■pysr^-; SP5fflK'^^2 ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 s ***** )/r o ' Section ..J.^Lk?..Ay^..:. Number ...2-^-.^-.^-.-/ Izi7z f'^yjftrJtelz.7t; JJJ ^ TaJsavi-.S'? y. Hzzz^jwozzx-Z; JiSo^JlLr.razi, Si A COMPLETE PRACTICAL TREATISE VENEREAL DISEASES AND THEIR IMMEDIATE AND REMOTE CONSEQUENCES. INCLUDING OBSERVATIONS ON ATTENDED WITH DISCHARGES. CERTAIN AFFECTIONS OF THE UTERUS, BY WILLIAM ACTON, LATE EXTERNE AT THE FEMALE VENEREAL HOSPITAL, PARIS. FIRST AMERICAN EDITION, WITH ADDITIONAL ILLUSTRATIONS AND COLORED PLATES. NEW YORK: J. S. REDFIELD, CLINTON HALL, CORNER OF NASSAU AND BEEKMAN STREETS. 1846. \ 1-%'fc* i--"> \'/^ ;i \\:J TO / PHILIP RICORD, D.M.P. SURGEON TO THE VENEREAL HOSPITAL, PARIS ; LAUREATE OF THE INSTITUTE OF FRANCE, &C, &C, &C. My dear Sir : Europe may admire the genius of the author of the " Traite Pra- tique sur I'lnoculation," the British critic may call you the French Hunter, and the Institute may crown you with its laurels ; but the pupil who, for a series of years, has watched you at the bedside, performing the varied experiments which are overturning long-received opinions, and collecting those facts which form the basis of a new school, can alone adequately feel, and sufficiently appreciate, that honest and manly candor which is always ready to acknowledge errors, and that generosity which allows others to participate in opinions still unpublished. To have acquired and still to retain the friendship of such a man, will always be a source of pride and satisfaction—feelings which have been not a little increased by your kindly permitting me to in- scribe this volume to you, and thus affording me an opportunity of stating to my countrymen the friendly relations which subsist be- tween us. Believe me, my dear Sir, To be your grateful friend, WILLIAM ACTON. 5, -George Street, Hanover Square, March, 1841. PREFACE. Among the valuable works and monographs which the English language possesses on the subject of this treatise, a surgical lecturer would be embarrassed in selecting or recommending any one book as affording a complete view of Venereal Diseases. Volumes en Stricture, Syphilis, Gonorrhoea, &c, fill his shelves, and each work has its peculiar recommendations ; but, with the exception of Astruc and Hunter, he will in vain inquire for the authors who have treated on Venereal Diseases at length. The pupil who wishes to investigate this subject, is obliged to consult a variety of works, and he soon finds himself embarrassed by the most glaring contradictions between contemporary or preceding writers, and the limited number of cases that come under his obser- vation does not allow him to separate what is truly valuable from among the chaotic mass of authorities. The author has attempted to fill up this blank in medical literature ; he has consulted the principal authors that have written on the sub- ject ; he has retained what is practical, and from the extensive op- portunities of observing the natural history of the disease, and the various plans of treatment in British and Continental hospitals, he hopes to have succeeded in reconciling some of the apparent incon- sistencies of previous writers ; and in presenting a body of doctrines compatible with the present advanced state of Pathology. Once for all, he pleads guilty to the charge of introducing some few terms new to English readers, and leaves them, in the words of Johnson, " Candidates or probationers, which must depend for their adoption on the suffrage of futurity." Let the critic suspend his 6 PREFACE. judgment upon them until he be in possession of the reasons which induced the author to attempt to alter the nomenclature of his sub- ject. Although fully aware of the truth of the observation of Hooker, that " change is not made without inconvenience, even from worse to better," still he has not dared to preserve terms sanctioned by their antiquity, " such as hernia humoralis and condylomata? at the expense of rendering himself unintelligible. The reader will find a very copious Analytical Table of Contents, which, it is hoped, will at once explain the system followed, and enable him to refer to any subject he may wish to investigate. The author can not but refer with pleasure to the illustrations ; and hopes that being the first of the kind that have ever been published in England, they will meet with the approbation of the profession. The original drawings, he feels confident, bear the stamp of their own value as true copies of nature, and he has only to add that they were chosen from among the thousands of cases witnessed at M. Ricord's Clinique, and submitted to his approbation. He has spared no expense in securing the assistance of first-rate artists, as the exe- cution of the plates proves. He would ill requite the favor that has been shown him, did he not publicly acknowledge how much he is indebted to the scientific liberality of the administration of the French hospitals, as well as to the surgeons of the female venereal institutions, in placing the patients at his disposal; thus affording him unexampled opportunities of studying female complaints. How far he has profited by such op- portunities the Plates themselves will testify ;—how deeply he is indebted to the officers of those institutions, no words can express. ANALYTICAL TABLE OF CONTENTS. INTRODUCTION. HISTORY OF VENEREAL DISEASES. Reasons for supposing that venereal diseases were known to the ancients ; historical documents cited to prove this position from Leviticus, the Proverbs, Ecclesiastes; quota- tions from Peter Paul Vergerius, Gulielmus de Saliceto, Bartholomew Glanville, Lan- franc of Milan, Bernard Gordon, Petrus de Argeleta ; notices by Beckett in the Philoso- phical Transactions; quotations from John of Gaddesden ; different terms by which the disease was known at the commencement of the sixteenth century ; first called venereal disease by Bethencourt; description of the disease by Fracastorius, as seen in 1530 ; extract from the writings of Fernel in 1548; first methodical account of the effects of the disease given by Astruc ; summary of that author's opinions ; analysis of John Hunter's views ; those of Benjamin Bell; opinions of Broussais ; investigations of M. Ricord : divisions of the subject which he adopts. [Page 17^ History of the Theories entertained on the Nature and Origin of Vene- real Diseases.—Slight allusions in the sacred writings; opinions of the Greek and Latin authors ; theories of the thirteenth century; origin attributed to sidereal influence toward the fifteenth and sixteenth centuries ; opinion of Van Helmont; general belief at that time that the venereal disease was unknown previously to the taking of Naples; opinion of Astruc, Sanchez, Hunter, and Broussais ; belief in the spontaneous origin of venereal diseases; opinions of M. Ricord and the author that syphiloid diseases, or non-virulent affections, may arise spontaneously, and that syphilis or the virulent affec- tions never arise spontaneously at the present day ; origin of syphilis not known; similar ignorance as to the origin of other morbid poisons; probable causes of the aggravated forms in which it is generally met with. [p. 23. PART I. SYPHILOID DISEASES. CHAPTER I. BLENNORRHAGIA. Definition of syphiloid diseases ; meaning of the word blennorrhagia ; synonymous terms ; reasons for preferring the term blennorrhagia; observations on blennorrhagia as it occurs on all or any of the mucous membranes; predisposing causes; age; sex; opinion of M. Lisfranc : influence of temperament; locality; season; hygiene. [p. 27. Exciting Causes.—Various articles of food; influence of onanism; local irritation; various eruptions; syphilis (secondary) how far an exciting cause ; case illustrative of labor; inattention to cleanliness; menstruation; worms. Reflections on the fore- going causes. [p. 30. 8 ANALYTICAL TABLE OF CONTENTS. Contagion : definition of; influence of; habit as a protection against the disease, case illustrative of this view ; the medical man must not be too credulous; form of certificate that a surgeon may be called upon to give. [P- 35- Epidemics of Blennorrhagia.—Description of one; how far deserving the name ; on the time that elapses between the action of the cause and the occurrence of the affec- tion ; case cited by Bell; explanation of. [P; 36 Symptoms.—Local symptoms ; characters of the discharge ; course of the affection ; may terminate in ; metastasis; resolution ; continuation under the chronic form. [p. 37. Pathology of Blennorrhagia.—Simple increased redness; excoriation; granu- lation ; ulceration; references to the plates ; recurrence of the disease. [p- 39. Complications.—Local swelling; buboes; hemorrhage ; chancre ; constitutional syphilis; rheumatism. [p. 41. Diagnosis.—Of the position of the affection derived from the secretions; their chymi- cal characters; physical characters; value of blood in the secretion, as a sign of the complication of chancre ; of semen; diagnosis of mind and virulent blennorrhagia; consideration of the previous opinions on this subject; buboes ; morality of the female ; color of the discharge ; the duration and acute nature of the complaint; induration; pain, &c, along the canal; M. Ricord's researches on this subject; inoculation the only sure sign ; means of forming a rational diagnosis. [p. 42. Prognosis; dependence upon the mucous membrane affected; influenced by the duration of the complaint; previous attacks; complications, &c. The probability of secondary symptoms; of swelled testicle occurring after peculiar treatments considered ; the circumstances which indicate that the complaint is contagious ; rules to be followed ; line of conduct the surgeon ought to adopt in delicate affairs. [p. 47. Treatment.—History of the various plans that have been recommended ; the opinion of the humoral pathologists; 'when and why mercury was used; treatment recom- mended by Sydenham ; Bell the first to propose a direct treatment; division of the sub- ject of treatment:—1. prophylactic ; 2. abortive ; 3. curative. [p. 49. Prophylactic Treatment.—Precautions to be taken, 1st, by diseased persons, so that they do not communicate the disease to healthy individuals; 2d, by a sound in- dividual who exposes himself to the contagion. [p. 51. Abortive Treatment.—Reasons for employing it; the objects we wish to attain; general means ; direct or local means. fp. 52. Curative Treatment.—In the acute stage ; remarks on the application of leeches; baths; injections; diluent drinks ; in the chronic stage, or blennorrhea; revulsive general treatment. [p. 54. Copaiba.—Therapeutic effects of; action on the stomach ; intestinal canal; urinary organs; skin ; nervous system ; the dose of copaiba necessary ; administration by the rectum; various forms under which it may be given. The copaiba capsules; their advantages; preference shown to those of M. Mothes ; dose; rules to be followed in the administration. _ [p._ 55. Cubebs.—Action on the stomach; ill effects which sometimes follow its administration; the dose of; manner of administering it; capsules of cubebs; action of cubebs on the urinary organs ; notice of turpentine ; tonics ; blisters. [p 59. Direct Treatment.—Enumeration of the preparations in use. [p. 60. CHAPTER II. observations on blennorrhagia in the male. Section I.—Balanitis.—Synonymous terms ; definition ; causes; influence of the prepuce. _ ... [P- 61- Symptoms.—Circumstances which may render the diagnosis difficult; course and termination of the complaint; complications ; secondary symptoms never follow simple balanitis; causes which have induced authors to form a different opinion. [p. 62. Diagnosis.—Difficulties that may present themselves; importance of inoculation, [p. 64. Prognosis. [p- 64. Treatment.—In simple cases; in inflammatory affections; treatment of the complica- tions • observations on phymosis; indications for the employment of cauterization and incision. [p- 64. SECTION II.—Gonorrhoea. Synonymous terms; reasons for retaining the term gonorrhoea. [p. 66. Causes.—Individual circumstances which predispose to gonorrhoea; influence of a large meatus urinarins; mechanism of the introduction of the contagious matter; the situation of gonorrhoea. [p. 66. ANALYTICAL TABLE OF CONTENTS. 9 Symptoms.—Cause of the dysuria, chordee, &c.; observations on the divisions of gonorrhoea, as described by Bell; reasons for not adopting them. [p. 67. Diagnosis.—Of a simple case ; difficulties that a surgeon may meet with ; means of ascertaining the exact situation of the affection ; importance of becoming acquainted with the exact seat of the disease, as foretelling the probable complications. [p. 68. Complications.—Abscess; inflammation of the prostate ; buboes; balanitis ; chancre ; immense practical importance of a knowledge of this complication. [p. 68. Chronic Gonorrhoea or Gleet.—Symptoms.—Nocturnal pollutions; influence on gleet; inflammatory stricture. Impotence—causes of; treatment of nocturnal pollu- tions. , a , tP- 69- Treatment of Gonorrhoea.—The abortive treatment; general and local means; plan of employing injections; position of the patient; sort of instrument; quantity of fluid; consequences which follow injections ; strength of the injection ; other plans of employing injections ; method recommended by Mr. Carmichael of Dublin; the reason why they have fallen into disrepute ; injections do uot occasion strictures; when arose this belief; proof that injections cure stricture. [P- 71- Curative Treatment of the Acute Stage of Gonorrhoea.—General and local treatment; treatment of complications; chordee; retention of urine; abscess; hemor- rhage ; inflammation of the neck of the bladder ; chancre; buboes. [P- 75. SECTION III.—Epididymitis. Synonymous Terms—from Sir A. Cooper, Sir B. Brodie, Wallace, Rochoux, Ri cord, &c. IP- 78' Symptoms first met with in the epididymis; condition of the gonorrheal discharge ; manner in which the other parts contained in the scrotum become successively attacked ; constitutional symptoms. [.P- 7?- Pathological Anatomy.—Cases cited by authors to prove that the affection is principally confined to the epididymis. [p- 80- Causes.—Predisposing ; exciting; period at which the exciting cause acts; the great importance of stati.stics in a therapeutical point of view. tyV' Complications.—Enumeration, and their relative frequency ; rarity of affection of the testis itself. tP" 89' Terminations.—Their importance and relative frequency. ..,. JP- -8?' Diagnosis— Cases which present peculiar difficulties; instance of epididymitis occurring when the testis was in the canal; all authors agreed that the epididymis is the first part affected; opinion of Sir A. Cooper, Sir B. Brodie, &c.; M. Velpeau[s means of detecting fluid in the tunica vaginalis; diagnosis of affection of the testis itself; eczema and its complications may occasionally simulate epididymitis; characters of abscess of the scrotum. . LP- 83, Prognosis.—Generally favorable; chances of the occurrence of complications con- sidered ; will the testis completely recover its functions? means of forming an Treatment.—Indications for the prevention of the complaint; observations on leeches; puncturing the scrotal veins; treatment necessary for the gonorrhoea; of the com- plications. ... IP" r Method of employing Compression.—Explanation of woodcut; consequences ot compression ; indications for its employment; counter-indications; modus operandi of compression; necessity for its reapplication. [P- 88. Treatment of Chronic Stage of Gonorrhoea.—Recommendation of similar plan to that spoken of under the head of Abortive Treatment; treatment of gleet, by cauteri- zation with the instrument of Lallemand; consequences of this treatment; employment of the proto-ioduret of iron—its doses, &c.; advantage to be expected from the Tent; plan of introducing it; counter-indication to its use ; other plans that have been proposed ; their relative merits alluded to. [P- 9a SECTION IV.—Strictures. Definition.—Division into spasmodic, inflammatory, and organic or permanent, [p. 95. Spasmodic Stricture.—Causes; frequency of attacks, attributed to muscular con- traction. Symptoms; quotation from Sir B. Brodie. Diagnosis; prognosis; treatment, as recommended by Sir B. Brodie. . „ ,- .• ^".l Inflammatory Stricture.—Causes of the affection ; frequent complication ot the other forms; treatment should be of an active antiphlogistic nature ; the employment of instruments prejudicial. c.i!P Permanent Stricture.—Definition; may depend upon—1st, alterations ot the sur- face of the mucous membrane; 2dly, alterations of the substance or panetes; 3dly, alterations of surrounding parts. Description of the lesions of the surface-VlcerB; vegetations • false membranes; cicatrices ; haemorrhoidal state of.—Description ot the 10 ANALYTICAL TABLE OF CONTENTS. Lesions of the substance or pavietes—Simple hypertrophy with softening, or induration ; fungous degeneration ; specific induration ; various general affections may give rise to stricture.—Description of the alterations of surrounding Parts—Abscesses, indurations, affections of the prostate, &c. [p- 98. Causes.—Blennorrhagia a frequent one; case showing that other causes produce stricture ; injections are not a cause ; general situation of; opinion of Hunter, Civiale, Ricord, Crosse, on the number of strictures ; form may be various. [p. 100. Symptoms.