIONS.                  21
                           MEIGS (CHARLES  D.), M. D.,
             Professor of Obstetrics, &c. in the JefTerson Medical College, Philadelphia.

OBSTETRICS:  THE SCIENCE  AND  THE  ART.   Third edition,  revised
  and improved.  With one hundred and twenty-nine illustrations. In one beautifully printed octavo
  volume, leather, of seven hundred and fifty-two large pages.   $3 75.
  The rapid demand for another edition of this work is a sufficient expression of the favorable
verdict of the profession.   la thus preparing it a third time for the press, the author has endeavored
to render it in every respect worthy of the favor which  it has received.  To accomplish this he
has thoroughly revised it in every  part.   Some portions have been rewritten, others added, new
illustrations have been in  many instances substituted for  such as were  not  deemed satisfactory,
while, by an alteration in the typographical arrangement, the size of the work has not been increased,
and the price remains unaltered.  In its present improved form, it is, therefore, hoped that the work
will continue to  meet the wants of the  American profession as a sound, practical, and extended
 System of Midwifery.
  Though the work has received only five pages of
enlargement, its chapters throughout wear the im-
pressof careful revision. Expunging and rewriting,
remodelling its sentences, with occasional new ma-
terial, all evince a lively desire that it shall deserve
to be regarded as improved in manner as well as
matter.  In the matter, every stroke of the pen has
increased the value of the book, both in expungings
and additions — Western Lancet, Jan. 1857.
  The best American work on Midwifery that is
accessible  to the student and practitioner—N. W.
Med. and Surg. Journal, Jan. 1857.
  This is a standard work by a great American Ob-
stetrician.   It is the third and last  edition, and, in
the language of the preface, the author has "brought
the subject up to the latest dates of real improve-
ment in our art and Science."—Nashville Journ. of
Med. and Surg., May, 1857.
                          BY  the same author.  (Lately Issued.)

WOMAN:  HER DISEASES AND  THEIR  REMEDIES.   A Series of Lec-
  tures to his Class.  Third and Improved edition.  In one large and beautifully printed octavo
  volume, leather.    pp. 672.   $3 60.
  The frratifvin- appreciation of his labors, as evinced by the exhaustion of two large impressions
^^or^rXxS^^ has not been lost upon the author, who has endeavored m every
wav to^endeT it wor hv of the favor with which it has been received.  The opportunity thus






Females.
                                              such bold relief, as to produce distinct impressions
                                              upon the mind and  memory  ofthe reader.— The
                                              Charleston Med. Journal.
                                                Professor Meigs has enlarged and amended this
                                              great work, for such it  unquestionably  is, having
                                              passed the ordeal of criticism at home and abroad,
                                              but been improved thereby; for in this new edition
                                              the author has introduced real impronmorti, and
                                               ncreased the value and utility of the book im-
                                              measurably.  It presents so  many novel, bright,
                                              "nd sparkling thoughts;  such an exuberance of new
                                              ideas on almost every page, that we confess out
                                              selves  to have become  enamored with  the  book
                                              and its author; and cannot withhold our congratu-
                                              Utions from our Philadelphia confreres  that such a
                                              teacher is in their service.—N. Y. Med. Gazette.
well as the ooscuresv »«")>="., ■"V"7/.7t»iTri, ollt in
Prof. Meigs, are isolated and made to stand out in
                                   BY THE SAME AUTHOR.




  octavo volume, extra cloth, of 365 pages, j^    .             ^ ^ ^ ^   &         ^

                                               nf those which bear his name.  Indeed we  doubt
                                               whethe? a^y material improvement will be made on
                                               Xe teaches of this volume for a century to come,
                                                Lee U is sleminently practical, and based on pro-
                                               found knowledge of the  science and consummate
                                               skUl in the art of healing, and ratified by an ample
                                               and extensive experience, such as few men have the
                                               industry or good fortune to acquire.-iV. Y. Med.
                                               Gazette.
  It contains a vaBt amount of practical knowledge.
by one who has accurately observed and retained
the experience of many years, and who tells the re-
sult in a free, familiar, and pleasant manner.—Dub-
lin Quarterly Journal.
  There is an off-hand fervor, a flow, and a warm-
heartedness infecting the effort o? Dr Meigs, which
is entirely captivating, and which absolutely hur-
ries the reader through from beginning to end.  Be-
sides, the book  teems with  solid instruction, and
it shows the very highest evidence of ability, viz.,
 L clearness w^Ih which the information, ,.  pre-
sented.  We know of no better test of one's under-
standing a subject than the evidence of the power
ofTuchfly explaining it. The most elernenUry.,as
well as the obscurest subjects, underthe penci  of
  The instructive and, interesting author rf this




fresh and vigorous, attractive and racyj p


baiidWM«l, »• H ''-■""il°i0™,t*f«mth.
A TREATISE  ON^S
           rt.  .nonen*uu=........--------mT77I1gNE'S OPERATIVE SURGERY, based

MAYNE,S  DISPS|ATORJcANBcrp^g I ^^tf jb^-JSaT ^fe
  PEUTICAL REMEMBRANCER  ^       |   ,ated from ^^^"^^usillustratumsonwood.
                                                 fnone handsomehoctavo volume, extra cloth, of
                                                 nearly six hundred pages. 9* &■
PEUTICAL RK^EE^Medica, with every
the entire lists of  Materia J*tawa,     R    ^
Practical Formula conteined in  tn     .^ ^
Pharmacopeias. Edited, w'ththe^.            , 
22                    BLANCHARD  or  LEA'S  MEDICAL
                        MACLISE (JOSEPH),  SURGEON.
SURGICAL  ANATOMY.   Forming  one volume,  very  large  imperial quarto.
  With sixty-eight large and splendid Plates, drawn in the best  style and beautifully colored.  Con-
  taining one hundred and ninety Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.   Strongly  and handsomely  bound in extra cloth, being one of the
  cheapest and best executed Surgical works as yet issued in this country. $11 00.
  %* The size of this work prevtnts its transmission through the post-office as a whole, but those
who desire to have copies forwarded  by  mail,  can receive them in five parts, done  up in stout
wrappers.  Price $9  00.
                                                 Of great value to the student engaged in dissect-
                                               ing, and to the surgeon at a distance from the means
                                               of keeping up his anatomical knowledge.—Medical
                                               Times.
                                                 A work which has no parallel in point  of accu-
                                               racy and cheapness in the English language.—N. Y.
                                               Journal of Medicine.
                                                 To all engaged in the study or practice of their
                                               profession, such a work is almost indispensable__
                                               Dublin Quarterly Medical Journal.

                                                 Country practitioners will find  these plates of im-
                                               mense value— N. Y. Medical Gazette.

                                                 We  are extremely gratified to announce to the
                                               profession the completion of this truly magnificent
                                               work,  which, as a whole, certainly  stands  unri-
                                               valled, both  for accuracy of drawing, beauty of
                                               coloring, and all the requisite explanations ofthe
                                               subject in hand.—The  New Orleans  Medical and
                                               Surgical Journal.

                                                 This is by far the ablest work on Surgical Ana-
                                               tomy that has come  under our  observation. We
                                               know of no other work that would justify a stu-
                                               dent, in any  degree, for neglect of actual dissec-
                                               tion.  Jn those  sudden  emergencies that so  often
                                               arise, and which require the instantaneous command
                                               of minute anatomical knowledge, a work of this kind
                                               keeps the details ofthe dissecting-room perpetually
                                               fresh in the memory .—The Western Journal of Medi-
                                               cine and Surgery.

     ro mIZTaIT rf at Which thi« work i8 furnished, and the beauty of its execution,
require an extended sale to compensate the publishers for  the heavy expenses incurred.

                            MORLAND (W.  W.), M. D.


DpSofES  ?J ™^MO™^^^ of their Diagnosis,

  K^^a^ assist &sr se &rdsome—J™>ol

JwtotoHS^ oSf Ihelisease sTo^hich Zul^?™* **««*>**** convenient compass
both medical and surgTcaf.  Thea rVS the author haX7 "IF** T hable' *5ith their «"*t"ent,
the most recent inv&i-ttionTii?«M?™T« / * ,   en throuShout *> condense the results of
portance, wuhou  at  the,  lamVrtmJ^le""nd suc.cinct™anner, omitting nothing  of practical inj-
urious 'elSSS'.'d  imporTan.  ^krhave^eTentlvlnn^6^  wi* «»«*•«* peculations.
subject, but none  it is believed ™h?,L^uecently appeared  on different departments  of the
Dr. MorlandhL attempted.   '      thorouSh|y cover, the whole ground  in the manner  which
  One of the greatest artistic triumphs of the age
 in Surgical  Anatomy.—British American Medical
 Journal.
  Too much cannot be said in its praise; indeed,
 we have not language to do it justice.—Ohio Medi-
 cal and Surgical Journal.
  The most admirable surgical  atlas we have seen.
 To the  practitioner deprived of demonstrative dis-
 sections upon the human subject, it is an invaluable
 companion.—N. J. Medical Reporter.
  The most  accurately engraved  and beautifully
 colored  plates we have ever seen in an American
 book—one of the best and  cheapest surgical works
 ever published.—Buffalo Medical Journal.
  It is yery  rare that so elegantly printed, so well
 illustrated, and  so useful a work, is offered at so
 moderate a price.—Charleston Medical Journal.
  Its  plates  can boast a superiority which places
 them almost beyond the reach of competition.—Medi-
 cal Examiner.
  Every practitioner, we think, should have a work
 of this kind within reach.—Southern Medical and
 Surgical Journal.