—Description of those derived from passing water; other causes than stricture may give rise to them ; symptoms derived from ejaculation of the semen ; other symptoms ; gleet often a symptom of stricture ; difference of opinion on the part from which it proceeds; these symptoms insufficient to distinguish stricture ; value of the diagnosis derived from an exploration of the canal by instruments; necessary to try to pass various sizes and shapes before coming to an opinion on the existence of stric- ture ; two plans of exploring the canal—1st, from before backward—2d, from behind forward ; appreciation of; means of ascertaining the depth of a stricture; exact position and direction of, by means of the porta empreiute.; description of woodcut. [p. 102. Diagnosis.—Of stricture generally, and of the various lesions on which it depends; of vegetations; of the osdematous and hoemorihoidal state; cicatrices; simple callous strictures; specific indurated stricture. [p. 107. Prognosis.—Of stricture depending on vegetations ; hypertrophy, with ramollisse- merit; cicatrices; callous stricture; specific induration ; spasmodic stricture. [p. 109. Treatment.—Circumstances which counter indicate any treatment; general reflections on ; division into general and local treatment; notice of constitutional treatment; means of local treatment; injections. [p. 109. Dilatation.—Various means of employing it; 1st, sudden dilatation, or dilatation brusque of M. Ricord ; appreciation of; in what cases useful; in what instances it may be prejudicial; Mr. Mayor's observations on the employment of bougies; 2d, rapid dilatation, or Lallemand's plan ; cases which do not admit of this treatment; reasons for rejecting it; 3d, gradual dilatation ; rules for employing it; period that the bougie should remain in the stricture ; their repetition ; cases unfitted for dilatation in general; cases which will be benefited by it; comparison between permanent and temporary dilatation; observations on permanent dilatation; ill consequences which sometimes follow ; advantages to be expected from. Temporary Dilatation.—Time during which a bougie should be kept in the stricture ; objections to it; M. Ricord's plan; action of dilatation threefold; 1 st, acts by compression; 2d, acts by suppuration; 3d, by ulcera- tion : it should be our object to produce only the effect of compression ; dilatation may act on the face, or on the parietes of the stricture; Dupuytren's treatment; Ducamp's treatment; plan of M. Benique ; instruments with which dilatation should be performed; conical bougies; their advantage: recommended by Dupuytren; advantages of em- ploying the bougie a ventre; remarks on flexible soft bougies ; Sir B. Brodie's observa- tions on wax bougies ; gum elastic bougies the best; inflexible or hard instruments; flexible ivory bougies: whalebone bougies; appreciation of them; observations on maintaining the cure of stricture. [p. m. Cauterization.—History of; this treatment not applicable to all cases; beneficial effect in spasmodic structure; in vegetations, &c, useful in some cases of permanent stricture; in what cases useless; Hunter's employment of caustic to the face of the stricture; Ducamp to the parietes; rules for the employment of cauterization ; strictures may be cauterized with a variety of substances ; preference shown to the nitrate of silver; M. Ricord's plan of cauterization, when he is unable to penetrate the stricture ; method of cauterizing the parietes of, or Lallemand's plan of treatment; explanation of wood cuts ; length of time that the caustic remains in contact with the tissues ; ob- servations on its reapplication; consequences of cauterization; opinion of Sir B. Brodie on the armed bougies. Tp. ng_ Scarification or Incision.—History; means of employment; puncture; scarifica- tion of ihe parietes; description of M. Ricord's instrument; manner of employing it; notice of other plans; filing a stricture; employment of the actual cautery. [p. 124! SECTION V.—Affections of the Prostate Gland. Causes.—Enumeration of. r_ jgjj Symptoms.—Rarely met with alone ; the more usual train ; symptoms as characterized by the catheter ; stream of urine ; notice of the age and temperament in which the dis- ease occurs; course of the affection ; opinion of Sir A. Cooper. [p. 126 Pathology.—Sir E. Home's opinions. Prognosis. Diagnosis.—Means of forming one. Treatment in the first stage of the disease ; objections to the use of bougies j observa- tions of Sir E. Home on the use of instruments. [p j.29 p. 128. p. 129. p. 129. ANALYTICAL TABLE OF CONTENTS. 11 SECTION VI.—False Passages. Portions of the urethra most subject to; dimensions and directions of; predisposing causes; influence of instruments in occasioning false passages; false passages produced by small instruments, of slight importance; precautions to be taken to avoid making false passages. [p. 131. Symptoms.—Notice of the causes of errors. [p. 133. Prognosis.—Circumstances which modify it; necessary to study the direction of. [p. 134. Treatment in recent cases; observations on overcoming the obstacle. [p. 136. SECTION VII.—Disease of Cowper's Glands. Symptoms may be mistaken for circumscribed abscess of the urethra. [p. 136. Treatment.—Termination in infiltration of urine ; consequences of treatment, [p. 137. SECTION VIII.—Infiltrations of Urine. Causes. Symptoms.—Direction which the urine follows. [p. 137. Treatment.—Importance of free incisions. [p. 138. SECTION IX.—Fistulous Openings. Their situation ; course ; direction ; consequences of. [p. 139 Treatment in simple cases; Mr. Dieffenbach's plan of treating them. [p. 141. CHAPTER III. blennorrhagia in the female. Notice of causes which are peculiar to the female genito-urinary mucous mem- brane, [p. 143. Morbid Appearances.—Description of the state of the mucous membrane as to color, dec; papular vaginitis ; the various characters it may assume ; vagina subject to various eruptions. [p. 143. The appearances of the discharges from the female genito-urinary organs in the acute and chronic affections; importance to study them as diagnostic signs. [p. 144. Symptoms.—Similar, though depending upon various causes; usually local; general symptoms often absent; enumeration of local symptoms which are common to all these affections; symptoms of blennorrhagia. Of the Vulva, of the Urethra.—Means of detecting disease in the urethra; relative frequency of the affection. Of the Vagina. —Indolent character of symptoms; where to find traces of a discharge. Of the Uterus. —The discharge is sometimes the only symptom; advantages of employing the speculum; the bivalve speculum recommended ; description of the instrument; method of introducing it; indications for finding the neck of the uterus ; counter-indications to the employment of the speculum ; description of the speculum chair. [p. 145. Complications in blennorrhagia of the vulva. Description of, and their diagnosis; phymosis of the vulva—of the urethra—of the urelus. Ovarite, symptoms, one of the causes of ovarian dropsy ; specific ulcers ; simple ulcers; diagnosis of. [p. 150. Observations on Contagion.—The mucous membrane usually diseased when the complaint is contagious; impossibility of distinguishing whites from contagious dis- charges ; diagnosis of virulent from simple blennorrhagia; form of certificate recom- mended, [p. 152. Prognosis.—Of blennorrhagia of the vulva—of the urethra—of the vagina—of the uterus. [p. 153. Treatment.—Of blennorrhagia of the vulva ; of prevention ; abortive treatment not nsualy applicable in the acute stage; of the urethra—of the vagina—of the uterus. [p. 153. Complications.—Retention of urine ; cystitis; stricture; abscess; fistula}; phymosis; bubo; nervous complications; ovaritis. [p. 155 12 ANALYTICAL TABLE OF CONTENTS. CHAPTER IV. FORMS OF BLENNORRHAGIA COMMON TO BOTH SEXES. SECTION I.—Blennorrhagic Oththalmia. Synonymous terms ; frequency; situation. IP- ^"- Causes.—Difference of opinion upon ; two theories ; description of the first, or sym- pathy; appreciation of it; reasons for disbelieving it; reasons for believing in the opposite opinion, or in direct contact of the secretion ; considerations on predisposing causes, such as age sex, &c.; deductions. LP; 157. Symptoms.—At an early period ; examination of the eye ; state of the secretions; granular condition ; no deduction can be drawn from it; course of the disease ; rapidity in disorganizing the structures of the eye. [P- 158. Diagnosis—No one symptom sufficient; considerations on the intensity of the in- flammation ; coincidence of the blennorrhagia. [p- 159. Prognosis.—Very severe ; recommendation to call in a second opinion ; Dupuytren's practice. _ [p. 160. Treatment.—Lisfranc's opinion; M. Ricord's treatment; leeches, observations on ; the employment of nitrate of silver in substance ; how applied; rules for the reapplica- tion of; on the use of mercury. [p. 160. SECTION II.—Blennorrhagia of the Anus. Does there exist such a disease ? Yes. Reasons for supposing it common; no foundation for the opinion. [p. 162. Symptoms.—Description of. [p. 163. Causes.—Direct contact; influence of general causes. [p. 163. Diagnosis.—Always difficult; the value of the funnel-shape of the anus ; causes which give nse to it; not always present; color of the discharge; its value as a diagnostic sign ; inoculation, its value ; buboes ; the antecedents of the patients ; no one unequivocal sign ; importance to be placed on a rent of the rectum. [p. 163. Prognosis.—Unfavorable ; why. |p. 164. Treatment.—The first indications ; general means ; direct means. [p. 164. SECTION III.—Blennorrhagia of the Mouth, Nose, and Ears. Fabulous. [p. 165. Blennorrhagia of the Umbilicus and Groin.—Causes. Treatment, &. [p. 165. SECTION IV.—Vegetations. Synonymous Terms. [p. 165. Pathology.—Color, stricture, &c. [p. 165. Causes.—Opinion of Sir A. Cooper on their contagion ; case illustrative of the im- portance of a correct opinion of cause. [p. 166. Complications. Diagnosis. Prognosis. [p. 167. Treatment.—Appreciation of the several plans of treatment. [p. 168. SECTION V.—Herpes Prjeputialis. Case from note-book, detailing cause, symptoms, diagnosis, and treatment [p. 169. SECTION VI.—Eczema. Causes. Symptoms. Treatment. [p. 172, SECTION VII.—Excoriatiohs. Definition. Situations. [p. 173, Treatment.—Preventive and curative. [p. 174. ANALYTICAL TABLE OF CONTENTS. 13 PART II SYPHILIS. CHAPTER I. PRIMARY SYMPTOMS. Definition of syphilis; division into stages; meaning of first, second, third stages. [p. 175. SECTION I.—Chancre. M. Ricord's Definition. Anatomical Characters.—As proved by inoculation ; natural manner in which chancre may commence; microscopic examination of the secretion of. [P- I76- Varieties of Chancres in the Ulcerative Stage.—1st, Phagedenic chancre; 2d, Diph- theritic phagedenic; 3d, Indurated; 4th, Indurated phagedenic; 5th, Gangrenous chancre. [P- 1'8. Period of Reparation; Varieties of; Cause of Chancre.—Meaning of the term cause; traced in the present instance to the secretion of another chancre ; circumstances which compose, form part of, dispose to, prevent the action of; impossibility of isolating the cause ; influence of chymical agents upon it; reasons for calling it a virus. [p. 180. Origin of the Syphilitic Virus.—Not spontaneous at the present day; hypothesis founded on analogy. Circumstances and conditions necessary for the production of the effects of the Virus. [p- 182. Of the chancre from which the virus is taken. [p- 183. Means and conditions of the agents of transmission ; refutation of received opinions on this subject, practical illustrations of which are important to the surgeon. [p. 184. The necessary conditions of the parts about to be contaminated ; destruction of the epidermis necessary; apparent exceptions; explanation of; influence of age; state of the skin; influence of sex; the question, Are there any persons insusceptible of syphilis ? answered in the negative; incubation does not exist; apparent exceptions explained. Is there more than one cause of chancre ? Only one. [p- 187. Causes of the Varieties of Chancre.—Varieties not to be attributable to anyone cause; examples, enumeration of the most frequent in cases of the diphtheritic varieties; gangrenous phagedenic; serpiginous; indurated. [p.^191. Diagnosis of Chancre during its ulcerative stage.—The means of forming a rational diagnosis ; observations on the appearance as aiding the diagnosis; the situation ; the history ; the value of various complications ; how far a diagnosis can be formed from the course. . [P- I?4- Observations on the absolute diagnosis; value of inoculation; cases illustrative of. [P- 196. Diagnosis of the reparative stage of chancre. [p. 197. Prognosis of Chancre—Consideration of it as a local disease; usual period of cure; probability of the occurrence of the varieties supervening on simple chancre, such as diphtheritic; serpiginous; gangrenous; indurated. Relative to the probable duration of a simple chancre ; enumeration of the causes which influence it, such as situation, size, number, constitution ; probable duration of a diphtheritic, serpiginous, gangrenous, indurated chancre. [P- 198. Probability of the occurrence of complications. _ [P-200' Prognosis in reference to the probability of successive accidents; meaning of this term ; of chancre (successive); of bubo ; circumstances which will tend to modify the prognosis, such as situation, &c.; influence of treatment on prognosis. [P-_202' Prognosis considered in reference to the probability of general and constitutional infection ; the circumstances to be borne in mind ; stage of the sore ; duration of the chancre ; number and size; probability derived from the varieties, viz., phagedenic gangrenous ; influence of the indurated ; influence of the complications on the prognosis, such as Dhvmosis : bubo; prognosis to be derived from the treatment, local and general. [P- 202. 14 ANALYTICAL TABLE OF CONTENTS. Treatment.—Prevention of chancre ; reflections upon ; methods employed in France ; duties of the medical practitioner ; Is it possible to prevent the occurrence of chancre . Proposed means of preventing the spreading of the affection ; precautions to be taken by the recipient; those recommended to be used by the already infected, to prevent transmission. [P- 204- Curative Treatment.—Of the chancre on its first appearance ; observations on the employment of lunar caustic ; treatment of the variety called phagedenic diphtheritic ; indications necessary to be attended to ; gangrenous phagedenic ; serpiginous chancre ; observations on the obstinacy of this sore; general and local means ; indurated chancre; objects the surgeon ought to have in view in treating this form ; local treatment; general treatment; observations on the use of mercury; its dose; preparation; preparatory measures; prejudicial effects of; treatment of; mention made of excision. [p. 208. Treatment of indurated phagedenic chancre. [p. 209. Treatment of the complications of chancre.—From position; chancres in the urethra ; diagnosis of this affection; prognosis; treatment; chancre situated at the fraenum ; balanitis; phymosis; the indications and method of employing caustic in these last two forms. [p. 216. Operation for phymosis ; M. Ricord's plan of circumcision. [p. 219. Paraphymosis ; reduction of; operation for relieving. [p. 221. SECTION II.—Bubo. Definition of; meaning of the term venereal bubo; syphilitic bubo; anatomical characters of syphilitic bubo; termination of, in delitescence; resolution; suppuration; in induration. [p. 222. Causes of Syphilitic Bubo.—Remarks on lymphatic vessels ; action of the virus may be twofold, by absorption, by irritation. The predisposing causes—Influence of age, sex, temperament; general condition of the patient; influence from the situation of the chancre; size of; how far the treatment of primary sores may influence buboes, [p. 224. Symptoms of bubo. [p. 228. Diagnosis of Syphilitic Bubo.—1. Previous to the suppurating stage ; importance to be placed on the antecedents ; distinction between syphilitic bubo and bubon d'emblee; description of this last-mentioned form. 2. When suppuration exists ; inoculation the only sure guide. [p. 228. Prognosis of Syphilitic Bubo.—Inquiries necessary previous to forming our prognosis; prognosis of bubo depending upon absorption, or upon irritation ; the probability of a syphilitic bubo suppurating; the probable duration of a bubo; circumstances which influence the prognosis ; probability of the occurrence of secondary symptoms, [p. 230. Treatment of Syphilitic Bubo.— The Prophylactic Treatment—Indications to be borne in mind, particularly of chancres; treatment of the early stages of bubo ; influence of compression upon ; treatment of the inflammatory stage of bubo ; influence of blisters; observations on the use of caustics; indications for puncturing buboes; method of puncturing ; treatment of suppurating open buboes. [p. 232. CHAPTER II. SECTION I.—Secondary Symptoms. Definition; synonymous terms; history of secondary symptoms; classification of; M. Ricord's and the author's division explained ; general observations on secondary symptoms; are secondary symptoms dependent upon absorption of the virus? reasons for the belief; can they occur without previous chancres ? the chances of error, [p. 239. Predisposing Causes; influence of temperature, food, age, sex, temperament; does absorption of the virus take place by means of the veins or absorbents ? Hypothesis on this subject. [p. 241. Period at which secondary symptoms appear after the occurrence of primary symptoms. [p. 244. Observations on the average period ; exceptional cases. [p. 245. SECTION II.—Secondary Affections on the Skin. Division ofr into the following forms: Exanthematous ; Papular; Vesicular; Pustu- lar ; Tubercular. [p. 246. Description of Exanthemata; period of their appearance; natural course of. [p. 247. ANALYTICAL TABLE OF CONTENTS. 