  No such lithographic illustrations of Burgical re-
gions have hitherto, we think, been given.—Boston
 Medical and  Surgical Journal.

  As a surgical  anatomist, Mr. Maclise  has proba-
bly no superior.—British and Foreign Medico-Chi-
rurgical Review.
                            MACKENZIE  (W.),  M.  D.,

A PKACTIc/rmSi^oV %ffiS£t$5'itifow  OF THE



  plates and numerous wood?cuT Vfi  §h&ads°™ octavo volume, leather, raised bands, with
n.  «e 'J6?1186 of Pi  Mackenzie indisputably holds
the first place, and forms, in respect of learnine and
research, an Encyclopaedia unequalled in extent bv
any other work ofthe kind, either English or foreign
—Dixon on Diseases ofthe Eye.         •«»«»«.

  Few modern books on any department of medicine
or surgery have met with such extended circulation,
?*'" Procured for their authors a like amount of
?t^rTJ?e%lt7L  Th« immense research which
LuhteP/Ti'f-he,ith0r0u(r,h  ft<Taintance with the
subject, practically as well as theoretically,and the
able manner in which the author's stores of learning
and experience were  rendered available for eeneral
use, at once procured for the first edition, as well on
the continent as in this country, that high position
as a standard work which  each successWed t o^
^„„.n°fr.<;firm yeStfbli,8hed'in  "Pite of 'he attrac"
tions of several rivals of no mean ability.  We con-
sider it the duty of every one who has the love of his
make8h,!ZPTfdrthe^elfare1of hi» Patient at heart, to
work fnThf' r/ami,laJ Wlth thi8 the moat complete
toe eve   M^r** lan«e UP°» 'he diseases of
me eye—Med. Times and Gazette.

doubtehfe»rf1!,.?diti0n °f. thi5 8t«nd"d work will no
tion.  i**? ful,y aPPrec«ted as the three former edi-
for the lliSCTCe8Sary ? ^ a word in its P™'1*,
 he ™J   Ct .has already  been passed upon it by
fe°,fat.C°mPflen' JfdSe8.  »-nd "Mackenzieon the
Eye" has justly obtained a reputation which it is
Fn,fi,f™# T^? cal1 world'^-Britehand
Foreign  Medieo-Chirurgical Review.   ■""*"'a ana

t™HiR"ennnWredition °/ ,Dr- Mackenzie's celebrated 
AND  SCIENTIFIC PUBLICATIONS.
23
                          MILLER (JAMES), F. R. S.  E.,
                     Professor of Surgery in the University of Edinburgh, &c.

PRINCIPLES OF SURGERY.  Fourth American, from  the third  and revised
  Edinburgh edition.  In one large  and very beautiful volume, leather, of 700 pages,  with  two
  hundred and forty exquisite illustrations on wood.   $3 75.
  The work of Mr. Miller is too well and too favor-
ably known among us, as one of our best text-books,
to render any further notice of it necessary than the
announcement of a new edition, the fourth in  our
country, a proof of its extensive circulation among
us.  As a concise and reliable exposition of the sci-
ence of modern surgery, it stands deservedly hi?h—
we know not its superior__Boston Med. and Surg.
Journal.
  It presents the most satisfactory exposition of the
modern doctrines ofthe principles of surgery to be
found in any volume in any language.—iV. Y. Journal
of Medicine.
  The work takes  rank with Watson's Practice of
Physic; it certainly does not fall behind that great
work in soundness of principle or depth of reason-
ing and research.   No physician who values his re-

                            bv the same  author.  (Now Ready.)

THE  PRACTICE  OF  SURGERY.    Fourth  American  from the last  Edin-
  burgh edition.  Revised by the American editor.  Illustrated  by three hundred and sixty-four
  engravings on wood.   In one large octavo volume, leather, of nearly 700 pages.  $3 75.
putation, or seeks the interests of his clients, can
acquit himself before his God and the world without
making himself familiar with the sound and philo-
sophical views developed in the foregoing book.—
New Orleans Med. and Surg. Journal.
  Without doubt the ablest exposition of the prin-
ciples of that branch of the healing art in any lan-
guage.  This opinion, deliberately formed  after a
careful study of the first edition, we  have  had  no
cause to change on examining the second. This
edition has  undergone thorough revision by the au-
thor ; many expressions have been modified, and a
mass of new matter introduced.  The book is gotup
in the finest style, and is an evidence of the progress
of typography in our country.—Charleston Medical
Journal and Review.
  No encomium of ours could add to the popularity
of Miller's Surgery.  Its  reputation in this country
is unsurpassed by that of any other work, and, when
taken in connection with  the author's Principles of
Surgery, constitutes a  whole, without reference to
to which no conscientious surgeon would be willing
practice his art.— Southern Med. and Surg. Journal.
  It is seldom that two volumes have ever made so
profound an impression  in so short  a time as the
" Principles" and  the " Practice" of Surgery by
Mr. Miller—or so richly merited the reputation they
have acquired.  The author is an  eminently sensi-
ble, practical, and well-informed man, who knows
exactly what he is talking about and exactly how to
talk it.—Kentucky Medical Recorder.
  By the almost unanimous voice of the profession,
his works, both on the principles and practice  of
surgery have been assigned the highest rank.  If we
were limited to but one work on surgery, that one
should be Miller's, as we regard it as superior to all
others.—St. Louis Med. and Surg. Journal.

  The author has in this and his " Principles," pre-
sented to the profession one of the most complete and
reliable  systems of Surgery extant.  His style  of
writing is original, impressive, and engaging, ener-
getic, concise, and lucid.   Few have the faculty of
condensing so much in small space, and at the same
time so persistently holding the attention.  Whether
as a text-book for students or  a  book of reference
for practitioners, it cannot be  too strongly recom-
mended.—Southern Journal of Med. and Physical
Sciences.
               MONTGOMERY (W. F.),  M. D.,  M.  R. I. A., &.C.,
        Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c.
AN EXPOSITION OF THE SIGNS AND  SYMPTOMS OF  PREGNANCY.
  With some other Papers on Subjects connected with Midwifery.  From the second and enlarged
  English edition.  With two exquisite colored plates, and numerous wood-cuts.   In one very
  handsome octavo volume, extra cloth, of nearly 600 pages. (Just Issued, 1857.)  $3 7o.
  The present edition of this classical volume is fairly entitled to be regarded as anew work, every
sentence having been carefully rewritten, and the whole increased to more  than double the original
«ize    The title ofthe  work scarcely does justice to the extent and importance  of the  topics
brought under consideration, embracing, with the  exception of the operative  Procedures .of mid-
wifery  almost everything connected with obstetnes, either directly or incidentally;  and  there are
fewKdans who will lot find in its pages much that will prove of great interest and value m
ErPSy practice  The special Essays on the Period of Human Gestation, the Signs of Delivery
and the Spontaneous AmpuTation and other Lesions of the Foetus in Utero present topics  ofthe

"ffi^^^S^^                      »« found ~°< the handsomest yet issued
from the American press.
  A book unusually rich in practical suggestions —
Am Journal Med. Sciences, Jan. 1857.
  These several  subjects so interesting in them-
selves, and so important, every one of them, to the
most delicate and precious of social relations, con-
trolling often the honor and domestic peace of a
family, the legitimacy of offspring, or the life of its
parent, are all treated with an elegance of diction,
lulness of illustrations, acuteness and justice ot rea-
soning, unparalleled in obstetrics, and unsurpassed in
medicine.  The reader's interest can never flag, so
fresh, and vigorous, and classical is our author's
style;  and one forgets, in the renewed charm of
every page, that it, and every line, and every word
has been weighed and reweighed through years of
preparation; that this is of all others the book of
Obstetric Law, on each of its several topics; on all
points connected with pregnancy, to be everywhere
received as a manual of special  jurisprudence, at
once announcing fact, affording argument, establish-
ing precedent, and governing alike the juryman, ad-
vocate, and judge.  It is not merely in its legal re-
lations that we find this work so interesting.  Hardly
a page but that has its hints or facts important to-
me general practitioner; and not a chapter without
especial matter for the anatomist, physiologist, or
pathologist. — N. A. Med.-Chir. Review, March,
1857.
      MOHR (FRANCIS),  PH. D., AND REDWOOD (TH EOPHI LUS).
PRAPTFPAL  PHARMACY.   Comprising the  Arrangements, Apparatus, and 
24                    BLANCHARD &  LEA'S  MEDICAL
                               NEILL (JOHN), M. D.,
                         Surgeon to the Pennsylvania Hospital,See.) and

                      FRANCIS GURNEY  SMITH, M. D.f
              Professor of Institutes of Medicine in the Pennsylvania Medical College.