15 The Papular.—Parts most liable to; divisions of. Lichen. Psoriasis. Lepra. on the palms of the hands. [p. 247. The Vesicular.—Rarity of the affection. [p. 249. Pustular.—Course; termination. In Rupia.—Ulcerations; general state of the system; variety of the pustular form. Impetigo. [p. 249. The Tubercular form.—Description of; description of the variety called Condy- loma, and of the French term Mucous Tubercle; situation of; predisposing causes; liability of mistakes; course of the affection; termination of; varieties of Condy- lomata, [p. 250. Complications of Secondary Symptoms above described.—Influence of itch in, as a complication ; existence of eczema ; lepra and various affections of the skin ; primary symptoms, a complication ; importance of the knowledge of this fact; the influence of scrofula, scurvy, as complications. [p. 253. The Diagnosis.—Importance to be placed on the previous history ; whether positive or negative ; value of concomitant disease as influencing the diagnosis ; whatdependence is to be placed on the color of the eruption; how far can the diagnosis be substantiated by the treatment which has preceded, or that under which the patient recovers, [p. 254. The Prognosis.—Circumstances under which it may be considered favorable ; cir- cumstances which lead to an opposite conclusion. [p. 556. Treatment of Secondary Symptoms.— The Curative Treatment.—Indications to be borne in mind ; general treatment; baths ; importance in the opinion of the author; method of employing baths; on the employment of sarsaparilla; on the use of gold, and its preparations; those ot silver. On the employment of mercury; on the history of; observations on the doctrines of the mercurialists and non-mercu rialists; author's opinions on the efficacy of mercury ; in what cases it should be employed ; manner of employing it; on the action of mercury on secondary symptoms. [p. 259. Salivation.—Predisposing causes of; quantity of mercury necessary to produce it; period of time most to be dreaded, at which it will appear; description, course, and treatment of salivation ; termination of; diagnosis of salivation ; on the employment of mercurial ointment; mercurial plasters ; calomel; fumigations; internal use of mercury; calomel and opium; corrosive sublimate ; proto-ioduret of mercury; local applications to the various syphilitic affections of the skin—as lichen, lepra, psoriasis, mucous tubercle, &c. [p. 263. SECTION III.—Syphilitic Affections of the Mucous Membrane. Mucous membranes that may be the seat of the affection. [p. 270. Syphilitic Affections of the Mouth and Throat.—Division into. [p. 270. Primary Affections.—Causes; other instances cited; anatomical characters of: cause ; reasons for believing it a rare affection ; opinion of Mr. Colles ; M. Guersent's opinion; symptoms; diagnosis; cases which present difficulties; means of arriving at a correct opinion ; prognosis ; treatment. [p. 271. Secondary Syphilitic Affections of the Mouth and Throat.—Cases; ana- tomical characters; cases; the predisposing and exciting considered; symptoms; concomitant disease ; diagnosis; prognosis ; treatment. [p. 280. Tertiary Syphilitic Affections of the Mouth and Throat.—Anatomical characters ; sketch of its commencement and progress; history. [p. 288. Diagnosis.—Value of each symptom; inquiry if a strumous sore throat exists; does a chronic inflammatory affection ever appear? cases; can scorbutic disease of the throat be mistaken for a syphilitic affection 1 the diagnosis of syphilitic affections and cancer considered. [p. 290. Prognosis. Treatment. [p. 296. SECTION IV.—Syphilitic Affections of the Eye. Division of. [p. 298. Secondary Affections.—Quotation from Mr. Lawrence. [p. 299. Syphilitic Iritis.—History? known and described in 1773; symptoms of"; Mr. Tyrrell's opinion on ; statistics by Mr. Lawrence; showing at what period of life it occurs, &c. [p. 301. Causes.—Predisposing and exciting; probable reason why the disease is rarely met with in Paris; prognosis; diagnosis; value of each symptom individually consider- ed, [p. 302. Treatment.—Employment of mercury. [p. 305. SECTION V.—Syphilitic Affections of the testicle. Synonymous terms; symptoms; pathology; extract from Sir A. Cooper's work; predisposing and exciting causes ; diagnosis; prognosis and treatment. [p. 308. 16 ANALYTICAL TABLE OF CONTENTS. CHAPTER III. TERTIARY SYMPTOMS. Definitions; history; Hunter's opinion upon ; cause; predisposing causes; influence of previous disease; influence of treatment of the primary and secondary affections; course of tertiary symptoms ; complications of; prognosis; diagnosis. [p. 309. Description of Tertiary Symptoms affecting the Cellular Tissue.—Tuber- cles of; tertiary affections in the osseous system. [P- 313. Periostitis.—First, second, and third variety. [P 314. Ostitis.—Divisions of; terminations various. _ [P« 315. Treatment of Tertiary Symptoms.—Indications of treatment; preventive means ; curative means; employment of opium ; mercury—observations upon ; on the employ- ment of the hydriodate of potass; dose; manner of increasing it; effects of the salt on the system ; treatment of the individual forms of tertiary symptoms ; local treatment of tumors situated in the subcutaneous cellular tissue; treatment of ulcers; observations on the submucous tumors. [p. 316. Treatment of Affections of the Osseous System.—Pains in the bones; treatment of periostitis and its varieties; treatment by means of blisters; local treatment of ostitis ; observations on necrosis and caries. [p- 320. CHAPTER IV. SYPHILIS IN CHILDREN. Primary Symptoms considered; ulcerations which may be mistaken for. [p. 321. Secondary Symptoms.—How does the foetus become affected; does the mother infect the child by means of the milk ? can the father directly contaminate the foetus ; reasons for our disbelief; allusion to Messrs. CoUes' and Carmicheal's opinions ; does syphilis cause abortion at the seventh month ? reasons for doubting it. [p. 322. Symptoms. Prognosis. Treatment.—Can the child communicate the disease to its nurse ? the conditions under which this may take place; consideration of some errors the surgeon may fall into. [p. 324. INTRODUCTION. HISTORY OF VENEREAL DISEASES. A very superficial consideration of the laws which regulate the animal economy in a state of health and disease, together with the various operations of these laws on the difierent structures of the human frame, is sufficient, I think, to entitle the pathologist of the present day to infer that various affec- tions, both organic and functional, now recognised as following sexual inter- course, must have existed in all ages and in all climates • these I have included under the collective term of "Venereal Diseases."* Believing, however, that it is not sufficient for the purposes of this work to render such an inference merely probable, I shall in the following pages at- tempt to prove, from authentic historical records, that various diseases answering to this definition were known, and have been described, by persons living in the early ages. These I shall trace down to the present time; but in doing so I shall be as concise as possible, and only dwell upon such points as may be of practical use. An attentive perusal of the twelfth and fifteenth chapters of Leviticus must convince any impartial person that the Jewish lawgiver, in strictly enjoining ablution and separation to women after delivery and menstruation, or, as is said at the eighteenth verse, particularly to " the woman with whom man shall lie with seed of copulation," must have had in view the prevention or cure of affections liable to follow sexual intercourse at that time. This regulation was promulgated about the year 2400 A. M. On referring to the fifth chapter of Proverbs, the reader will find Wisdom ad- monishing her pupil, and desiring him to avoid strange women, lest his flesh and body be consumed. And in Ecclesiastes it is stated, that " whosoever joineth himself to adulterers shall become impudent, and that rottenness and worms shall have him to heritage." Thus we find allusion made to it again about the year 2950 A. M. On the authority of Peter Paul Vergerius the elder, it is stated that "Uber- tinus of Carrara, the seventh of that name, and the third governor of that city, died at Padua, the 29th of March, in the year 1245, of a lingering disease of his private parts, occasioned by too much venery."f * By the term venereal diseases, I mean all those affections which are, more or less, di- rectly or indiiectly, the consequence of sexual intercourse, in whatever way effected. t Astruc, p. 58. 2 18 INTRODUCTION. Gulielmus de Saliceto, a physician of Placenza, in 1270, states in his work " De Apostemate in Inguinibus,"* " This disease, called a bubo, dragoncelli, or impostume of the groin, for the most part arises from a cold humor which is expelled from the liver to those places which are weak and empty; it some- times also proceeds from a hot humor, and sometimes it comes from a foulness in the yard (in virga corruplio), contracted by lying with an unclean woman, or from some other cause. In Astruc's treatise,t it is stated that an eyewitness, Theodoric, a celebrated physician in the year 1290, in his Chirurg., lib. vi., cap. 55, says, that " whoever converses with a woman who has lain with a leper will catch the distemper. Bartholemew Glanville, in his book De Proprietalibus Rerum, translated in 1398 by John Trevesa, speaks of "Unclene spostyd glemy and guyttery, the nosethrilles ben stopyl, the wasen of the voys is rough, and the voyce is hoorse, and the heere falls." This disease of leprosy " comyth of fleshly lying by a woman after that a leprous man hathe laye by her; also it comyth of fader or moder; and so thys contagyon passyth into the chyle, &c. And also when a chylde is fedde wyth corrupte mylke of a leprouse nourryce." In Henry the Eighth's time there were six leprous or lazar houses. Lanfranc of Milan, a pupil of Gulielmus de Saliceto, who consequently lived about the year 1290,}. states, that chancres and ulcers of the penis follow from coition with a foul woman. Bernard Gordon, professor of physic in the Uni- versity of Montpelier in 1300,|| says that "diseases of the yard are numerous, following lying with a woman whose womb is unclean, full of putrid sanies, virulence," &c. In a manuscript, in Lincoln College, Oxford, cited by Beckett, and corrobo- rated by Dr. Wagstaff, in the thirtieth volume of Phil. Transact., it is stated on the authority of Thomas Gascoigne, chancellor of that university, that " Joan, de Gaunt mortuus est ex tali putrefactione membrorum genitalium, et corporis sui causatd per frequentionem mulierum." This took place in the year 1399. About the year 1423, Petrus de Argelata, of Bologna,§ says, that the reten- tion of the poisonous matter lodged between the glans and prepuce, after a man has had to do with a foul woman, causes the part to become black, and the sub- stance of the yard mortifies, &c. He likewise speaks of the occurrence of bubo in the groin as a consequence of this affection. In the thirtieth volume of the Philosophical Transactions, page 843, Beckett cites the following passage from a book in the custody of the bishop of Win- chester, supposed to be written in the year 1430, and entitled " De his qui cus- todiunt mulieres habentes nephandam infirmitatem .-" " That no stew-holder keep noo woman wythin his house that hath any syeknesse of brenning ;1T but that she be putte out, upon the peyne of makeit a fyne unto the Lord of a hundred shylyngs." •Lib. i, cap. 42. tL. c.,$. 53. t Tract. 3, Doct. ii., cap. 11. Practicae seu artis completae, &c. And also in Tract. 3 Doct. iii., cap. 11. De ficu et cancro et ulcere in Virga virili. II Lilii Medicinae Particul, vii., cap. 5. De passionibus virgae. t> Chirurgiae, lib. ii., tract. 30, cap. 3. " De pustulis qua adveniunt virga propter conversationem cumfoedi muliere, qua alba sunt vel rubra." T On the authority of a manuscript of John Arden, surgeon to Richard II., the word bren- ning is thus defined: " A certain heat and excoriation of the urethra." INTRODUCTION. 19 Beckett quotes the following questions as being put to persons who were said to be lepers; he cites them from an ancient book of surgery : " If there were any of his lygnage that he knew to be lazares, and especially their faders and moders, for by any other of their kynred they aught not to be lazares, then aught ye to enquire if he hath had the company of any leprous woman, and if any lazar hath meddled with her afore him; and lately, because of the infect matter and contagious filth that she had received of hym. Also his nosthrills be wide outward, narrow within, and gnawn. Also if his lips and gumms are foul, stynking, and coroded. Also if his voice be hoarse, and as he speaketh in the nose." John of Gadesden* not only alludes to the possibility of contracting the com- plaint from a leprous woman, but mentions the precautions which should be adopted to avoid contagion. " Hie qui concubuit cum muliere cum qua coivit leprosus puncturas intra carnem et corium sentit, et aliquando calefactiones in toto corpore. " Primo notandum est ille qui timet et excoriationem et arsura virgae post co- itum statim lavet virgam cum aqua mixta aceto, vel cum urina propria, et nihil mali habebit."f " Si quis vult membmm ab omni corruptione servare, cum recedit a muliere quam suspectam de immunditie, lavet illud cum aqua frigida cum aceto mixta, vel cum urina propria interius vel exterius intra preputium."} The affections to which we have alluded, and which were described as exist- ing previously to the 15th century, had received no particular name; but after the severe epidemic observed at Naples, and which was so well described by Fracastorius, they became known under the title Morbus Neapolitans, or Gal- licus, Mai des Francois, and soon after the terms Gore, Grande Gore, Verolle, Grande Verolle, were successively given to them in consequence of the general pustular eruption by which they were attended. Lastly, the affections were described under the title Scorra Pestilentialis, by Sebastian Brant, in 1496, and by Grunpeck, a German physician. Gaspar To- rella writes on the subject a treatise, Contra Pudendagra, in 1498. It was generally known by one or other of these denominations until Jaques de Bethencourt of Rouen called it the Venereal Disease, in a book entitled Nova Panitentialis Quadragesima, nee non Purgatorium in Morbum Gallicum, sive Venereum. Paris, 1527. In the year 1530 Fracastorius || writes thus : "When it first broke out among us, it discovered itself by the following symptoms : the patient was low-spirited, complained of weariness, and had a pale look; at last, for the most part, little ulcers appeared about the pudenda, which were extremely obstinate, and, after they were cured in one part, broke out afresh in another. Afterward a kind of crusty pustules appeared upon the skin, beginning in some upon the scalp (which was most frequently the case), and upon other parts in others. At first they were only small, but increased, by degrees, in a short time, to the size of the husk of an acorn, and had a good deal the same appearance, not unlike those scabs which appear on the heads of boys. Of these scabs there were *Doct. 61. tRosaAnglica. Pavia, 1492. Car. 61. In the library of the College of Surgeons. t car. 107. II Ds Morbis Contagiosis. Lib. ii., cap. 2. De Morbo Gallico. 20 INTRODUCTION. several different kinds, some of them small and dry, others large and moist; some of a livid color, some of a palish white, and some hard and reddish. All of them opened in a few days, and discharged a thick foetid matter; nor is it possible to express what the quantity of that matter perpetually discharged was, nor how nasty it was in quality. Afterward the ulcerated parts became eroded in the same manner as those ulcers which are called phagedenic, and sometimes they infected not only the flesh, but likewise the very bones. When it attacked the head chiefly, it produced acrid rheums, which eroded sometimes the palate, sometimes the uvula, sometimes the jaws and tonsils. In some it destroyed the lips, in others the nose, in others the eyes, and in others the whole pudenda. Besides this the limbs in a great many were disfigured with gummy tumors, which frequently grew to the size of an egg, or a small loaf, and, being laid open, dis- charged a white mucilaginous matter. That tough hardness appeared chiefly in the legs and arms, and, sometimes became ulcerated; sometimes it continued entire till death. But, besides all the above-mentioned symptoms, as if they were only trifling, there occurred violent pains of the arms, frequently, together with pustules, sometimes before, sometimes after, very obstinate and lasting, and excessively tormenting. They were most violent in the night, and the pain was not properly in the joints,' but in the muscles and nerves. However, there were pustules sometimes without pains; and in some, pains without pustules ; but the greater part was afflicted with both. In the meantime, all the limbs became feeble, the body emaciated, the appetite quite lost; the patient had no sleep, but was either melancholy or very irritable, with a strong inclination to lying in bed. His face and legs swelled; sometimes, though rarely, the disease was attended with a slight fever; some had a pain in the head, which was last- ing, and not to be subdued by any medicines."* During the following years, John de Vigo, Peter Maynard, Nicholas Massa. Fallopius, and others, make mention of the remaining symptoms, which are now universally recognised. Fern el, in 1548, thus writes : " On whatever part of the body the Lues first settles, there fixing itself, it excites a pustule, and soon after a small ulcer. Thence extending further, it fixes its roots, and sensibly penetrates the interior by a forced unceasing action; and in fine, unless you shall have opposed to it some remedial measures, it devastates and commits ravages on the whole by its virulence. From this it is manifest that a certain poison constitutes the essence of the disease, creeping over or insinuating itself into the whole body, in no manner differing from the poison of the rabid dog or scorpion. The signs of it are various, depending on the nature of the parts over which it spreads. When the virus, for the sake of illustration, has its origin in copulation, from the pri- vate parts bedewed with moisture, it determines, first, pustules in those parts which are very obstinate, and then small ulcers which are difficult to treat, and are of rather a bad character. Then the vapor or effusion, creeping inward bv *• This description of Fracastorius may apply even at the present day. Let any one who is cognizant with large venereal hospitals be asked if he does not often meet with cases of this kind. Females of abandoned lives apply for admission, giving the description here spoken of, viz., laboring under severe secondary symptoms, and do not mention, or altogether deny the previous existence of primary symptoms. Fracastorius was unaware of the relation be- tween secondary and primary symptoms. There are Fracastorii at the present day, in spitr of the progress of surgery. INTRODUCTION. 21 the hollow canal of the pudendum (for it is not credible that any humor or fluid enters it), it impoverishes (labefactat) the blood of the vena cava and the spirit contained in the larger artery, and then the bubo breaks out in the groin. Hence a gonorrhoea manifests itself from the diseased spermatic ducts and kid- neys, by which this most foul virus is ejected as by belching. When this exe- crable disorder has invaded the liver and stomach, a certain slight abdominal flux breaks out, and soon after the blood is infected with the liver, by which all the veins of the body become implicated; and in this manner disseminated in the limbs, muscles, and skin, it having been repulsed, breaks out silently, and worse than before. Livid and reddish pustules occur, ulcers covered with crusts and teters, in some persons excavated and malignant ulcers, and in bil- ious persons phagedenic and corroding sores ; in the melancholic temperament, cancrous or cancerous ulcers; and in the phlegmatic they are more superficial (leviori), but more foul, and discharging a foetid, mucous humor; and in san- guineous persons they are more thickly set, and resemble carbuncles. All, in- deed, with very hard, indurated, tumid, and inverted edges, which (ulcers) hav- ing eaten the flesh, feed upon the bones themselves ; at first the thin bones (as, for instance, those of the palate and nose), then those of a more solid consist- ence, which, becoming putrid and carious,,are thrown off. It follows, as a nat- ural consequence, that when the head is attacked, or the brain is the seat of the disease, many pituitous humors, disproportionate to the condition of the part, collect, which, if shut up in the head, produce a severe and considerable pain; but if they point under the scalp, and should be determined toward the joints and limbs, they excite most dreadful and daily tortures, increased greatly at night; or they excite very hard tophi and scirrhous tumors, by no means free from pain. Although the matter appears pituitous, nevertheless, being- im- pregnated with this deadly matter of poison, it partakes of its acrid properties. Thus hiding itself under the periosteum of the bones, it produces pain both by its acrimony and. by distension. Penetrating the substance of the bones as it were by minute tubes, it expands them and dilates them into tumors—which (bones) at length being attacked with caries, become putrid. If the matter be- ing less biting and acrid does not destroy the skin, its malignity or noxious va- por, being poured out around the hair, occasions (in the language of Fernel) an effluvium; on which account the greater part appear without hair on the head, eyebrows, or body; but the hair may be reproduced. " But its effects are not confined to the external parts alone; they extend to the internal parts, affecting even the viscera, which are found, as in exanthema- tous diseases, on dissection, covered with pustules and ulcers."* * Joan. Fernelius de Abditis Rerum Causis. Lugduni. Liber ii., cap. xiv. De Morbis Contagiosis, p. 210. Who can deny this accurate description of the ravages of syphilis ? No author of the pres- ent day can add to the category of the affections successively attacking the various parts of the body, but their relation to primary symptoms was unknown ; this, however, was not sur- prising ; at the present day I not unfrequently meet with such cases at St. Bartholomew's Hospital, among the female patients, the genital organs covered with primary sores, the body concealed, as it were, by scabs, the throat and bones suffering simultaneously. Such cases, of course, are contagious, and were arranged under the head of contagious diseases, but no distinctions were made in those days. Fernel, like many modern surgeons, viewed the ulcers as one and the same, and considered them contagious—an error, as will afterward appear. 22 INTRODUCTION. In the year 1736, Astruc, physician to Louis the Fifteenth, wrote his celebra- ted treatise on the Venereal Disease; to him is due the merit of having writ- ten the most learned book of the day, and of having treated the subject in a methodical manner. The work of Astruc is divided into two parts; in the first he describes the first stage, or local venereal diseases; in the second he treats of the second stage, or confirmed pox; in other words, of the venereal disease when it has become universal. Under the first stage he included, 1. Virulent gonorrhoea and all its conse quences. 2. Venereal buboes. 3. Chancres. 4. Verrucae and condylomata Under the second stage, or confirmed pox, he describes successively, 1. Dis eases of the genitals. 2. Diseases of the skin. 3. Diseases of the mouth and nose. 4. Venereal pains. 5. Diseases of the bones. 6. Glandular and lym- phatic tumors. 7. Diseases of the eyes. 8. Diseases of the ears. 9. Disor- ders of the functions. Hunter, in 1784, like Astruc, admitted the existence of a venereal virus, and traced an admirable picture of the disease; he, moreover, taught that this virus on which the venereal disease depended, might affect the system in two modes. Primarily or locally, secondarily or constitutionally. By his experiments on inoculation, he proved that these divisions existed, and might easily be distin- guished. The same learned author believed that the primary effect of the venereal virus was twofold. When it came in contact with a mucous surface, a gonor- rhoea resulted; when, on the contrary, it was placed in apposition with the skin, chancres would follow. Hence his classification of gonorrhoea and syphilis as the primary effects of one and the same virus. He called public attention to the induration which he believed always at- tended true primary sores,* and did not consider as syphilitic such primary .ul- cerations as presented no such appearance. John Hunter further professed that the venereal virus in either of its two primary forms could give rise to constitutional effects, which he has so ably described in his valuable work, under the term Lues Venerea. c In 1782, Benjamin Bell brought forward his experiments and reasons for sep- arating gonorrhoea from syphilis or chancre, and his views were afterward adopted and corroborated, in 1812, by Hernandez of Toulon. In 1815, the celebrated Broussais taught that syphilis is an irritation which affects the exterior of the body as does scrofula; that the physiological school of medicine ought only to note the forms and degree of irritation in the differ- ent organs, and that it should alone occupy itself with means to oppose it. Messrs. Jourdan and Richond, the pupils of Broussais, followed up the doctrine of their teacher, and denied the existence of a virus; " Call it what you will " say they, " but name it not virus." They consequently reject the idea of the constitutional phenomena of poisoning, which they regarded merely sympathetic of local irritation. In 1830, M. Ricord commenced his investigations on the causes and natural history of venereal diseases. The first result he obtained was to convince him- * De Vigo had long before done this, but Hunter laid stress upon a point which seems to have been generally overlooked. INTRODUCTION. 23 self and the public that a special cause (perfectly independent of the sexual or- gans) gave rise to and occasioned the propagation of syphilis; he moreover attached a strict meaning to each term he employs, instead of that chaos of synonymous terms which existed in the writings of preceding authors. Considering the term " venereal diseases" in its most extended sense, he defines it to be, " all those affections which are more or less, directly or indi- rectly, the consequence of sexual intercourse, in whatever way affected." Venereal diseases thus defined, he arranges in two orders. Order I. contains diseases depending upon common causes, independent of any special agent, reproducing themselves daily, and under all possible condi- tions; consisting of simple affections, in a word, non-virulent. We call them syphiloid diseases. Order II. contains diseases depending upon a special principle, distinct from all the ordinary morbific causes ; affections which give rise to special effects called virulent. We call them syphilis. This second order has three distinct stages. 1st Stage includes primary symptoms, which are the immediate effect of the morbific cause occurring on the spot where the virulent agent has been depos- ited. Example, chancre. 2d Stage comprehends secondary symptoms, which are the consequence of absorption into the system of this virulent cause. They are hereditary, but not capable of transmission by inoculation. Example, certain affections of the skin and mucous membranes, iritis, &c. 3d Stage comprises tertiary symptoms, not capable of being transmitted by inoculation, nor hereditary, but subject to pathological transformations and alter- ations of the submucous and subcutaneous, or of the fibrous or osseous, tissues. II. HISTORY OF THE THEORIES ENTERTAINED ON THE NATURE AND ORIGIN OF VENEREAL DISEASES. It may be thought by some superfluous to dwell uron these subjects, inas- much as they have been already treated of in the previous part of this historical sketch. The perusal of this section will, however, I trust, prove that such is not the case, as the notice taken of them was only incidental, and they still require further elucidation. In the sacred writings, from the slight allusions made to these affections, no one will be surprised to find that these points are barely dwelt upon; but there is apparently no reason to believe that they were supposed to differ from other diseases, except in consequence of the manner in which they were contracted; in fact, they seem to have consisted of simple inflammatory affections, which yielded to ordinary means. Whether the affections described in the Proverbs were mere inflammatory dis- eases, or maladies of a specific nature, is a question which I shall not now stop to examine. The various affections of the genital organs, of which mention is made by Hippocrates, Celsus, and other ancient writers, as they are not stated to have 24 INTRODUCTION. followed sexual intercourse, can not be noticed here; neither will it be neces- sary to state the various theories which these fathers of physic entertained on their cause—such as too great continence, a dyscrasy of the humors, &c. In the year 437, as mentioned in a former part of this introduction, a disease of the genitals which followed connexion was supposed to depend upon the judgment of Heaven. In the 13th century, as we learn from the writings of Gulielmus de Saliceto and John of Gaddesden, the disease, although attributed to contagion from foul women, was supposed to originate in hot humors, which find their way out of the body through the womb. A little later the disease was stated to have arisen in consequence of persons being affected with the leprosy; and we may offer it as a probable conjecture, that under this term were included affections which would now be called venereal. Such were the opinions entertained regarding the disease we have sketched in the previous pages, up to the end of the fifteenth century; in fact, many authors of great repute believe that, up to this period, no such affections as may be called venereal had existed. Whether these opinions be correct I shall leave to the consideration of my readers, as they are now in possession of the data on which to decide, and I shall at once pass on to the opinions entertained at that period on the nature and origin of venereal affections. Those authors who wrote at the latter end of the fifteenth and commence- ment of the sixteenth century, were convinced that venereal affections, which at that time assumed such severe forms, owed their origin to the fatal influence of the stars, to the conjunction of Venus and Mars, or of Jupiter and Venus. Among this class may be enumerated the names of Torella, Maynard (Peter), Fracastorius, &c.; and hence we may infer the influence that astrology and the planets were supposed to exercise in producing disease, even by the best-edu- cated physicians of the day. There were, however, others who treated as idle fancies these supposed stories of astrologers, and the malign influence which the air was supposed to produce; thus, the venereal disease being generally ac- knowledged to be a contagions malady, the same causes were stated to develop it as are now considered to give rise to epidemics. These opinions, however, gradually lost ground, and a more special cause was sought after, as the nature of the means and ordinary sources of contagion became more generally known ; among others, they (venereal diseases) are again attributed to leprosy, to ulcers in the womb, to poisoned wells, to the use of lime in bread, &c. Van Helmont, in 1640, believed that the disease first sprang from unnatural connexion between a man and a horse laboring under the farcy, which occurred, as he believed, about the time of the siege of Naples. Dr. Linden thought that it had its origin " in sodomy sometimes committed between men and monkeys, or the satyrs of the ancients." Having given the principal hypotheses, I shall pass to the opinions of more modern authors, not, however, omitting to state that the major part of the au- thors believed that the diseases which they described were new, and not known previously to the taking of Naples. That learned and laborious author, Astruc, was of opinion that venereal dis- eases were not known in Europe previously to the year 1493, when, he states they were brought into Spain by the followers of Columbus, on their return af- ter the discovery of America. The same author quotes various passages from contemporary writers to prove the correctness of his opinion, and states that INTRODUCTION. 25 venereal diseases were endemic in the Antilles, and especially in the island of St. Domingo, whence they were directly imported. In subsequent pages he cites various passage for the purpose of proving that they are of native growth, and that the following places may be considered as so many seed-plots of the venereal venom : viz., the kingdom of Peru; New Spain; Florida; the midland part of Africa under the line; the island of Java; the Molucca islands; the country of China. As to the immediate source of the diseases in these countries, Astruc attribu- ted them to the nature of the diet, to immoderate promiscuous intercourse, and the virulent acrimony of the menstrual flux. Having explained in this manner the original appearance of the venereal dis- ease, Astruc informs us that it was communicated by sexual intercourse to the Spaniards, who imported it into Europe; thence it spread among the Neapoli- tans. Soon afterward he traces it among the French, who contracted it from lying with infected women at the siege of Naples, and it soon afterward spread over the other countries of Europe. In 1752, Sanchez* wrote a book to contradict the opinion which the writings of Astruc had made popular, and came to the following conclusions :— 1st. That the venereal disease was known in France previous the arrival of Columbus. 