AN  ANALYTICAL  COMPENDIUM  OF  THE   VARIOUS  BRANCHES
  OF MEDICAL SCIENCE; for the Use and Examination of  Students. A new edition, revised
  and improved.  In one very large and handsomely printed  royal 12mo. volume, of about one
  thousand pages, with 374  wood-cuts.  Strongly bound in leather, with raised bands.  $3 00.
  The very nattering reception which has been accorded to this work, and the hi^h estimate placed
upon it by the profession, as evinced by the constant and increasing demand  which has rapidly ex-
hausted two large editions, have stimulated the authors to render the volume  in its present revision
more worthy of the  success which has attended it.   It has accordingly been  thoroughly examined,
and such errors as had on former occasions escaped observation have been corrected, and whatever
additions were necessary to maintain it on a level with the advance of science  have been introduced.
The extended series of illustrations has been still further increased and much improved, while, by
a slight enlargement  of the page, these various additions have been incorporated without increasing
the bulk of the volume.
  The work is, therefore, again presented as eminently worthy ofthe favor with which it has hitherto
been received.  As a book for daily reference by the student requiring a guide to his more elaborate
text-books, as a manual for preceptors desiring to stimulate their  students by  frequent  and accurate
examination, or as a source from which the practitioners of older date may easily and cheaply acquire
a knowledge ofthe changes and improvement in professional science, its reputation is permanently
established.
  The best work of the kind with which we are
acquainted.—Med. Examiner.
  Having made free use of this volume in our ex-
aminations of  pupils, we can speak from experi-
ence in recommending it aa an admirable compend
for students, and as especially useful to preceptors
who examine their pupils.  It will save the teacher
much labor by enabling  him readily to recall all of
the  points upon which his pupils should  be ex-
amined.  A work of this sort should be in the hands
of every one who takes  pupils into his office with a
view of examining them; and this is unquestionably
the best of its class.—Transylvania Med. Journal.

  In the rapid course of lectures, where work for
the students is heavy, and review necessary for an
examination, a compend  is not only valuable, but
it is almost a sine qua non. The one before us is,
in most of the divisions, the most unexceptionable
of all books of the kind  that we know of. The
newest and soundest doctrines and the latest im-
provements and discoveries are  explicitly,  though
eoncisely, laid before the  student.  There is a class
to whom we very sincerely commend this cheap book
as worth its weight in silver—that class is the gradu-
ates in medicine of more  than ten years' standing,
who have not studied medicine since.  They wfll
perhaps find out from it that the science is not exactly
now what it was when they left it off.—The Stetho-
scope
                              NEILL  (JOHN),  M.  D.,
                  Professor of Surgery in the Pennsylvania Medical College, Ac

OUTLINES  OF  THE  VEINS AND LYMPHATICS.   With handsome colored
  plates.  1 vol., cloth. $1 25.

OUTLINES OF THE NERVES.   With handsome plates.   1 vol., cloth.  $1 25.


               NELIGAN (J.  MOORE),  M. D., M. R. I. A., &c.
                             (A splendid work. Just Issued.)

A^nASt?F,C?7AP?VS DISEASES-  In one beautiful quarto volume, extra
  dlsea*T $4PiSndldcoloredPlates, presenting nearly one hundred elaborate representations of


of D^seairoMne'skT6 mSS 'tf ^tt  and a°CUrate rePre^ntation of all the varieties
-iJ^tf  r      .  .u     hJle l c%be consulted "* conjunction with any work on Practice  it has
especial reference to the author's « Treatise on Diseases of the Skin,"  so favorably feceived'bv the
profession some years since.  The publishers feel justified in saying th*^few moreTbeau Tfullvexe
cuted plates have ever been presented to the profession of this country.
  A compend which will very much aid the practi-
tioner in this difficult branch of diagnosis.  Taken
with the beautiful plates of the Atlae, which are
remarkable for their accuracy and beauty of color-
                                             long existent desideratum much felt by the largest
                                             class of our profession.  It presents, in quarto size,
                                             18 plates, each containing  from 3 to 6 figures, and
                                             forming in all a total of 90 distinet representations
                                             of the different species of  skin affections, grouped
                                             together in genera or families. The  illustrations
                                             have been taken from nature, and have been copied
                                             with such fidelity that they present a striking picture
                                             ot lite; in which the reduced scale aptly serves to
                                             give, at:a coup d'ceil, the remarkable peculiarities
                                             of each individual variety.   And while thus the dis
                                             ease is rendered more definable,  there is yet no loss
                                             of proportion incurred by the necessary concentra-
                                             tion. Each figure is highly colored, and so truthful
                                             has the artist been that the most fastid ous observer
                                             could not justly take exception to the correctness of
                                             vrl e.XeCY 1?*, °X.the Pictures under his scrutiny—
                                             Montreal Med. Chronicle.

                                  BY THE SAME AUTHOR.

A  PRACTICAL TREATISE  ON  DISEASES  OF THE  SKIN    Second
  American edition,   n one neat royal 12mo. volume, extra clot!; of 33?pages   $1 00.

   Kgr The two volumes will be sent by mail on receipt of Five Dollars.

OWEN  ON  THE DIFFERENT  FORMS  OP I   rw „„i
  THE SKELETON, AND  OF  THE  TEETH. |   SKuS? fi*? "^ Cl°th' Wlth nuaier0Ui
    ,----- -- ------ «■-vwm* *M.-jr ****vi utnui| UI LUlUr*
ing, it constitutes a very valuable addition to the
library of a practical man.- Buffalo Med. Journal,
Sept. 1856.

  Nothing is often more difficult than the diagnosis
of disease ofthe skin; and hitherto, the only works
containing illustrations have been at rather incon-
venient prices—prices, indeed, that prevented gene-
ral use.  The work before us will supply a want
long felt, and minister to a more perfect acquaintance
With the nature and treatment of a very frequent
and troublesome form of disease.—Ohio Med. and
Surg. Journal, July, 1856.

  Neligan's Atlas of Cutaneous Diseases supplies a 
AND SCIENTIFIC  PUBLICATIONS.                   25
                              PEASLEE  (E. R.), M. D.,
         Professor of Physiology and General Pathology in the New York Medical College.

HUMAN  HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology;
  for the use of Medical Students.   With four hundred and thirty-four illustrations.  In one hand-
  some octavo volume, of over 600 pages.  (Now Ready, 1858.)  $3 75.
  It embraces a library upon the topics discussed i ceive this contribution to physiological  science,
within itself, and is just what the teacher and learner " Not with vain thanks, but with acceptance boun-
need.  Another advantage, by no means to be over-
looked, everything of real value in the wide rai.ge
which it embraces, is with greut skill compressed
into an octavo volume  of but little more than six
hundred pages.  We have not only the whole sub-
ject of Histology, interesting in itself,ably and fully
discussed, but what is of infinitely greater interest
to the student, because  of greater practical value,
are its relations to Anatomy, Physiology, and Pa-
thology, which are here fully and satisfactorily set
forth.  These great supporting branches of practical
medicine are thus linked together, and while estab-
lishing and  illustrating each other, are interwoven
into a harmonious whole.  We commend the work
to students  and physicians generally. — Nashville
Journ. of Med. and Surgery, Dec. 1857.
  It far surpasses our expectation.  We never con-
eeived the possibility of compressing so much valu-
able information into so compact a form. We will | March, 1858
not consume space with  commendations.  We re
teous."   We have already paid it  the practical
compliment of making abundant use of it in the
preparation of our lectures, and also of recommend-
ing its further perusal most cordially to our alumni;
a recommendation which we  now extend to our
readers.—Memphis Med. Recorder, Jan. 1858.
  We would recommend it to the  medical student
and practitioner, as containing a summary of all that
is known ofthe important subjects which it treats;
of all that is contained in the great works of Simon
and Lehmann, and the organic chemists in  general.
Master this one volume, we would say to the medical
student and practitioner—master this book and you
know all that is known of the great fundamental
principles of medicine, and  we have no hesitation
in saying that it is an  honor to the  American  medi-
cal profession that one of its members should have
produced it.—St. Louis Med. and Surg. Journal,
             PEREIRA (JONATHAN),  M.  D., F.  R. S., AND L. S.

THE  ELEMENTS  OF  MATERIA   MEDICA  AND   THERAPEUTICS.
  Third American edition, enlarged and improved by the author; including Notices of most of the
  Medicinal Substances in use  in the  civilized world, and forming an Encyclopaedia of Materia
  Medica.  Edited, with  Additions, by Joseph Carson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania.   In two very large octavo volumes of 2100 pages,
  on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with
[ raised bands.  $9 00.

                                PARRISH  (EDWARD),
  Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c.