2d. That the Spanish army could not have given the disease to the French troops, as it did not come in contact with them. 3d. That it commenced in Italy, at the beginning of the year 1493, as an epidemic. Hunter declines giving an opinion on the origin of venereal diseases, as he thinks it could be of little practical benefit. Having previously noticed at length his division of the diseases, and the opinion he entertained on the spe- cific nature of the virus, which caused both gonorrhoea and syphilis, I shall not here allude to them. Broussais and his followers, as I stated before, denied that the venereal dis- ease depended upon a virus. M. Richond, in 1826, published a work, entitled " De la Non-Existence du Virus Vencrien." Practitioners of this school be- lieve that venereal diseases depend upon simple inflammatory affections, result- ing from the mode of the peculiar vitality of the organs primarily affected, and of their sympathetic power over certain parts of the economy. They believe that the diseases in question may arise spontaneously, and in- stances are given by them in which this is said to have occurred. Having now traced the principal opinions (from the earliest times to the pres- ent day) which have been entertained on the origin and nature of venereal dis- eases, I shall, in as concise a manner as possible, give my own opinions, which I have every reason to believe are those of M. Ricord; but as the professor of the Hopilal du Midi has not yet published on this subject, I am unable to quote his words. Venereal diseases, according to the definition which I have already given of the term, have probably existed from the most remote ages, or at least the non- virulent class of such affections. Proof of this has not only been adduced from history, but I have likewise the following reasons for the belief: At the pres- * Sur l'Origine de la Maladie Venerienne. Paris, MDCCLII. 26 INTRODUCTION. ent day we find that all these non-virulent affections* may be developed sponta- neously, and that we can produce them at will; hence I conclude that it is more than probable that they existed long before they were described, because the same agents were then in action to produce these affections as at present. Thus I admit the spontaneous origin of all non-virulent diseases, and that when once developed they may be propagated by contact, under circumstances which I shall hereafter allude to. In respect to the second order of venereal diseases, or virulent affections,] I can only now assert (and must refer to the subsequent chapters for proof), that we are not acquainted with any cases (nor do any such exist on record) which prove that syphilis, properly so called, can arise spontaneously ; all the experi- ments made to produce it de novo have completely failed; and a careful inves- tigation of the disease proves, on the contrary, that it has been contracted from a person who has himself contracted it of another, and it is in this way that the disease is now propagated. I thus deny most positively the spontaneous origin of this form, or of syphilis, properly so called; the exact laws and periods at which it ceases to be contagious, as far as my observations extend, will be mentioned hereafter. When this disease began (for necessarily it must have had an origin) I, in common with many previous writers, admit my ignorance. I can trace it (as I have done) as far back as the year 1494, and on this point there is little differ- ence of opinion; previously to that year authors ate not agreed: for my own part, I believe that a disease similar to syphilis was known previously to the year 1494, as may be gleaned from the authors I have cited; but I am as firmly induced to believe that the exact date of its outbreak is unknown, and that we are in ignorance of those circumstances which first gave it birth, or in what country it first made its appearance; in this respect the same lack of informa- tion reigns as in a vast number of other diseases, the origin of which we are equally unable at the present day to ascertain. I believe that the disease has had various phases; at one period it has assumed a very mild character, in con- sequence of attention to cleanliness and peace. On the other hand, in time of war and famine, it has assumed aggravated forms depending upon evanescent causes; and the disease, though always smouldering, will break out again, and rival in intensity those forms described by Fernel and Fracastorius, should the world become the scene of that condition of society which existed in the six- teenth century. In proof of this, I need only cite Dr. Ferguson's account of the disease as it attacked our men in the Peninsula, and gained it the name of the Black Lion of Portugal. Having given, then, my own opinions, which will be more fully developed in the succeeding pages, I turn from this theoretical part to describe practically a disease on which the author and reader will more certainly agree. * By the term non-virulent affections I mean diseases, the consequences of sexual inter- course, depending upon common causes, and not on any special one ; as, for example gon- orrhoea, &c. t By this term are meant those affections which depend on a special principle, distinct from all the ordinary morbific causes. A COMPLETE PRACTICAL TREATISE, &c, &c., &c. PART I. SYPHILOID DISEASES. CHAPTER I. BLENNORRHAGIA. For the purpose of bringing the subject of venereal diseases in a clear and methodical manner before my readers, I shall adopt the arrangement of M. Ricord, pointed out at pages 22, 23, of the Intro- duction. Order I.—Comprehends the non-virulent venereal affections, called syphiloid by M. Ricord. Definition.—By the term syphiloid diseases are meant those af- fections which follow sexual intercourse, reproducing themselves daily, often contagious, but not depending upon a special cause—non- inoculable. Under this order is included blennorrhagia, and its consequences ; excoriations, herpes, eczema, and all other affections the result of sex- ual intercourse, not included under the second order, or virulent affec- tions. Blennorrhagia, from B\ewa, mucus, and 'Peu, to flow, signifies a discharge from mucous membranes, consisting usually of mucus, and depending upon inflammation of that membrane, being to the urethra, vagina, or conjunctiva, what bronchitis is to the bronchi, with this difference only, that blennorrhagia most usually depends upon, or is contracted in, sexual intercourse. Gonorrhoea.—The disease here spoken of, under the term blen- 28 BLENNORRHAGIA. norrhagia, has been successively known by a variety of names. Among others, authors have employed the term gonorrhoea, derived from Tovn, semen, and /5e&>, fluo, it being supposed that the disease de- pended upon a discharge of semen. The impropriety of employing the term gonorrhoea, at the present day, will at once become evident; in the first place, it is objectiona- ble, inasmuch as the discharge which attends it does not contain semen, and it is by no means applicable as a general term (in the manner I have proposed to employ the word blennorrhagia) to the affections of mucous membranes. Thus, when the disease affects the uterus, under causes other than those of contagion, we fear we should be altogether misunderstood if we spoke of gonorrhoea of the uterus. By choosing another term, I hope gradually to wean the minds of practitioners from the idea that gonorrhoea, as they call it (blennorrhagia, according to my views), is always the consequence of contagion, although they are unable to distinguish it, except by the cause. Chaude pisse is the term employed usually in France in non- medical language, derived from chaude, hot, and pisser, to urinate ; but though graphically describing one of the symptoms very frequently present, still it is objectionable, as many patients, particularly females, do not complain of scalding in making water, when the affection is confined to the upper part of the vagina. Puorrhoea is the name given to the disease which we are de- scribing, by a French writer : he wishes to imply, that the affection gives rise to, or is accompanied by, a discharge of pus. Now, al- though it happens that pus is mixed with the discharge, still it alone does not constitute the affection, for I shall presently show it to con- sist of muco-pus, and the quantity of the latter secretion will differ greatly. The inconvenience, therefore, of using such a term will be at once apparent. Arstjra is another term that old writers employed to designate this disease, as they supposed it to be a species of purgation to man, and replaced menstruation in the female, which in their opinion was the outlet of bad humors. Clap.—This term, now commonly employed in England, is derived from the French term clapier, meaning a depot of matter, or anything that is filthy. The impropriety of using such a term in this work need not be dwelt upon. Mucite.—The physiological school in France applies this term to blennorrhagia, implying a simple inflammation of the mucous mem- BLENNORRHAGIA. 29 brane. The propriety of adopting this term will be considered here- after. Catarrhal inflammation is another term by which this disease has been known, and Capuron has spoken of it as a venereal catarrh, not implying, by that term, that it depends upon a principle distinct from inflammation, but wishing to use the term venereal as I have done in speaking of venereal affections, viz., that the disease is a con- sequence of sexual intercourse. Catarrhal primary syphilis.—In the valuable work on the Ve- nereal Disease, by the late Mr. Wallace, I find blennorrhagia de- scribed under this term. Notwithstanding such an authority, I think no term could be more improper, as it brings us back to that period when gonorrhoea and syphilis were supposed to arise from one and the same virus. Brenning is the last term of which I shall speak ; and it is here mentioned, more to complete the history of the synonymous terms, than with the intention of recommending it as a general one to describe the disease in question, arising as it does from so many causes. After a careful consideration of the terms which are and have been in use, I come to the conclusion that the use of the term blennor- rhagia presents the fewest objections, although, like the others, it may be cavilled at. In the following pages, then, it will be employed, and although derived from B\ewa, mucus, and 'Peu, to flow, still it is not intended to express that the discharge, which is a consequence of the disease, consists only of mucus ; it is rather a muco-purulent dis- charge, as any one may readily satisfy himself. In making use of this term, let not the reader consider that the dis- ease depends upon anything specific, or different from common in- flammation ; for, after a close study of uncomplicated cases we can find no reason for agreeing with those authors, who seem disposed to admit a blennorrhagic virus, or, in other words, to distinguish gonor- rhoea from leucorrhoza. Blennorrhagia is then defined to be a simple inflammation of the mucous membrane, a consequence more or less direct of sexual inter- course, not necessarily, although often, contagious ; this last character depending upon a morbid secretion of the stimulating matter, which, acting on another mucous membrane, will occasion a blennorrhagia, but will (on inoculation) produce no disease of the cellular tissue into which it is introduced. In fine, blennorrhagia differs in no respect from other inflammations of mucous membranes, otherwise than in its 30 BLENNORRHAGIA. usual situation, and in the manner in which it is contracted. Blen- norrhagia thus considered may occur in nearly all the mucous mem- branes. In the male, the urethra or prepuce may become diseased; in the female, the vagina, uterus, &c.; and in both sexes, the con- junctiva and rectum. The affection, as far as my personal observa- tion has gone, does not attack either the buccal or nasal mucous membrane. The epithelium alone may be the seat of the affection, or the sub- stance of the mucous membrane may participate in it; lastly, the follicles may become affected, or the sub-mucous cellular tissue be simultaneously or consecutively attacked. (Seepi.I. &IL,figs. 1,2, 3,4.) Causes of Blennorrhagia.—The causes of blennorrhagia, con- sidered in reference to mucous membranes generally, may be divided into two classes, the predisposing and exciting. Predisposing Causes.—Under the head of predisposing causes, age may be cited as an important feature. Infants are found to be more predisposed to the affection than adults, ceteris paribus; and this predisposition seems to depend upon the delicate state of their mucous membranes. Who that has seen the treatment of new-born children, is not acquainted with the fact that they are particularly liable to blennorrhagic affections of the eyes, glans, and prepuce, from causes that would fail to give rise to the complaint in adults ? The sex has likewise its influence as a predisposing cause ; it is an indisputable fact, that the female is mo*re liable to discharges of a blennorrhagic character than the male.* In Paris, says M. Ricord, woman may be said to have habitually a discharge, call it what you will, leucorrhcea, gonorrhoea, fieurs blanches, &c.: it affects all ages and all stations. " Were I called upon," adds the same author, " to estimate the proportion of discharges in the male and female, I should say that it is a hundred times greater in the little girl than in the boy ; a thousand times greater in the adult female than in the male." The temperament plays its part, likewise, as a predisposing cause. Every individual who is subject to congestion, or an oedema- tous state of the mucous membranes, is predisposed to blennorrhagia ; * M. Lisfranc, in his clinical lectures, is in the habit of stating, that, being called one day into the country, to perform an operation on a washerwoman, he amused himself out of scientific curiosity, during the time his assistants were preparing the necessary apparatus, in examining the linen of the Parisian ladies, a load having just arrived (for his patient did the washing on a large scale). He found that evident symptoms of blennorrhagic discharges were present upon nearly all. This may give the reader an idea how common the disease must be in the French capital. BLENNORRHAGIA. 31 hence the lymphatic temperament is a strong predisposing cause. It may be here stated, that preceding blennorrhagic affections predis- pose the individual to future attacks ; hence people are sometimes said to be subject to a blennorrhagic diathesis : but such a term has been abused ; it is no more correct than to speak of a sore throat dia- thesis. Daily observation, nevertheless, proves that any portion of the body which has been the seat of disease is, cceteris paribus, more liable to become a second time affected, than one which has not been previously affected. This applies especially to mucous membranes, as a tumid state of parts, and a liability to a return of the hypersecre- tion, remain long after the cure of the blennorrhagia. Locality.—Habitation is another predisposing cause : in a cold, moist climate, or in damp situations, blennorrhagic affections are more common than under opposite circumstances. The season of the year is not without its influence. In spring and autumn, discharges from mucous membranes are more common than in summer or winter. Hygiene is daily found to predispose, more or less, to the same effect. Under this general term mention should be made of the in- fluence of clothing. Light and imperfect clothing may be considered as one of those causes which predispose females in the higher ranks of life to discharges of a blennorrhagic nature. They will usually, whatever be their station, sacrifice comfort to appearance ; hence the mignon shoe and the open-worked stocking are worn, in spite of the cold feet they produce: a chilliness of the extremities follows the insufficient quantity of woollen under-garments, and gives rise to what are called white discharges. The peasant-girl, who protects herself from the cold by woollen petticoats and worsted stockings, observes M. Ricord, is not subject to leucorrhoea. Hence we may draw the practical lesson of strongly recommending warm clothing in cases of blennorrhagic affections. Having passed in review the principal predisposing causes, let me now speak of those that may be considered more directly to act as efficient or exciting causes. Exciting Causes.—Food of a stimulating, heating nature, as well as salt provisions, act as exciting causes. Beer, of all beverages, has been more especially accused of this effect, but on insufficient. grounds ; it is, however, certain, that of all beverages it is the one which will the soonest bring back a discharge when taken during convalescence. In Germany, the students who drink beer, though of a weak kind, to great excess, know this so well that they avoid it 32 BLENNORRHAGIA. most particularly when laboring under blennorrhagia, and I had occa- sion to see cases where the discharge was recalled by even one glass of that liquid. They consider their red wine of the greatest benefit, and find that a bottle of their strongest Rudesheimmer does not so much harm as one glass of beer. Among other articles of food, asparagus has a tendency to produce blennorrhagia ; hence its use should always be forbidden to patients liable to the affection in question. There are, in fact, certain persons who can not eat that vegetable without having an urethral discharge on the following morning. The use of cantharides is often followed by the same effect. It has been stated that horse-exercise will produce, in the female, this affection. Frequent and long-continued sexual indulgence, or too severe continence, are likewise said to act as exciting causes, and so I believe they may, when predisposition exists. While, on the one hand, M. Jourdan thinks that onanism is one of the most common causes, M. Ricord entertains a different opinion. Far from supposing that masturbation is always followed by blennor- rhagia, I imagine it to be a strongly exciting cause. The following case shows that there exists some reason for this opinion. During the period I performed the duties of Externe, under Professor Vel- peau, at La Charite, a mother brought into the hospital a little girl of three years of age, affected with a Avhite swelling and a discharge from the vagina. She stated that the infant was in the constant habit de s'amuser, as she called it, and when left alone, repeated continu- ally this mal-practice. She further traced the habit, so early com- menced, to a plan which nurses in France have of tickling the genital organs of children who are peevish. This, for the moment, quiets them ; but infants repeat these manipulations even at a very early age, as this case proves. On inquiry, I found that this was not an isolated case, and leads in after life to most vicious propensities. Local irritation, or mechanical causes, such as bougies, pessaries, calculi, or any substance that individuals introduce into the vagina, rectum, or urethra, will act as causes of the disease. On this sub- ject, M. Ricord states, that a woman was brought into the wards of Dupuytren, complaining of great pain in the vagina. On examina- tion by the toucher, that eminent surgeon was not a little astonished at finding his finger opposed on all sides by a wall of porcelain, when, after sundry efforts, a large jam-pot was pulled out, which this female had introduced so far that she herself was incapable of withdraw- ing it. BLENNORRHAGIA. 33 Enemeta have been accused of causing blennorrhagia, probably on insufficient evidence ; but their employment may recall a discharge when it is getting well. There are certain pathological or morbid states of the constitution which occasion the disease in question. Thus scrofula, gout, can- cerous affections, various skin diseases, secondary symptoms, partic- ularly the mucous tubercle, have undoubtedly this effect.* M. Ricord related a case, during the last winter, of a female who was affected with an herpetic affection running along the whole length of the va- gina ; the disease lasted eight days, and gave rise to a discharge which ceased with the eruption. Labor may be considered as not an unfrequent cause of blennor- rhagia ; the lochia, instead of disappearing after the usual time, be- come irritating, and give rise to chronic discharges. • Inattention to Cleanliness.—There is no one cause, perhaps, among those I have previously mentioned, which gives rise to blennorrhagia so frequently as inattention to cleanliness. Women, more especial- ly, are liable to much blame on this score; they wash every other part of the body, but, unhappily for their own comfort, as well as that of their husbands, they seem to be averse to let clean water reach the vagina. Such neglect of cleanliness is not found in the case of prostitutes only, but is met with in many other women. Certainly those who have the direction of young females would do well to rem- edy this inattention. M. Ricord states that all ranks would be bene- fited by sundry hims on this subject. Menstruation has its influence in producing the affection in ques- tion. Of this fact no people were more aware than the Jews ; and we find it strictly forbiolden in the Mosaic law to have connexion with a woman about this period, and no doubt it arose out of the fact that such intercourse was found to propagate blennorrhagic affections. * A good illustration of this happened in one of the patients at the venereal hospital during the last winter. A man came in suffering under various secondary symptoms, particularly the mucous tubercle (condyloma) around the anus. He drew my attention to a discharge which proceeded from the umbilicus. On examination, a mucous tuber- cle was distinctly recognised in this position, and M. Ricord took the opportunity of showing it to his class : no doubt many of my countrymen will remember well the case. Now here is the secretion from the tubercle giving rise to a blennorrhagic discharge. Had such a case occurred in the vagina, most persons would have considered that the gonorrhceal or leucorrhoeal discharge, as it would there be called, gave rise to second- ary symptoms, whereas the converse is true. Moreover, as mercury is of the greatest advantage in curing secondary symptoms, and was here employed with advantage, so would such treatment be cited as a further proof that gonorrhoea and syphilis are one and the same affection. 3 34 BLENNORRHAGIA. Worms.—Intestinal worms exert an influence in producing the disease ; as they may act by occasioning a sympathetic action be- tween the rectum and vagina—irritation in the one organ is lelt gen- erally in the other; or again, by the passage of the worms from the anus to the vulva. M. Ricord states that he has seen a case where he could distinctly trace the blennorrhagia to this cause. I have met with several cases of blennorrhagia in children, which show the im- portance of medical men being acquainted with this fact. The fol- lowing may prove interesting. A woman brought a female child to the hospital, which she had left very much to itself, as she was obliged to go out to work during the day; and observing a discharge on its linen, questioned it, and said that she believed a boy had given the disease to the child. On further interrogation, this was by no means so evident; the mother had asked the child if she did not play with such a boy, and the child replying in the affirmative, she con- cluded the boy had ravished her child. A dose of scammony brought away a great quantity of worms, and the child got perfectly well. Renal and vesical affections, as well as haemorrhoids, will act in the same way in producing discharge from the male and female organs of generation. Reflections on the foregoing Causes.—Having now passed in re- view those agents which can be rationally considered as predisposing and exciting causes of blennorrhagia, 1 may observe that, thus con- sidered, it presents nothing that is specific ; it may arise under the most varied circumstances and causes. Its existence in the male or female, therefore, is of itself no proof of libertinism; it may occur in the most modest as well as in the youngest child. Hence, in medi- cal jurisprudence, the necessity of being guarded in our opinion, and the surgeon, in family disputes on the subject of contagion, should be especially cautious, and always lean to the weak side.* Thus the opinion of Tod, viz., that blennorrhagia depends upon a specific virus, * I have at present under my care a case illustrative of this, and how much good a medical man may do in arranging those family disputes arising from blennorrhagia. A very respectable looking female applied to me for a discharge of twenty months' stand- ing, which she asserted her husband had given her. On examination, a large ulcera- tion of the neck of the uterus was observed. This patient stated, that twenty months before she had miscarried, and the discbarge had been increasing ever since; and as she had observed stains on her husband's linen, she was sure he had gone astray, and that she had contracted the foul disease from him. He denied the accusation, and ac- cused her of infidelity, and they led a most unhappy life. In about three weeks after, this female was cured, the husband soon got well, and they are now perfectly satisfied that the affection in the one was the consequence of the miscarriage, and the clap in the other a consequence of the previous affection in the female. BLENNORRHAGIA. 35 is no longer tenable. But this leads me to speak of contagion in ref- erence to blennorrhagia. Contagion.—I have previously avoided, except in the definition, even alluding to the possibility of this affection being contagious, in order that I might comprise that subject in a separate paragraph. Every one well knows that it is by contagion that this disease most frequently extends itself; and some have imagined that it is only in such a way as this that it can be contracted. This opinion has, how- ever, been shown to be incorrect. Whenever, then, the word contagion is used, let it be understood to mean, that if the muco-purulent secretion from any of the foregoing causes of blennorrhagia comes in contact with another portion of previously healthy mucous membrane, either in the same individual or in another, it will, in many cases, but not in all, produce a similar affection ; not, however, in virtue of anything specific in the muco- pus, but as a consequence of simple irritation—like any chemical irritant, in fact. But it is not always enough to bring the secretion in contact with a healthy mucous membrane, in order to produce blennorrhagic affec- tion. There are various circumstances which must be combined, to produce the effect, although we can not always seize upon them. Every individual exposed to contagion is not affected, any more than when exposed to a draught of air he should be seized with coryza, although his neighbors on the right and left may be attacked by it. In some cases we arrive at, or suppose we know, the cause of this circumstance, Tnt» we may say that habit, or, as the French call it, acclimatement, may account for the impunity or manner in which some individuals are exempt from the affection. The following case will illustrate our position—we borrow it from a collection of memoirs published by M. Ricord. A companion to an elderly lady was in the habit of receiving a lover who was a very old friend ; and during a long intimacy contracted no disease, although this lady, his mistress, suffered under a discharge. It happened that a second lover pre- sented himself, who was previously perfectly free from disease. No sooner, however, had this young man enjoyed her favor, than he found himself attacked with a discharge, although the original lover, notwithstanding frequent intercourse, was never seized with any af- fection. The second lover got cured of his complaint, and although he visited this lady afterward, he did not contract any fresh disease. But a third Lothario was, like his predecessor, subject to the same penalty for her first favor, and was in his turn rendered exempt from 36 BLENNORRHAGIA. a second attack. On examining the female, M. Ricord found there existed a catarrh of the uterus, which was more or less purulent, and a granulated appearance on the surface of the neck of the uterus was very apparent.* Now in this case it appears that habit prevented the original lover from contracting a blennorrhagia, although exposed in the same manner as the other two, who in their turn became in- sensible to a second infection. In this respect habit may have its influence, as in cases of certain fevers which are said not to attack the natives, but only strangers, who become, after a time, unaffected, although exposed to the same influences. Although contagion is one of the most frequent causes of blennor- rhagia, surgeons must not be too credulous, otherwise they will be liable to be often deceived. Women will frequently hatch up a story as to the manner in which they have contracted a discharge. It is not uncommon for nurses, for example, to account for a discharge which they may be subject to, by saying they have contracted it from the child they have taken in to nurse, wishing to make you believe that it is through the milk they themselves have become affected. If, on examining such children, no disease of the mouth or genital organs is found, the surgeon may flatly contradict them, as such a means of contagion is impossible. Before quitting the subject of contagion, I should say a few words on certificates, a subject which annoys very frequently a medical man. In consequence of judicial inquiries, or family feuds, a female presents herself and asks the surgeon for a certificate to the effect that she is not subject to a contagious disease, or is not in a condition to communicate any discharge, under which she herself is laboring, to another person. M. Ricord recommends that the surgeon write one to the following offect, having previously carefully examined the woman with a spec- ulum, and finding no ulcerations :— " I certify, &c, that-------presents no symptoms of a syphilitic disease, but has a catarrh of the vagina, uterus, &c, and may proba- bly [or not, as may be] communicate the disease to another." No surgeon can be warranted in stating more. Epidemics of Blennorrhagia.—Blennorrhagia, in the preceding paragraph, has been considered as a sporadic disease, but it is repre- sented by some authors as occurring epidemically. One of these so called epidemics, says M. Ricord, fell under my notice during the building of the Magdalene. An epidemic existed among the masons, *• See plate II., fig- 3, which represents a similar appearance. BLENNORRHAGIA. 37 and occurred to so great an extent that, when a mason presented him- self as an out-patient, I immediately told him he worked at that build- ing, and came to consult me for a clap; and the poor fellow thought me a prophet, so sure was I to be right in my statement. This sup- posed epidemic simply depended on the collection of a great number of workmen together, who lived in common with a few women suffer- ing under blennorrhagia. Such is the explanation of these so-called epidemics, and the word can not be more unfitly used as applied to such cases. It will not, perhaps, be out of place here to say a few words on the period that elapses between exposure to the causes, and the occur- rence of the blennorrhagia. The period is usually some few days, but will depend upon the greater or less reaction which takes place, as well as other circumstances, for a certain space of time always passes between the last connexion and the appearance of the dis- ease. Some authors have observed cases which occur so long after con- nexion, that they have been induced to believe in what is called in- cubation. Among others, Bell cites a case to prove this point. A person went on board a ship, where he could have no means of con- tracting gonorrhoea (adds Bell), and on the fiftieth day after being at sea, a discharge from the urethra appeared and continued some time. Here, then, is a case of gonorrhoea which was contracted on shore, and broke out at the end of fifty days ; the intervening time was the period of incubation. Now, giving Bell all the credit for veracity, it does not seem neces- sary that we should come to his conclusion. Might not the man have contracted the discharge by certain mal-practices ? But even this was not necessary. It has been above stated that various causes will produce the disease, as well as contagion, particularly scorbutic complaints. Is it not more rational, then, to suppose that these very rare and exceptional cases depend on some cause above alluded to, rather than to believe that incubation exists, or that gonorrhoea may be concealed in the system, to break out when it pleases its good will and pleasure ? I believe, in fine, that blennorrhagic affections are produced soon after the causes which excite them come into action. Circumstances may retard them two or three days : in this respect they resemble other diseases. The Symptoms of Blennorrhagia.—A blennorrhagic affection may be ushered in by loss of appetite and the other signs of an in- 38 BLENNORRHAGIA. flammatory disease, constituting the general symptoms. These are, however, often absent. The local symptoms consist in heat, a tension of the part, followed by increase of the natural secretions, which soon afterward tend to diminish, and may altogether cease, giving rise to that form which has been vulgarly called dry clap. It does not, however, remain long in this state, for the secretion again becomes not only increased, but altered, taking on a mtico-purulent character, and the pus will pre- ponderate in proportion to the severity of the inflammation of the cel- lular tissue. The discharge changes in color; at first it is milky, then more or less gray or green, or, in proportion as blood is mixed with it, it will have various shades. To these circumstances the pa- tient will pay great attention. The odor, as well as the thickness of the discharge, will vary much. The course of the affection will be either acute or chronic ; how- ever, the symptoms have usually a tendency to progress until about the twelfth or twentieth day. From that period it as gradually de- creases in severity. From being purulent, the discharge assumes a muco-purulent or simple mucous character; and lastly, only an aug- mented but natural secretion remains. The terminations of the affection may be various. Soon after its invasion, the blennorrhagia may terminate suddenly, either under the influence of treatment, or without any reason that we can assign : such may be called delitescence. It has been supposed that the dis- ease, after existing a certain length of time, may be cured locally and suddenly, but at the risk of being driven into the system and break- ing out afresh in some other part; in other words, that a metastasis of blennorrhagia may take place, analogous to that which occurs in rheumatism. M. Ricord states, that after a careful consideration of cases where the affection is supposed to be driven into the system, and cases of this kind have been observed in his hospital from time to time, he is by no means convinced that a blennorrhagic affection is cured in one part of the body, merely to break out in another. From what he has observed as happening occasionally, he is induced to believe that some other affection may come on during, or coinci- dent with, a blennorrhagia; which disease, acting on revulsive prin- ciples (as a blister or seton would), may moderate or cure the blen- norrhagia. For instance, should a patient, during a gonorrhoea be seized with any other affection, say fever, that may have the effect of producing such a revulsive action, that the discharge will for the time abate. I have seen this happen pretty often ; but such is not BLENNORRHAGIA. 