 AN  INTRODUCTION TO PRACTICAL PHARMACY.   Designed as a Text-
  Book for the Student, and as a Guide for the Physician and  Pharmaceutist.   With many For-
  mulae and Prescriptions.  In one handsome octavo  volume, extra cloth, of 550 pages, with 243
  Illustrations. $2 75.
book, which contains the leading facts and principles
of the science of Pharmacy, conveniently arranged
for study, and with special reference to those features
of the subject which possess an especial practical in-
terest to the physician.  It furnishes the student, at
the commencement  of his studies, with that infor-
mation which is of the greatest importance in ini-
tiating him into the domain of Chemistry and Materia
Medica; it familiarizes him with  the compounding
of drugs, and supplies those minutiae which but few
practitioners can impart.  The junior practitioner
will, also, find this volume replete with instruction.
__Charleston Med. Journal and Review, Mar. 1856.

  There is no useful information in the details of the
apothecary's or country physician's office conducted
  A careful examination of this work enables us to
speak of it in the highest terms, as  being the best
treatise on practical pharmacy with which we are
acquainted, and an invaluable vade-mecum, not only
to the apothecary and to those practitioners who are
accustomed to prepare their own medicines, but to
every medical man and medical student.  Through-
out the work are interspersed valuable tables, useful
formulas, and practical hints, and the whole isillus-
trated by a large number of excellent wood-engrav-
ingg.__Boston Med. and Surg. Journal.
  This is altogether one ofthe most useful books we
have seen.  It is just what we have  long felt to be
needed by apothecaries, students, and practitioners
of medicine, most of whom in this country have to  C,F„„1,V.V„.7 „„.-----, ,,...,--------------------
Dutuo their own prescriptions. It bears, upon every  according to science that is omitted. The young
Daee the impress of practical knowledge, conveyed  physician will find it an encyclopedia of indispensa-
ma main common sense manner, and adapted to the | j,ie medical knowledge, from the purchase of a spa-
combrehension of all who may read it.  No detail | tuia t0 the compounding of the most learned pre
has been omitted, however trivial it may seem, al- i -..;~»;™.  Th. wntir i» hv theshleat nharmaeeuti*
though really important to the dispenser of medicine.
—Southern Med. and Surg. Journal.
  To both the country practitioner and the city apo-
thecary this work of Mr. Parrish is a godsend.  A
careful  study of its contents  will give  the young
graduate a familiarity with the value and mode of       ia|1  by tne  ltnfle_.
administering his prescriptions, which win oe oi  as  majority of  physicians are obliged to  compound
much use to his patient as  to himselt.— va. mea.  ^^  own medicines, and  to them a work of this
Journal.                                       kind is indispensable.—N. O. Medical and Surgical
  Mr Parrish has rendered a very acceptable service  journal.
to'the practitioner  and student, by furnishing this |


                               PARKER  (LANGSTON),
                          SuTgeon to the Queen's Hospital, Birmingham.

Tin?  MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI-
1U „ „ Vim wrnNDARY •  comprising the Treatment of Constitutional and Confirmed Syphi-
   MA?Y    SPand  sSessful method.  With numerous Cases, Formula, and Clinical Observa-
   llonsy From the Third and entirely rewritten  London edition.  In one neat octavo volume,

   extra cloth,  of 316 pages.  $1  75.
Bcriptions. The work is by theablest pharmaceutist
in  the United States, and  must meet with an im-
mense sale.—Nashville Journal of Medicine, April,
1856.

  We are glad to receive this excellent work.  It
will supply  a want long felt by the profession, and
especially by  the student  of  Pharmacy. A large 
26
BLANCHARD &  LEA'S  MEDICAL
                        PIRRIE (WILLIAM), F. R. S. E.,
                      Professor of Surgery in the University of Aberdeen.

THE  PRINCIPLES  AND PRACTICE  OF  SURGERY.  Edited  by John
  Neill  M  D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania
  Ho^phalT&c.  In one very handfome octavo volume, leather, of 780 pages, with 316 illustrations.
  $3 75.
  We know of no other surgical work of a reason-
able size, wherein there is so much theory and prac-
tice, or where subjects are more soundly or clearly
taught.—The Stethoscope.
  There  is scarcely a disease of the bones or soft
parts, fracture, or dislocation, that is not illustrated
by accurate wood-engravings.  Then, again, every
instrument employed by the surgeon is thus repre-
sented.  These engravings are not only correct, but
really beautiful, showing the astonishing degree of
perfection to which the art of wood-engraving has
arrived. Prof. Pirrie, in  the work before us, hai
elaborately discussed the principles of surgery, and
a safe and effectual practice predicated upon  them.
Perhaps no work upon this subject heretofore issued
is so full upon the science of the art of surgery__
Nashville Journal of Medicine and Surgery.
                               RICORD (P.), M. D.,
A TREATISE ON THE VENEREAL DISEASE.   By John Hunter, F. R. 8.
  With copious Additions, by Ph. Ricord, M. D.  Translated and Edited, with Notes, by Freeman
  J. Bumstf.ad. M. D , Lecturer on Venereal at the College of Physicians and Surgeons, New York.
  Second editicn, revised, containing a resume of Ricord's  Recent Lectures on Chancre.  In
  one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. (Now Ready,
  December, 1858.)
  In revising this work, the editor has endeavored to introduce whatever matter of interest the re-
cent investigations of syphilographers have added to our knowledge of the subject.  The principal
source from winch this has been derived is the volume of "Lectures on Chancre," published a few
months since by M. Ricord, which affords a large amount of new and instructive material on many
controverted points.   In the  previous edition, M. Ricord's additions amounted to nearly one-third
ofthe whole, and with the matter now introduced, the work may be considered to present his views
and experience more thoroughly and completely than any other.  The value of the original treatise
of Mr. Hunter is too well known to require praise.  Perhaps no medical work in the English lan-
guage has so thoroughly stood the test of lime, or has so completely assumed the position  of a
classic, and a volume like the present, containing the united  labors of the highest authorities on so
difficult and important a subject, becomes ind^pensable to all who desire  to keep themselves on a
level with the progress of medical science.
  Every one will recognize the attractiveness and
value which this work derives from thus presenting
the opinions of these two maeiers side by side.  But,
it must be admitted, what has made the fortune of
the book, is the fact that it contains the " most  com-
plete embodiment of the veritable doctrines of the
llfipital du Midi," which has ever been made public.
The doctrinal ideas of M. Ricord, ideas which, if not
universally adopted, are incontestably dominant, have
heretofore only been interpreted by more or less skilfu 1
                                            secretaries, sometimes accredited and sometimes not.
                                              In the notes to Hunter, the master substitutes him-
                                            self for his interpreters, and give? his original thoughts
                                            to the world in a lucid and perfectly intelligible man-
                                            ner.  In conclusion we can say that this is incon-
                                            testably the best treatise on syphilis  with which we
                                            are acquainted, and, as we do not often employ the
                                            phrase, we may be excused for expressing the hope
                                            that it may find a place in the library of every phy-
                                            sician.— Virginia Med. and Surg. Journal.
                                 BY THE SAME AUTHOR.
RICORD'S LETTERS ON SYPHILIS.  Translated by W. P. Lattimore, M. D.
  In one neat octavo volume, of 270 pages, extra cloth.   $2 00.
                        ROKITANSKY
    Curator of the Imperial Pathological Museum,
A  MANUAL  OF PATHOLOGICAL
  bound in two. extra cloth, of about 1200 pages
  king, C. H. Moore, and G. E. Day.  $5 50
  The profession is too well acquainted with the re-
putation of Rokitansky's work to ne«d our assur-
ance that this is one of the most profound, thorough.
and valuable  books ever issued from the medical
press.  It is sui generis, and has no standard of com-
parison. It is only necessary to announce that it is
issued in a form as cheap as is compatible  with its
size and preservation, and its sale  follows as a
matter  of course.  No library can be called com-
plete without it.—Buffalo Med. Journal.

  An attempt to give our readers any adequate idea
of the vast amount of instruction accumulated  in
these volumes, would  be feeble and hopeless.  The
effort of the  distinguished author to concentrate
in a small space his great fund of knowledge, has
(CARL),  M.D.,
and Professor at the University of Vienna, Ac.
  ANATOMY.   Four  volumes,  octavo,
  Translated by W. E. Swaine, Edward Sieve-


 bo charged his text with valuable truths, that any
 attempt of a reviewer to epitomize is at once para-
 lyzed, and must end in a failure.—Western Lancet.
   As this is the highest source of knowledge upon
 the  important subject of which it  treats, no real
 student can afford to be without it.  The American
 publishers have entitled themselves to the thanks of
 the profession of their country, for this tiineous and
 beautiful edition.—Nashville Journal of Medicine.
   As a book of reference, therefore, this work must
 prove of inestimable value, and we cannot too highly
 recommend  it to the profession.—Charleston Med.
 Journal and Review.
   This book is a necessity to every practitioner.—
 Am. Med. Monthly.
                           RIGBY  (EDWARD), M.D.,
                    Senior Physician to the General Lying-in Hospital. Ac
A  SYSTEM  OF  MIDWIFERY.   With  Notes and  Additional  Illustrations.
  Second American Edition.  One volume octavo, extra cloth, 422 pages.  $2 50.
                        by the same author.  (Now Ready, 1857 )
ON THE  CONSTITUTIONAL   TREATMENT OF  FEMALE  DISEASES.
  In one neat royal 12mo. volume, extra cloth, of about 250 pages.  $1  00.