39 the opinion usually entertained. Persons believe, for example, that a gonorrhoea quickly suppressed by treatment will give rise to ophthal- mia, swelled testicle, and rheumatism. On the contrary, I think it more probable that any one of the foregoing diseases may arise du- ring the course of a gonorrhoea, and, if violent, will act as a revul- sive ; but the original complaint, instead of being cured, is only ameliorated for the time : it will return to its former severity. In this respect blennorrhagia resembles other affections of the system ; and it is of use, in a practical point of view, to know that these affec- tions are rather coincidences than caused directly by blennorrhagia driven into the system. Resolution.—The most ordinary termination of blennorrhagia is by resolution; that is to say, a gradual diminution in the symptoms and secretions takes place. Such has been always considered as the most favorable termina- tion ; but of this I shall again speak under the head of treatment. It will be there seen that I do not think a gonorrhoea should be allowed to go on unchecked, for a cure by delitescence is preferable. Continuation under the Chronic Form.—Surgeons have usually stated that the affection may terminate in a chronic form. Such lan- guage is, however, not correct, as their so-called termination is un- doubtedly but a continuation of the disease under a chronic form. M. Ricord observes, he was consulted by a military man for a gleet which he had been subject to for thirty years. Could it then be said that the blennorrhagia terminated thirty years ago, as he had suffered ever since that period ? The acute stage of the disease may then terminate, or pass into a chronic one, which depends on various alter- ations of the tissues, consisting sometimes in hypertrophy, with indu- ration, or with softening of the mucous or sub-mucous tissues. Pathology of Blennorrhagia.—The lesions of the mucous membranes which result from blennorrhagia are numerous ; yet very few specimens are preserved in even our best museums of pathologi- cal anatomy. Works on the venereal disease are equally deficient in information on these points. In books on this subject, one writer has copied another, and seems to have dissected books rather than bodies ; hence, since the time of Morgagni, how few new pathologi- cal illustrations have we on the disease, and how seldom do we see the urethra opened in post mortem examinations ! For these reasons I shall describe the subject in the following pages at some length. Hunter states it as his opinion, founded on the examination of the urethra of two men who were hanged while suffering under gonor- 40 BLENNORRHAGIA. rhoea, that this disease is attended with no changes of the mucous membrane. Other writers, in copying him, have been contented with this view, although they forget that a mucous membrane, wherever it is placed, is subject to certain diseases in common. Why should the urethra, then, be more exempt than other similar membranes 1 Ob- servation of the genito-urinary mucous surfaces during life, as well as after death, have clearly proved, that either acute or chronic inflam- mation will produce such alterations in it as are not generally stud- ied, much less known. By means of the speculum, the state of the female organs, in cases of blennorrhagia of these parts, has been suf- ficiently demonstrated ; and from the analogy of the tissues, it might have been supposed that the same morbid appearances would be found in the male, could we observe his urethra. Gonorrhoea, how- ever, seldom terminates fatally. The following appearances I can speak of, from direct observation, as occurring in the vagina, &c. In acute stages of blennorrhagia, the mucous membrane is simply redder than usual in its whole extent, exactly resembling what takes place in balanitis, or what is commonly called gonorrhoea prseputialis. (See plate III, fig. 1.) In some cases this redness, accompanied by a good deal of local swelling, puts on an erysipelatous character, which has induced Fabre to term it gonorrhee seche, as it gives rise to very little discharge. In other instances there exist distinct patches of reddened cuticle or epithelium, surrounded by a healthy appearance of the mucous membrane. These patches are covered with little pieces of de- tached and softened cuticle, or spots, as seen in the drawing (plate III., fig. 3). All species of discharges may accompany these morbid states, and require to be removed before these appearances are dis- tinctly brought into view. In some places there may be erosion of the epithelium, and distinct granulations may be observed emerging from the body of the mucous membrane, as seen in plate I., fig. 2. Ulcerations of all characters may be met with in any point of the internal organs, as most Eng- lishmen who have attended M. Emery's clinique have had ample means of observing, and as may be seen in plate II., A. fig. 1. When the disease is in a chronic state, I have often observed the mucous membrane paler than usual, but presenting at certain points a tume- fied appearance, and stripped of epithelium, or covered by pale gran- ulations similar to those observed in cases of chronic inflammation of the conjunctiva. This condition of parts is very liable to bleed under slight causes. In some cases I have witnessed distinct vege- BLENNORRHAGIA. 41 tations in the whole course of the vagina, as well as at the orifice of the urethra. In plate III., fig. 2, vegetations are seen sprouting from the urethra of the male. This is the second case which I have ob- served during the last winter. M. Ricord states he has, in two cases (examined after death), found distinct ulcerations, with an indurated base, situated on the mucous membrane, an inch and a half within the carunculae myrti- formes. The plate showing ulcerations of the urethra in the male will be given in a wood-cut, in the second part of this work. In neither of these cases was there any analogy to cancer or scirrhous disease. In addition to the changes* above mentioned, distinct induration, or cicatrises, and other morbid appearances, may occur ; but any fur- ther description must be reserved for what we shall have to say on stricture. With reference to the termination of blennorrhagia, it will be often found very uncertain, as every one well knows ; hence the tendency of patients to accuse unjustly certain women of giving them the dis- ease, whereas a warm bath or a too copious dinner will recall a com- plaint which was on the wane. Blennorrhagia may not only return, but recur at regular intervals. I have seen a few cases of this kind, which I may call periodical, as they were accompanied with intermittent fever, and seemed to depend upon irritation about the neck of the bladder. Certain other causes, also, may influence the return of blennorrhagia ; thus certain patients have an annual gonorrhoea, which follows the carnival. In these cases, drinking and dancing reproduce the discharge, if there is any predisposition. These periodical attacks of blennorrhagia, again, depend upon causes which we are not able always to ascertain, independently of sexual indulgence. " I have," says M. Ricord, " seen more than one person attacked with gonorrhoea annually, in consequence of eat- ing asparagus, and, on leaving off this vegetable, the discharge has ceased. Complications.—In the previous pages, blennorrhagia has been described as it. may occur; but in a variety of cases it is not such a simple disease : numerous accidents arise during its course, and will be here described under the head of complications. The local swel- * The illustrations which are annexed place these lesions now beyond a doubt, and I have had too many opportunities of showing their existence in England, to suppose that they are confined to Paris, and do not equally exist in this country. 42 BLENNORRHAGIA. ling may be so great that the urine may be prevented from passing along the canal, giving rise to retention depending upon an inflam- matory stricture. The lymphatic vessels may become likewise in- flamed, and buboes or swelling of the lymphatic glands result, as occurs after an irritation in any part of the foot. These buboes may be the result of a direct extension of the inflammation along the lym- phatic vessels to the glands, or may depend upon sympathy, or that law of the animal economy which causes the one extremity of a canal or tube, when irritated, to swell or sympathize with the other extremity, without the intervening part of the tube or canal being sensibly affected. These last are properly called sympathetic bu- boes. <^ I have seen haemorrhage occur during the course of a blennorrha- gia, which, like other haemorrhages from mucous membranes, may depend upon simple exudation from the surface, or upon the rupture of vessels around ulcerations, or from a varicose state of the venous system of the part. Fresh exposure to contagion, as well as any excess in diet, by ex- aggerating the severity of a previously existing blennorrhagia, will act as a severe complication, by increasing the morbid condition of the mucous membrane. Chancre is a frequent complication. It keeps up the irritation, and gives rise to a secretion, which, from its position, we can not always remove as soon as it is formed. Constitutional syphilis has been above stated to be a frequent cause. It may likewise be a complication, as will appear in subsequent chap- ters. I shall hereafter describe one of the most frequent complications, namely, epididymis, or what is usually termed swelled testicle; but it can not find a place here, as we are describing only what is gen- eral in regard to the affection, without reference to locality. Notice has previously been taken of rheumatism occurring during the course of a blennorrhagia. Authors generally are not agreed upon the relation between these two affections ; and having no fixed opinion, I therefore speak of it as a complication, observing, that rheumatism may come on during the time that a patient is suffering under blennorrhagia. I am, however, induced to believe that blen- norrhagia is not the exciting cause, though it may be a predisposing one, of rheumatism. The Diagnosis of Blennorrhagia.—From what has been above stated, it will appear at once that the diagnosis of blennorrhagia is BLENNORRHAGIA. 43 easy, characterized as the disease is by a muco-purulent discharge. There are, however, several points which are deserving of attention, as distinguishing the position, intensity, &c, of the affection. The character of the discharge will often give the surgeon some notion of the exact situation of the disease. When he observes a glairy secretion, resembling the white of egg, he is justified in stating that the neck of the uterus is affected ; when the discharge is com- posed of muco-pus, he may be assured that it arises from the urethra, vulva, or vagina, &c. Some assistance may be derived likewise from chemical tests, to decide whence the secretion issues, as it is found that the muco-pus of the vagina is acid, whereas that coming from other sources is alkaline. When the mucous membrane is alone inflamed, the secretion is formed almost solely of mucus ; when, however, the sub-mucous tis- sue becomes affected, we observe the secretion to assume a more or less purulent character in proportion as this tissue is affected. The existence of blood, mixed with muco-pus, will generally lead the surgeon to expect an ulceration of the canal, which he can not examine. But here there are many sources of error, as blood may be poured out in consequence of excessive inflammation. Usually, however, I have been able to distinguish, or at least to suspect, the existence of a chancre, from the appearance of the discharge, when it has a grayish or reddish tint, and is of a thin consistence ; and inoculation has frequently proved these surmises to be correct. I shall not here stop to point out the error of those who consider that, because blood is mixed with the blennorrhagic secretion, the disease was contracted from a woman during a menstrual period. Lallemand of Montpellier has, in his late work entitled " Les Pertes Seminales," laid great stress on the existence of semen in these discharges of a chronic character. A careful examination, however, should be made, before it is asserted that the spermatic fluid is present, as what is often called semen is nothing more than the prostatic fluid, which is to be distinguished from the former by its containing no animalcules, when viewed under the microscope. When semen is present in the discharge, we may usually affirm that blennorrhagia has reached the opening of the vesiculae seminales, and, by the irritation it produces, gives rise to the ejaculation of se- men, which becomes mixed with the secretion. The acute may be distinguished from the chronic stage in the urethra, by the former being accompanied with pain in making water, and the secretion be- ing purulent; whereas the latter is accompanied by no scalding in 44 BLENNORRHAGIA. making water, and the secretion is mucus. It will hereafter be found that the existence of the one or the other stage occasions a great dif- ference in the treatment. A very important point of diagnosis may be drawn from the exist- ence of the complication of chancre, as it enables the surgeon to de- cide whether a blennorrhagia is of a virulent or a mild character. This point has been very much contested ; and although the ex- pressions virulent and mild are often met with, yet no two medical men are agreed upon the use of these terms. I shall, before explain- ing my own opinion upon this point, say a few words on the various suppositions which have been brought lately forward. Supposing that a male or female is laboring under a blennorrhagia, the question to be decided is, whether it be a virulent or a mild affec- tion. Some surgeons state that, before coming to an opinion, we must wait for the occurrence of secondary symptoms ; if they appear, it is a sufficient reason to call the blennorrhagia which has preceded, a virulent complaint. This opinion is just; but we would ask, of what use is a diagnostic sign which can be only given at so late a period, and when we have arrived at the diagnosis it is of no further use to us, as probably the blennorrhagia is cured 1 Other authors have considered the existence of buboes as the dis- tinguishing character of the two forms of the disease ; but, as will hereafter be shown, no dependance can be placed upon this sign, for any simple irritation on the foot, &c, will give rise to buboes; there- fore the mere circumstance of buboes, without reference to the pus they secrete, demonstrates nothing. Some, again, state that a virulent blennorrhagia follows connexion with a suspicious subject; whereas a mild affection may follow con- nexion with a modest woman. These distinctions, founded on the consideration of the causes, can not be adopted. Is the opinion on a subject like this to be based on the supposed or presumed morality of one woman over the other 1 Does not daily experience show (says M. Ricord) that girls of the most tender age, as well as persons holding high social positions, can and do contract virulent complaints, and may communicate these to persons who have connexion with them ? Let not. the fact of a disease being contracted from a more or less (apparently) virtuous woman be the means of founding a diag- nosis. Little dependence can be likewise placed on the opinion of those who state that the green color, as well as the presence of blood in the discharge, or the breaking out of the disease a long time after BLENNORRHAGIA. 45 connexion, can enable us to distinguish a virulent from a mild blen- norrhagia. Not long since, at the Academy of Medicine, it was stated that the duration of the disease may serve as a distinguishing feature of the two forms. A virulent complaint was stated as likely to last forty days, and a mild one twenty. This, however, is a very erroneous opinion, as will presently be shown.* The acute nature of the complaint, and the existence of ulceration, has been also cited as proving the existence of a virulent affection. This will likewise be shown to be incorrect. Induration of the canal, pain on pressure at a particular point, and the possibility of taking the impression of an ulceration with the porte empreint, or bougie armed with wax, have been cited as so many pathonomonic signs of the virulent form. It will hereafter be found, however, that these form but a probable diagnosis, as induration is by no means a constant character, and any simple ulceration will give rise to pain, and an impression may be occasioned by folds of the mucous membrane. I believe that authors have had ample reason for separating blen- norrhagia and its discharges into two forms, which they have called virulent and mild ; but I have before stated, that, previous to M. Ri- cord's investigations, they had completely failed to state on what cir- cumstances they depended, nor could they by any one symptom dis- tinguish one form from the other. As this is of great importance, I may be excused if I dwell somewhat longer on it, particularly as many other facts that I shall hereafter describe, depend upon the clear comprehension of this subject. The previous views of authors show how much difference of opin- ion existed on this subject when M. Ricord undertook to show that the cause of a virulent blennorrhagia depended upon the complaint being complicated with a chancre. In women, more especially, he found that what was called a virulent gonorrhoea depended upon the existence of ulcerations, which could not be discovered by an exam- ination of the external organs of generation, but which the use of the * M. Puch, one of the surgeons of the Venereal hospital, has stated to me that he can distinguish a mild from a virulent blennorrhagia by the period which elapses between the appearance of the discharge and the previous connexion. For the observation of a great number of cases of a mild blennorrhagia proves that the usual period is from a few hours to as many days ; on the contrary, in a virulent affection, the interval be- tween connexion and the first appearance of the discharge is from seven to fifteen days. That this is often the case, no one will doubt; but, if relied on, it may lead to many errors in practice. 