ROYLE'S  MATERIA  MEDICA  AND  THERAPEUTICS;  including  the
  Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United %ratP*
  With many new medic nes.  Edited by  Joseph Carson, M. D.  With ninety-eight iUustra ions"
  In one large octavo volume, extra cloth, of about 700 pages.  $3 00.      Y  g  ulU8lrallon8 
AND  SCIENTIFIC PUBLICATIONS.                   27
                     RAMSBOTHAM  (FRANCIS  H.), M.D.
THE  PRINCIPLES  AND PRACTICE OF  OBSTETRIC MEDICINE AND
  SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly
  revised by the Author.   With Additions by W. V. Keating, M. D.  In one large and handsome
  imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-
  four beautiful Plates, and numerous Wood-cuts in the  text,  containing in all nearly two hundred
  large and beautiful figures. $5 00.
  In calling the attention of the profession to the new edition of this standard work, the publishers
 would remark that no efforts have been spared to secure for it a continuance and extension of the
 remarkable favor with which it has been received.  The last London issue, which was considera-
 bly enlarged, has received a further revision from the author,  especially for this country.  Its pas-
 sage through the press here has been supervised by Dr. Keating, who  has made numerous addi-
 tions with a view of presenting more  fully  whatever was  necessary  to adapt it thoroughly to
 American modes of practice.  In its mechanical execution, a like superiority over former editions
 will be found.
                           From Prof. Hodge, of the University of Pa.
  To the American public, it  is most valuable, from its intrinsic undoubted excellence, and as being
 the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout
 our country.
  The publishers have shown their appreciation of | cine and Surgery to our library, and confidently
 the meritBof this work and secured its success by! recommend it to our readers, with the assurance
the truly elegant style in which they have brought
it out, excelling themselves in its production, espe-
cially in its plates.  It is dedicated to Prof. Meigs,
and has the emphatic endorsement of Prof. Hodge,
as the best exponent of British  Midwifery.  We
know of no text-book which deserves in all respects
to be more highly recommended to students, and we
could wish to see it in the handsof every practitioner,
for they will find it invaluable for  reference.—Med.
Gazette.
  But once in a long time some brilliant genius rears
his head above the  horizon of science, and illumi-
nates and purifies every department that he investi-
gates ; and his works become types, by which innu-
merable imitators model their feeble  productions.
Such a genius we find in the younger Ramsbotham,
and such a type we find in  the work now before us.
The binding, paper, type, the engravings and wood-
cuts are all so excellent as to make this book one of
the finest specimens of the art of printing  that have
given such a world-wide reputation  to its enter-
prising and liberal publishers. We welcome Rams-
t>otham's Principles and Practice of Obstetric Medi-
that it will not disappoint their most sanguine ex-
pectations.—Western Lancet.
  It is unnecessary to say anything in regard to the
utility of this work.  It is already appreciated in our
country for the value of the matter, the clearness of
its style, and the fulness of its illustrations. To the
physician's library it is indispensable, while to the
student as a  text-book, from which to extract the
material for laying the foundation of an education on
obstetrical science, it has no superior.—Ohio Med.
and Surg. Journal.

  We will only add that the student will learn from
it all he need to know, and the practitioner will find
it, as a book of reference, surpassed by none other.—
Stethoscope.
  The character and merits of Dr. Ramsbotham'a
work are so well known and thoroughly established,
that comment is unnecessary and praise superfluous.
The illustrations, which are numerous and accurate,
are executed in the highest style of art.  We cannot
too highly recommend the work to our readers.—St.
Louis Med. and Surg.  Journal.
                      SCHOEDLER (FRIEDRICH), PH.D.,
                        Professor ofthe Natural Sciences at Worms, Ac.

THE  BOOK  OF NATURE;  an Elementary Introduction to  the  Sciences of
  Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology.  First
  American  edition, with a Glossary and other Additions and Improvements; from  the second
  rcSh edXTranslated from  the  sixth German edition, by rWv Medlock, F. C. S, &c.
  fn !me voCe%mall octavo, extra cloth, pp. 692, with 679 illustrations.  * 1 80.

                           SMITH  (HENRY  H.), M.D.,
                   Professor of Surgery in the University of Pennsylvania, Ac.

MTNOTt SURGERY; or, Hints on the  Every-day Duties of the Surgeon.   Illus-
  .  ,«j i«, two hundred and forty-seven  illustrations.  Third and enlarged edition.  In one hand-
  l^^ll «SvoTum"f  PP- 456.  In leather, S2 25; extra cloth, $2 00.
                                BY THE SAME AUTHOR, AND
                         HORNER  (WILLIAM E.),  M. D.,
                   Late Professor of Anatomy in the University of Pennsylvania.

 am  ANATOMICAL ATLAS, illustrative of the Structure of the  Human Body.
A£ ot  vtumi largf imperial octavo, extra cloth, with about six hundred and fifty  beautiful

  figures.  «             ,  ...j  __j  _.„„..,,. „   iate the  student upon the completion of this Atlas,
                                              as it is  the most convenient work of the kind that
                                              has yet appeared ; and we must add, the very beau-
                                              tiful manner in which it is " got up" is so creditable
                                              to the country as to be flattering to our  national
                                              pride.—American Medical Journal.
  These figures are  well selected,  and present a
„„i,nlete and accurate representation of that won-
derfS  febrS, ?he human body.  The plan of  tins
Atlas  which renders it so pecuharly  convenient
for the sTudent, and its superb artistical execution,
have been akeady pointed out.   We must congratu-
                           SMITH <W.  TYLER),  M.  D.,
                       Physician Accoucheur to St. Mary's Hospital, &c.

nxr  PARTURITION,  AND   THE  PRINCIPLES   AND  PRACTICE  OF
0OBS?EtScS   Inone royal 12mo. volume, extra doth, of 400 pages.  $1 25.

                                  BY THE SAME AUTHOR.

a  praPTTCAL TREATISE  ON  THE PATHOLOGY  AND  TREATMENT
  OF ^EUCORRHCEA   With numerous illustrations.  In one very handsome octavo volume,

  extra cloth, of about 250 pages.
$1 50. 
28
BLANCHARD & LEA'S  MEDICAL
      SHARPEY (WILLIAM), M. D.,  JONES  QUAIN, M. D., AND
                       RICHARD  QUAIN,  F. R.  S., &.C.
HUMAN ANATOMY.   Revised, with Notes and Additions, by Joseph Leidt,
  M  D., Professor of Anatomy in the University of Pennsylvania.  Complete in two large octavo
  volumes, leather, of about thirteen hundred pages.  Beautifully illustrated with over five hundred
  engravings on wood.  $6 00.
  We have no hesitation in recommending this trea-
tise on anatomy as the most complete on that sub-
ject in the English language;  and  the only one,
perhaps, in any language, which brings the state
of knowledge forward  to the most recent disco-
veries.—The Edinburgh Med. and Surg. Journal.
                            SARGENT (F. W.),  M.  D.
ON BANDAGING  AND  OTHER OPERATIONS OF MINOR SURGERY.
  Second edition, enlarged.  One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood-
  cuts.  Extra cloth, $1 40; leather, $ 1 50.
  Sargent's Minor Surgery has always been popular,
and deservedly so. It furnishes that knowledge ofthe
most frequently requisite performances of surgical
art which cannot be entirely understood by attend-
ing clinical lectures.  The art of bandaging, which
is regularly taught in Europe, is  very frequently
overlooked by teachers in this country; the student
and junior practitioner, therefore, may often require
that knowledge which this little volume so tersely
and happily supplies.—Charleston Med. Journ. and
Review, March, 1856.
  A work that has been so long and favorably known
to the profession as Dr.  Sargent's Minor Surgery,
needs no commendation from us. We would remark,
however, in this connection, that minor surgery sel-
dom gets that attention in our schools that its im-
portance deserves. Our  larger works are also very
defective in their teaching on these small practical
points.  This little book will supply the void which
all must feel who have not studied its pages.—West-
ern Lancet, March, 1856.
SKEY'S OPERATIVE SURGERY.  In one very
  handsome octavo volume, extra cloth, of over 650
  pages, with about one hundred wood-cuts. $3 25.
STANLEY'S  TREATISE ON DISEASES OF
  THE BONES. In one volume, octavo, extra cloth,
  286 pages. $1 50.
SOLLY ON THE HUMAN BRAIN; its Structure.
  Physiology, and Diseases. From the Second and
  much enlarged London edition.  In  one octavo
  volume, extra cloth, of 500 pages, with 120 wood-
  cuts. $2 00.

SIMON'S GENERAL PATHOLOGY, as conduc-
  ive to the Establishment of Rational  Principles
  for the prevention and Cure of Disease.  In one
  neat octavo volume,  extra cloth, of 212 pages.
  SI 25.
                            TANNER (T.  H.),  M. D.,
                          Physician to the Hospital for Women, Ac.

 A  MANUAL  OF CLINICAL  MEDICINE AND  PHYSICAL DIAGNOSIS.
  To which  is added The Code of Ethics of the American Medical Association.   Second
  American Edition. In one neat volume, small 12mo., extra cloth, 87, cents.
  The work is an honor to its writer, and must ob- I tioners, it has only to be seen, to win for itself a
 tain a wide circulation by its intrinsic merit alone, place upon the shelves  of every medical  library.
 Suited alike to the wants of students and practi- | —Boston Med and Surg. Journal.

                                   Now Complete.
                 TODD (ROBERT BENTLEY), M. D.,  F. R. S.,
                    Professor of Physiology in King's College, London; and
                         WILLIAM BOWMAN, F. R. S.,
                     Demonstrator of Anatomy in King's College, London

 THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.  With
  about three  hundred large and beautiful illustrations  on wood. Complete in one larse  octavo
  volume, of 950 pages, leather.  Price $4 50.
  EF" Gentlemen who have received portions of this work, as published in the " Medical News
 and Library," can now complete their copies,  if immediate application be made.  It will  be fur-
 nished as follows, free by mail, in paper covers, with cloth backs.
  Parts  I., II., III. (pp. 25 to 552), $2  50.
  Part IV. (pp. 553 to end, with Title, Preface, Contents, &c),  $2 00
  Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Co
  A magnificent contribution to British medicine,
and the American physician who shall fail to peruse
 it, wih have failed to read one of the most instruc-
Contents, &c),  $1 25.
tive books of the nineteenth century.—N. O. Med
and Surg. Journal, Sept. 1857.
  It is more concise than Carpenter's Principles, and
more modern than the accessible edition of MQller'e
Elements; its details are brief, but  sufficieit;  its
descriptions vivid ; its illustrations exact and copi-
ous ; and  its  language terse and perspicuous___
Charleston Med. Journal, July, 1857.

  We know of nc work on the subject of physiology
so well adapted to the wants of the medical student.
Its completion has been thus long delayed, that the
authors mightsecure accuracy by personal observa-
tion.—St. Louis Med. and Surg. Journal, Sept. '57.
  One of the very best books ever issued from any
medical press.  We think it indispensable to every
readingrnedical man, and it may, with all propriety,
and with the utmost advantage be mace a text-book
by any student who would  thoroughly comprehend
the groundwork of medicine.—N. O. Med. News
June, 1857.

  Our notice, though it conveys but a very feeble
and imperfect idea of the magnitude and importance
of the work now under consideration, already tran-
scends our limits ; and, with the  indulg. nee of our
readers, anil the hope that they will peruse the book
tor themselves, as we feel we can with  confidence
recommend it, we leave it in their hands for them
to judge of its merits—The Northwestern Med. and
Surg. Journal, Oct. 1857.
                     TODD (R.  B.), M. D.,  F. R. S., &.C
CLINICAL  LECTURES  ON CERTAIN DISEASES  OF THE TTRTNARV
                                                        (Just Issued, 1857.)  $1 50.
ORGANS AND ON DROPSIES.  In one octavo volume. 
AND SCIENTIFIC  PUBLICATIONS.                   2'J
                    TAYLOR (ALFRED S.), M. D., F. R. S.,
               Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.   Fourth American  Edition.   With Notes and
  References to American Decisions, by Edward Hartshorns, M. D. In one large octavo volume,
  leather, of over seven hundred pages.   $3 00.
  This standard work has lately received a very thorough revision at the hands ofthe author, who
has introduced whatever was necessary to render it complete and satisfactory in carrying out the
objects in view.   The editor has likewise used every exertion to make it equally thorough with
regard to all matters relating to the practice of this country.  In  doing this, he has carefully ex-
amined all that has appeared on the subject since the publication of the last edition, and has incorpo-
rated all the new information thus presented.  The work has thus been considerably increased in
size, notwithstanding which, it has been kept at its former very moderate price, and in every respect
it will be found worthy of a continuance of the remarkable favor which has carried it  through so
many editions on both sides of the Atlantic.  A few notices of the former editions are appended.
we do not hesitate to affirm that after having once
commenced its perusal, few could be prevailed upon
to desist before completing it. «Iu  the last London
edition, all the newly observed  and  accurately re-
corded facts have been inserted, including much that
is recent of Chemical, Microscopical, and Patholo-
gical research, besides papers on numerous subjects
never before published.-Charieston Medical Journal
and Review.

  It is not excess of praise to say that the volume
before us  is the very best treatise extant on Medical
Jurisprudence.  In saying this, we do not wish to
be understood as detracting from the merits  of the
excellent works of Beck, Ryan, Traill, Guy, and
others; but in interest and value we think it must
be conceded that Taylor is superior to anything that
has preceded it.—N. W. Medical and  Surg. Journal.
  We know of no work on Medical Jurisprudence
which contains in the same space anything like the
same amount of valuable matter.—N. Y. Journal of
Medicine.
  No work upon the  subject can be put into the
hands of students either of law or medicine which
will engage them more closely  or profitably; and
none could be offered to the busy practitioner of
either calling,  for the purpose of  casual or hasty
reference, that would be more likely to afford the aid
desired. We therefore recommend it as the best and
safest manual for daily use.—American Journal of
Medical Sciences.
  This work of Dr. Taylor's is generally acknow-
ledged to be one of the ablest extant on the subject
of medical jurisprudence.  It is certainly one of the
most attractive books that we have met with; sup-
plying so  much both to interest and instruct, that |
                          BY the same  author.  (Nearly Ready.)

ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND
   MEDICINE.  Second American, from a second and revised London edition.   In one large
   octavo volume.
   The length of time which has elapsed since the first appearance of this work, has wrought so
 rreat a change in the subject,  as to require a very thorough revision to adapt the volume to the
 nre*ent wants of the profession.  The rapid advance of Chemistry has introduced into u-e many
 new substances which may become fatal  through accident, carelessness, or design—while at the
 same time it has likewise designated new and more exact modes of counteracting or detecting those
 Dreviouslv treated of.  Mr. Taylor's position as the leading medical jurist of England, has during
 this neriod conferred on him extraordinary advantages in acquiring experience in all that relates to
  his department, nearly all cases of moment being referred to him for examination, as an expert
 whose testimony is generally  accepted as final.  The  results of his labors therefore, as gathered
 Aetherithis volume, carefully  weighed and sifted, and presented  in  the clear and intelligible
 stf fe for which he is noted, may be received as an acknowledged authority, and as a guide to be
 followed with implicit confidence.

                             WILSON (MARRIS),  M. D.
  ON  DISEASES OF THE VESICULA SEMINALES.   See  "Lallemand,"

    page 19._______________

                      WILLIAMS  (C. J.  B.),  M.D., F. R. S.,
                  Professor of Clinical Medicine in University College, London, Ac.

  P-RTNCIPLES  OF MEDICINE.   An  Elementaiy View  of the  Causes, Nature,
    Vr -Totmont Diagnosis  and Prognosis of Disease; with  brief remarks on Hygienics, or  the pre-
    JervatTon of&   A new American, from the third and revised London edition.  In one octavo
    volume  leatner,  of about 500 pages.   $2 50.   (Just Issued.)
    Thp vprv reCent and thorough revision which this work has enjoyed at the hands of the author
  u  u   JZ,  if «n oomoletelv up to the present state ofthe subect that m reproducing it no addiuons
  has brought  it so completely up to ™£     . h  fa     k h'   herelofore met shows that its  im-
  have been found necessary.  1 he .,u^ef ™en?}    it wi„ ^ found eminently worthy a  continu-
  portance ^s been app ectated  a    nJP^    lorn            q  ^ ^j.^ q{ ^  ^.^

  *?*% °  and mSS Cm theldm  able manner inVhich the various inquiries in the  different
  student and practi '°ne^ f ^^j  ted> combined and generalized by an experienced practical phy-

  Si^idX^J^a^^ ta^^^ «d treatment of di*«e.
  sician, an                             _----A  recommend it for a text-book, guide, and  constant
                                                companion to every practitioner and every student
                                                who wishes to extricate himself from the well-worn
                                                ruts of empiricism, and to base his practice of medi-
                                                cine upon principles.—London Lancet.
                                                 A text-book to which no other in our language is
                                                comparable.—Charleston Medical Journal.
                                                 No work has ever achieved or maintained a more
                                                deserved reputation.—Va. Med. and Surg. Journal.
  We find that the deeply-interesting matter and
style of ?his book have so far fascinated us, that w
h/ve unconsciously hung upon its pages, not too
hmr indeed for our own profit, but longer than re-
v ewers can be permitted to indulge.  We leave the
fuXf analysis to the studentand practitioner.  Our
further anaiv»i          already been sufficiently
judgmen  of the work ms      y           ,ified

Se 8 The'vork .not of a controversial, but of
Ed dactic character; and a. such we hail  it, and
            ~ ™T rrtit? rumps AND TREAT- I  Second American Edition.  In one volume, octa-
^P^i^Sw^OH^mSSIriA  vo, extra cloth, pp 308.  81  75. 
30
BLANCHARD &  LEA'S  MEDICAL
1
            New and much enlarged edition—(Now Ready, Oct. 1858.)

                        WATSON (THOMAS), M.  D.,  8iC.
                        Late Physician to the  Middlesex  Hospital, Ac.

LECTURES  ON   THE  PRINCIPLES  AND   PRACTICE  OF  PHYSIC.
  Delivered at King's  College, London.  A new American,  from the  last revised and enlarged
  English edition, with Additions, by D. Francis Condie,  M. U., author of "A Practical Treatise
  on the Diseases of Children," &c.  With one hundred and eighty.five illustrations on wood.  In
  one very large and hand^me volume, imperial octavo, of over 1200 closely  printed pages in
  small type; the whole strongly bound in leather, with raised bands.  Price $4 25.
  The publishers feel that they are rendering a service to the American profession in presenting at
so very moderate a price this vast  body of sound practical information.  Whether as a guide for
the student entering on a course of instruction, or as a  book of reference for daily consultation by
the practitioner,  " Watson's Practice" has long been regarded as second to none; the soundness
and fulness of its teachings, the breadth and  liberality of its views, and the easy and flowing style
in which it is written having won for it the  position of  a general favorite.  That  this high reputa-
tion might be fully maintained, the author has subjected it to a thorough revision ; every portion
has been examined with the  aid of the most recent researches in pathology, and the results  of
modern investigations in both  theoretical and practical subjects have  been carefully weighed and
embodied throughout  its pages.   The watchful scrutiny of  the editor has likewise  introduced
whatever possesses immediate importance to the American physician in relation to diseases inci-
dent to our climate  which are little known in England, as well as those points in which experience
here has  led to different modes of practice;  and he has  also added largely to the series of illustra-
tions, believingthat in this manner valuable assistance may be conveyed to the student  in elucidat-
ing the text.  The work will,  therefore, be found thoroughly on a  level with the most advanced
state of medical science on both sides of the Atlantic.
  The additions which the work has received are shown by the fact that notwithstanding an en-
largement in the size of the page, more than  two hundred  additional  pages have  been necessary
to accommodate the two large volumes of the London edition (which sells at ten dollars), within
the compass of a single volume, and  in its  present form it contains the matter of at  least  three
ordinary  octavos.  Believing it to be a work which should  lie on the table of every physician, and
be in the  hands of every student, the publishers have put it at a price within the reach of all, making
it one of  the cheapest books as yet presented to the American  profession, while at the  same  time
the beauty of its mechanical execution renders it an exceedingly attractive volume.
  It would appear  almost superfluous  to adduce commendatory notices of a work which has so
long been established in the position of a standard authority as "Watson's  Practice."  A few ex-
tracts are, however, subjoined from reviews of the new and improved edition.
  The fourth edition now appears, so carefully re-  j   The lecturer's skill, his wisdom, his learning,ara
vised, as to add considerably to  the value of a hook  equalled by the ease of his graceful diction, his elo-
already acknowledged, wherever the English  Ian-   quence, and the  far higher qualities of candor,  of
guage is read, to be beyond all comparison the  best  courtesy, of modesty, and of generous appreciation
sjstematic work on the Principles and Practice of  of merit in others.  May he long remain to instruct
Physic in the whole rauge of  medical literature.  , us, and to enjoy, in the glorious  sunset of his de-
Every lecture contains proof of the extreme anxiety  dining years, the  honors,  the confidence and love
of the author to keep pace with he advancing know-I gained during his useful life.—AT. A.  Med-Chir.
ledge of the day, and to bring the  results of  the  Review, July, 1858
labors, not only of physicians, but of chemists and |
histolugists, before his readers,  wherever they can  i   Watson's  unrivalled, perhaps  unapproachable
he turned  to useful account.  And this is  done with ! work on Practice—the copious additions made  to
such a cordial appreciation of the merit due to  the
industrious observer, such a generous desire to  en-
courage younger and rising men, and such a candid
acknowledgment of his own  obligations  to them,
that one scarcely Knows whether to admire most the
pure, simple, forcible English—the vast amount of
useful  practical  information  condensed  into  the
Lectures—or the  manly, kind-hearted, unassuming
character of the lecturer shining through his work.
—London Med. Times and Gazette, Oct. 31, 1857.
  Thus these  admirable  volumes come before  the
profession in their fourth edition, abounding in those
distinguished attributes  of moderation, judgment,
erudite cultivation, clearness, and eloquence, with
which they were from the first invested,  but  yet
richer than before in the results of more prolonged
observation, and  in  the able appreciation of  the
latest advances in pathology and medicine by one
of the most profound medical thinkers of the day.—
London Lancet, Nov. 14, 1657.
which (the fourth edition)  have given it all the no-
velty and much of the interest of a  new book.—
Charleston Med. Journal, July, 1&58.

  Lecturers, practitioners, and students of medicine
will equally hail the reappearance of the work of
Dr. Watson in the form of a new—a fourth—edition.
We merely do justice to our own feelings, and, we
are sure, of the whole profession, if we thank him
for having, in the  trouble  and turmoil of a large
practice, made leisure to supply the hiatus caused
by the exhaustion  of the publisher's stock of the
third edition, which has been severely felt for the
last three years.   For Dr. Watson has not merely
caused the lectures to be  reprinted, but scattered
through the whole  work we find additions or altera-
tions which prove  that the author has in every way
sought to bring up  his teaching to the level of cha
most recent acquisitions in science.—Brit, and For.
Medico-Chir. Review, Jan. 1858.
                               WHAT TO  OBSERVE
AJ\,TP?  BEDSIDE  AND   AFTER  DEATH,   IN  MEDICAL  CASES

  iTSeSS^                                               roVat^exS


vaHe^^

                                    WILDE (W.  R.),
                  Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin

A£aRs^o|UtRheEeRar' A£LThH^ NATURE  AND  TREATMENT OF DIS-
  SluS?ations.  $2 80.       ^ "* handS°me °CtaV° V°lume> e*tra <*>*, <*  476 pages,  with 
AND  SCIENTIFIC PUBLICATIONS.                   31
            New and much enlarged edition—(Now Ready, Oct. 1858.)

                          WILSON  (ERASMUS),  F.  R.S.,
A  SYSTEM  OF HUMAN  ANATOMY,  General and  Special.   A new and re-
  vised American, from the last and enlarged Engli.-h Edition. Edited by W. H. Gobrecht, M. D.,
  Professor of Anatomy in the Philadelphia Medical College, &c.  Illustrated with three hundred
  and ninety-seven engravings on wood.  In one  large and exquisitely printed octavo volume, of
  over 600 large pages; leather.   $3 25.
  The publishers trust that the well earned reputation so  long enjoyed by this work will be more
than maintained by the present edition.  Besides a very thorough revision by the author, it has been
most carefully examined by the editor, and the efforts of both  have  been  directed to introducing
everything  which increased experience in its use has suggested as desirable to render it a complete
text-book for those seeking to obtain or to  renew an acquaintance with Human  Anatomy.   The
amount of additions which it has thus received may be estimated from the fact  that the present
edition contains over one-fourth  more matter than the last, rendering a smaller type and an enlarged
page requisite to keep the volume within a convenient size.  The author has not only thus added
largely to the work, but  he has also made alterations throughout, wherever  there appeared the
opportunity of improving the arrangement or style,  so as to present  every fact in its most appro-
 priate  manner, and to render the whole  as clear  and intelligible  as possible.  The editor has
 exercised the utmost caution to obtain entire  accuracy in the text, and has largely increased the
 number of  illustrations, of which there are about one hundred and  fifty more in this edition than
 in the last, thus bringing distinctly before the eye ofthe student everything of interest or importance.
   The publishers have felt that  neither care nor  expense should be spared to render the external
 finish ofthe volume worthy of the universal favor with which it has been received by the American
 profession, and they have endeavored consequently to produce in its mechanical execution an im-
 provement corresponding with that which  the  text has enjoyed.  It will  therefore be found one of
 the handsomest specimens of typography as yet produced in this country, and in all respects suited
 to the office table of the practitioner, notwithstanding the exceedingly low price at which it has
 been placed.
    A few notices of former editions are subjoined.
   This is probably  the prettiest medical book ever
 published,  and we  believe that its intrinsic  merits
 are in keeping with its exterior advantages, having
 examined it sufficiently to satisfy us that it may  be
 recommended to the student as no less distinguished
 by its accuracy and clearness of description than by
 its typographical elegance. The wood-cuts are ex-
 quisite.— British and Foreign Medical Review.
    An elegant edition of one of the most useful and
  accurate systems of anatomical science which has
  been isBued from the press.  The illustrations are
  really beautiful.  In its style the work is extremely
  concise and intelligible.  No one can possibly take
  up this volume without being struck with  the great
  beauty of  its mechanical execution, and the clear-
  ness of the descriptions which it contains is equally
evident.  Let students, by all means examine the
claims of this work on their notice, before they pur-
chase a text-book  of the vitally important science
which this volume so fully  and easily unfolds.—
Lancet.

  In every respect, this work, as an anatomical
guide for the student who seeks to obtain know-
ledge which he has not yet acquired, and  for the
practitioner who wishes to keep up that  which he
find'1  gradually fading from  his mind, merits our
warmest and most decided praise.—Med. Gazette.
  We regard  it. as the best Bystem now  extant for
students"—Western Lancet.
  It therefore receives our highest commendation.—
Southern Med. and Surg. Journal.
                         BY THE SAME AUTHOR.  (Just Issued.)

ON DISEASES OF THE SKIN.   Fourth  and enlarged American, from the last
  and improved London edition.  In one large octavo volume, of 650 pages, extra cloth, $2 75
  The writings of Wilson, upon diseases of the skin,
are by far  the most  scientific  and practical  that
have ever been presented to the medical world on
this subject. The present edition isagreat improve-
ment on all its predecessors.  To dwell upon all the
(treat merits and high claims ofthe work before us.
seriatim, would indeed be an agreeable service; it
would be a mental homage which we could freely
offer, but we should thus occupy an undue amount
ot space in this Journal. We will, howtver  look
at some of the more salient points with which it
abounds, and wh.ch make iiincompu.auiy superior in
excellence to all other treatises on the subject of der-
matology.  No mere speculative views are allowed
a place in this volume, which, without a doubt, will,
for a very long period, be acknowledged as the chief
standard work on dermatology.  The principles of
an enlightened and rational therapeia are introduced
on every appropriate occasion.  The general prac-
titioner and surgeon who, peradventure, may have
for years regarded cutaneous maladies as scarcely
worthy their  attention, because, forsooth, they are
not fatal in  their tendency;  or who, if they have
attempted their cure, have followed the blind guid-
ance of empiricism, will almost assuredly be roused
to a new and  becoming interest in this department
of practice,  through  the inspiring agency of  tnis
book.—Am. Jour. Med. Science, Oct. 1857.
                                     ALSO, NOW READY,

A  SERIES  OF  PLATES ILLUSTRATING WILSON ON  DISEASES  OF
  THF ^KIN •  consisting of nineteen beautifully executed plates, of which twelve are exquisitely
  PnloretV presenting the Normal Anatomy and Pathology of the Skin, and containing accurate le-
  presentaiions of about one hundred var.etie* of disease, most of them the size of nature.  Price
  in cloth $4 25.
  In beauty of drawing and accuracy and finish of coloring these plates will be found equal to
anything of the  kind as yet issued in this country
  One of the best specimens of colored lithographic
illustrations that have ever been pubfoshed in this
country   The  representations of  diseases of the
skin even to the most minute shade of coloring, are
remarkably accurate, giving the student or practi-
tioner a very correct idea of the disease he is study-
ing  We know of no work so well adapted to the
wants of the general practitioner as Wilson's,  with
Ihe accompi.uy.ng plates. - Med. and Surg. Re-
porter, May, 1853.
  We have already expressed our high appreciation
of Mr. Wilson's treatise on Diseases of the Skin.
The  plates  are  comprised  in a separate volume,
which we counsel all those who possess the text to
purchase.  It is a beautiful specimen of color print-
ing, and the representations  of the various forms of
skin disease are as faithful as is possible in plates
of the size.—Boston Med. and Surg. Journal, April
B, 1858. 
BLANCHARD  5s LEAS  MEDICAL  PUBLICATIONS.
                    WILSON (ERASMUS),  M. D., F. R. S.
                              Lecturer on Anatomy, London.
THE  DISSECTOR'S  MANUAL;  or, Practical and Surgical Anatomy.  Third
  American, from the last revised and enlarged  English edition.  Modified and  rearranged, by
  William Hunt, M. U.,  Demonstrator of Anatomy in the  University of  Pennsylvania. I"°ne
  large and handsome royal 12mo. volume, leather, of 582 pages, with  154 illustrations.  $2  00.
  The modifications and additions which this work has received in  passing recently through the
author's hands, is sufficiently indicated by the  fact that it is enlarged  by more than one hundred
pages, notwithstanding that it is printed in smaller type, and with a greatly enlarged page.
                                BY THE SAME AUTHOR.

ON  CONSTITUTIONAL  AND  HEREDITARY  SYPHILIS,  AND   ON
  SYPHILITIC ERUPTIONS.  In one small octavo volume, extra cloth, beautifully printed, with
  four exquisite colored plates, presenting more than thirty varieties of  syphilitic eruptions. $2 2D.
                                BY THE SAME AUTHOR.

HEALTHY SKIN; A Popular Treatise  on the Skin  and Hair, their  Preserva-
  tion and Management.  Second American, from the fourth London edition.   One neat volume,
  royal 12mo., extra cloth, of about 300 pages, with numerous illustrations.  $1 00; paper cover,
  75 cents.                         _________________

                                  (Now Complete.)
                           WEST (CHARLES), M.  D.,
Accoucheur to and Lecturer on Midwifery at St. Bartholomew's  Hospital, Physician to the Hospital for
                                   Sick Children, Ac.

LECTURES  ON  THE DISEASES OF WOMEN.  Now complete in one hand-
  some octavo volume, extra cloth, of about 500 pages; price  $2 50.

Also, for sale separate, Part  II, being pp. 309 to  end, with Index, Title matter,
  &c, 8vo., cloth, price $1.
J3P Copies done up in paper  covers, for mailing, will be sent, free of postage, to any address within
  the United States on receipt of One Dollar in current funds or  postage  stamps.   Subscribers to the
  "Medical News and Library" who received the first portion of this work as published in 1856
  and 1857, should lose no time in securing the completion.
Part I will no longer be sold separate.
  As the first part of this work formed a complete treatise on the Diseases of the Uterus, so Part
II is complete in itself as a text-book on the affections  ofthe  Uterine Appendages, the Ovaries,
Vagina, Bladder, and External Organs. It will be found  fully  to maintain  the high character ac-
quired by  the preceding portion  immediately on  its appearance,  and  the whole will constitute a
reliable text-book on this interesting and difficult branch of practice.
  A few notices of Part I are added.
painstaking, practical physician is apparent on every
page.—N. Y. Journal of Medicine, March, 1858.
  As a writer, Dr. West stands, in our opinion, se-
cond only to Watson, the" Macaulay of Medicine;"
he possesses that happy faculty of clothing instruc-
tion in easy garments; combining pleasure with
profit,  he leads his pupils, in spite of the ancient
proverb, along a royal road to learning.  His work
is one which will not satisfy the extreme on either
side, but it is  one  that will please the great ma-
jority who  are seeking truth, and one that will con-
vince the student that he has committed  himself to
a candid, safe, and valuable guide.  We anticipate
with pleasure the appearance of the second part of
the work, which, if it equals this part,  will com-
plete one of our very best volumes upon diseases of
females.—N. A. Med.-Chirurg. Review, July, 1858.
  We must now conclude this hastily written sketch
with the confident assurance to our readers that the
work will well repay perusal.  The conscientious,
                         BY THE SAME AUTHOR.  (Just Issued.)

LECTURES ON  THE DISEASES  OF INFANCY AND CHILDHOOD.
  Second American, from the  Second and Enlarged London  edition.   In one volume, octavo,
  extra cloth,  of nearly five hundred pages.  $2 00.
  We know of no treatise of the kind so complete
and yet so compact.—Chicago Med. Journal, Janu-
ary, 1858.
  A fairer, more honest, more earnest, and more re-
liable investigator of the many diseases of women
and children is not to be found in any country.—
Southern Med. and Surg. Journal, January 1858.

  We gladly recommend his Lectures as in the high-
est degree  instructive to all who are interested in
obstetric practice.—London Lancet.

  We have to say of it, briefly and decidedly, that
it is the best work on the subject in any language;
and that it stamps Dr. West as the facile princeps
of British obstetric authors.—Edinb. Med. Journ.
ligation by this able, thorough, and finished work
upon a subject which almost daily taxes to the ut-
most the skill of the general practitioner. He has
with singular felicity threaded  his way through all
the tortuous labyrinths of the difficult subject he has
undertaken to elucidate, and has  in many  of  the
darkest corners left a light, which will never be
extinguished.—Nashville Medical Journal.
  We take leave of Dr. West with great respect for
his attainments,  a due appreciation of his acute
powers of observation, and a deep sense of obliga-
tion for this valuable contribution to our profes-
sional literature.   His book is undoubtedly in many
respects the best we possess on diseases of children.
Dublin Quarterly Journal of Medical Science.
  Dr. West has placed the profession under deep ob-
                                 BY THE SAME AUTHOR.

AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER-
  ATION OF THE OS UTERI.  In one neat octavo volume, extra cloth.  $1 00.

                          YOUATT  (WILLIAM), V. S.

THE  DOG.   Edited by  E.  J.  Lewis,  M. D.   With  numerous  and beautiful
  illustrations.   In one very handsome volume, crown Svo., crimson cloth, gilt. $1 25. 
 
7 
 
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