46 BLENNORRHAGIA. speculum clearly proved to exist. But did all ulcerations give rise to a virulent gonorrhoea ? was the next question to be solved. At the time this eminent surgeon was investigating the subject, he often had occasion to treat the woman from whom some of his male patients had contracted the disease, and he found that there were various forms of ulcerations, the secretion of which caused simply a mild gonorrhoea. There existed others, however, which caused sometimes chancres on the glans penis and prepuce ; on other occasions, viru- lent gonorrhoeas. In vain did he try to distinguish these ulcerations by their physical characters. It was only by inoculation that he was enabled to prove why sores similar in appearance gave rise to such different consequences. Inoculation soon showed him that there may exist an ulceration of a specific character, which will be described in its proper place, and called chancre ; but there likewise exist ulcer- ations of a simple nature, the result of an inflammatory state of the mucous membrane, which were frequently the consequence of a blennorrhagia. From this moment, that which was previously doubtful became clear, and an inquiring and observing mind like his was not long in deciphering what had been the opprobrium medi- corum. From what the speculum showed clearly to exist in the vagina, he naturally concluded that similar appearances might exist in the ure- thra of the male, but which, from its small size, it was impossible to demonstrate. However, one opportunity of examining the urethra, followed soon after by a second, put him in possession of two cases, which he showed to the Academy of Medicine, in which chancres existed in the whole course of the urethra. (See cut on page 169.) He thus discovered the key to this hitherto difficult labyrinth, and concluded that the only diagnosis between virulent and mild blennor- rhagia is derived from inoculation. The experiments, frequently, repeated, of inoculating with the se- cretion of a simple mild blennorrhagia, produce only a slight irrita- tion, which subsides in a few hours ; whereas, if the complaint is virulent, or, in other words, depends upon, or is complicated with, a chancre which is concealed, or which can be brought into view by the speculum, the secretion introduced under the skin, in a similar way as in the former experiment, will produce a vesicle, pustule and chancre, as seen in the drawing (plateIV.,fig, 1, a, b, and c). This, then, I call the certain pathonomonic diagnosis of a virulent blen- norrhagia. A rational diagnosis may be drawn from the rosy, thin serous, or rusty color of the discharge, provided such be present, as BLENNORRHAGIA. 47 well as from an indurated spot in any point of the canal, accompanied with fixed pain, &c. Should buboes follow, which on inoculation give rise to the char- acteristic pustule, it may be asserted confidently that the blennorrha- gia is a virulent one. The occurrence of secondary symptoms, which only follow in a few cases, gives a further diagnosis of the same fact. It is, however, the rational diagnosis that the surgeon must usually depend upon, as inoculation can not always, be proposed, or he may find patients object to submit to it. He must, however, remember that it is but a rational one, and on such data be cautious how he risks his reputation by giving an opinion. The Prognosis of Blennorrhagia.—The prognosis, with refer- ence to the probable duration'of the disease, will depend in a great measure on the mucous membrane which is the seat of the disease. It is proved by experience that, when the conjunctiva or urethra is affected, a cure will not so readily ensue as when the prepuce or glans penis is attacked. When the uterine surface suffers, the sur- geon may feel assured that the complaint will resist treatment longer than when the vulva or vagina is affected. The same principle holds good in relation to the portion of the canal affected. It will be found that the disease will be more diffi- cult to cure in proportion as it has gained the deeper portions, or such as are the. farthest removed from the external openings. Hence it is, that blennorrhagia of the vagina or prostatic portion of the urethra are so intractable to treatment. If the blennorrhagia has existed but a short time, the cure will probably be speedy, and the more amenable will it be to plans of treatment, and vice versa. An acute attack of the disease will be cured easier and more speedily under treatment than the chronic form. The prognosis of the surgeon will be much modified by the cir- cumstance of his patient having or not having been previously attacked with blennorrhagia. If he has previously had a blennorrhagic affec- tion, the present complaint will be probably less severe, but more re- bellious to our means of treatment. It is evident that the occurrence of the various complications will modify considerably the prognosis. On this point I shall not insist, reminding my reader only that improper hygiene and treatment are very liable to produce them, especially the formation of abscesses along or around the parts affected. 48 BLENNORRHAGIA. Under the head of prognosis, it may be as well to consider a few of the questions which patients put to surgeons, more especially as it will enable me to state some important facts, and attempt to destroy some popular prejudices. A patient will sometimes ask the surgeon if the treatment he is about to prescribe will give rise to a stricture or a swelled testicle. It is a very common error to suppose that the treatment will occasion either of these complaints ; and this, like many other popular errors, has taken its source in medical writings, which have stated that a blennorrhagia speedily cured will give rise to various other com- plaints. M. Ricord says, we may state distinctly that no ill conse- quences are to be feared from any treatment, provided it is not grossly improper. If (pursues that surgeon) I were disposed to be aphoris- tic, I might say that the ill consequences will be few, in proportion as the cure is speedy; and I defy any one to produce a case cured in twenty-four hours from its commencement, which has been fol- lowed by any ill consequences. There are prejudices against speed- ily curing a blennorrhagia, and I may be told by some surgeons, " after a practice of full thirty years, I am of an opposite opinion." But I ask, may not such a practitioner have labored under a mistaken notion during thirty years ? Is implicit belief in a fact, for that space of time, a proof that that fact is true 1 Has not an old author said, and very truly, " experientia fallax V In addition to the questions relative to prognosis which the surgeon will be called upon to answer, he may have to reply to the following : Shall I, or shall I not, be subject to secondary symptoms ? To an- swer this question, a surgeon must of course ascertain if the blennor- rhagia be virulent or not. If it is a mild affection, he may, with every assurance, quiet the fears of his patient. If there be reason to suspect that he is suffering under a virulent form of the complaint, it does not necessarily follow, even then, that secondary symptoms will ensue ; for if the chancre can be cured pre- viously to the third day of its existence, no such symptoms ever will appear, and the shorter the subsequent duration of the chancre, the less probable will be the chance of infection; and if no induration attend it, most probably no secondary symptoms will follow. In my opinion, however, too great caution can not be used ; tell your patient that the complaint is complicated with chancre, otherwise he may lay to the score of your treatment effects which really depend upon the existence of the chancre, or his own neglect. Under the head of prognosis, I must consider the greater or less BLENNORRHAGIA. 49 probability of transmitting a blennorrhagia. On this score, patients are usually very inquisitive, and surgeons should be particularly guarded in any opinion they may give. Whately asserted, that as long as a discharge was merely white, there was no fear of commu- nicating it. Bell states, that if the secretion consists of mucus, we need entertain no fear on this head. M. Ricord considers that when the secretion is reduced to a thready mucus, which is transparent like vermicelli, contagion is not to be dreaded. On the contrary, as long as the secretion is purulent—a fact to be ascertained by simple inspection, or by means of the mi- croscope, whatever may have been the duration of the disease—it is capable of causing a similar complaint in any mucous membrane with which it comes in contact. Should, therefore, any pus be present in the secretion, the surgeon ought never to sanction sexual intercourse ; if the secretion be not purulent, let him wait some days before he gives his permission, to see if it does not become so. Impress strongly on your patients the necessity of abstaining from sexual intercourse as soon as any pus appears mixed with the secretion. Patients will sometimes ask the following question : "lam obliged to have connexion with my hus- band ; now, doctor, I am suffering under a discharge—what com- plaint will he contract from me V Inoculation will alone answer the question, and the surgeon will at once be able to tell the probable consequences. The same question relates to marriage; " and pa- tients," says M. Ricord, " present themselves to me to know whether they may marry, for often their fortune may depend upon a marriage. I persuade them against it, if they have a simple gonorrhoea, but if it be a virulent complaint, I wash my hands completely of the affair. If they still persist, I tell them that they may give a gonorrhoea to their wives which, unless cured previous to confinement, may cause a loss of eyesight to the child : called, however, afterward to cure the lady, I attempt to explain the affection which she has contracted, by speaking of the fatigue of the honeymoon, as well as the dejeuner a la fourchette, and in the interim cure both parties, of course forbid- ding connexion. Such is the part that a medical man often has to play, and many disputes in married life may be thus avoided, and the surgeon must, in these cases, lend himself to deception." The Treatment of Blennorrhagia.—In studying the history of the treatment of blennorrhagia, it is curious to see how it has dif- fered at various periods, being modified by the notions which medical men of the day entertained on its nature and causes. When it was 4 50 BLENNORRHAGIA. a prevalent idea that blennorrhagia depended upon, or consisted in, a loss of semen, such remedies were prescribed as surgeons supposed capable of checking spermatorrhea. At a later period, when humorism was in vogue, the discharge was supposed to consist of pus ; and as it was thought to chase the bad humors from the body, care was taken not to check the discharge the supposed outlet of various disorders. When we consider that medicine was but little advanced at this period, we are not surprised that this doctrine should have kept its ground for a long time ; but is it not astonishing that these prejudices are still entertained by many enlightened men, although they reject the ancient doctrines of the humoral theory ? It is lamentable to find that many of the practi- tioners of the nineteenth century are not more advanced than were those of the fifteenth, and obstinately resist any line of treatment which has for its object the cutting short a disease, for fear of conse- quences which they can not describe. " My treatment," says M. Ri- cord, " is opposed completely to this opinion. I allow a discharge to continue no longer than I can help. It is never my intention to pro- long the discharge ; if it continue, it is in spite of my treatment, which has been ineffectual in checking it." When, about the time of Fernel, blennorrhagia was first arrayed under the class of syphilitic diseases, and confounded with them, mercury of course was used in the treatment of both complaints, which were considered synonymous, and many and severe were the cases of salivation which resulted from such a confusion.* Notwithstanding the distinctions which modern practitioners have introduced, and although it is generally believed that the two affec- tions differ in toto, still at the present day many surgeons prescribe a course of mercury either during or after a blennorrhagia; some con- sider that small doses of mercury are advantageous as a species of alterative treatment. I shall have occasion to condemn this line of practice at a future period. Sydenham, who, in other respects, all must so much admire, was in the habit of prescribing purgative medicine, and, from his state- ment, appears to have met with great success ; but from my personal experience (says M. Ricord) I can not corroborate his opinions. * I lately saw, in the hospital of St. Bartholomew, a case which must formerly have been very common. An ostler had suffered from clap. Several weeks previous to coming to the institution, he went to a quack living in the city, who recommended Leake's pills, composed of mercury, and an aperient occasionally; his mouth became sore, and his clap got worse. This charlatan then recommended him to apply to a public institution. Under proper treatment he rapidly recovered. BLENNORRHAGIA. 51 Tod and his school have much eulogized the use of diuretics, under the supposition that frequent micturition might make the dis- eased humor pass out of the system. M. Ricord, in his appreciation of this treatment, has found no other effect result, except that of causing an acute attack of blennorrhagia to pass to a chronic one, which is by no means desirable. These various plans of treatment had successively held their sway in the medical world, when Bell proposed that a direct or local treatment should be resorted to ; but useful as these means may be in some few cases, it will be soon ap- parent to the surgeon that no one universal panacea can be recom- mended. Blennorrhagia, like all other diseases, will and must be treated according to the indications present. Having attempted to establish the fact that at its commencement a blennorrhagia is a local affection, that the number and severity of the accidents which follow depend not only on the severity, but likewise on the duration of it, I should state that it does not at once acquire its greatest severity, and, moreover, that it is not one of those affections which run a certain course, or last a certain time. I have attempted to prove that suppuration is not necessary to chase the peccant hu- mors from the body, and that we have no occasion to allow the dis- charge to continue during an indefinite period. I have shown that the fear of driving the discharge into the system by a rapid cure, or that of its causing certain accidents, is chimerical, and the opposite proposition has been established, that the sooner the patient is cured, the less he is exposed to these accidents. It follows, then, that the surgeon should attempt by his treatment to prevent the development, and to diminish the intensity of the symp- toms when he has been unable to check them at the onset, and in all cases to shorten the period of their duration as much as possible. We may now divide the subject of treatment in the following manner :— ]. I shall speak of the prophylaxis, or the preventive means. 2. Of the abortive* treatment. 3. Of the curative treatment. Prophylaxis, or Preventive Means.—It follows, as a consequence of the knowledge of the causes, that it is impossible always to pre- vent the occurrence of the disease, as it may arise spontaneously un- der circumstances over which the patient has no control; yet he may be able, in the greater number of cases, to prevent the occurrence of the affection by avoiding the causes that, as above stated, give rise to * By the term " abortive" treatment, I wish to express such means as cut short the disease before it can be completely established. 52 BLENNORRHAGIA. it; or, if the surgeon can not persuade a patient to avoid them alto- gether, at least he may often be able to induce him to take such pre- cautions as will render the occurrence of the disease less probable or less severe. Such precautions, then, I now proceed to describe. 1. As they relate to persons already affected, so that they do not communicate it to healthy individuals who may in any way expose themselves to the contagion. So large a number of females suffer under discharges, that, were the surgeon very cautious, he should, perhaps, forbid connexion alto- gether ; for M. Ricord states, that ninety-nine women and a half in every hundred, during some part of the month, suffer more or less from blennorrhagia. It is impossible, however, to forbid connexion altogether. But supposing a woman to be subject to an habitual dis- charge, she may, by taking certain precautions, prevent those who have connexion with her from contracting it. She should abstain from all heating or irritating dishes or beverages; and she should employ frequent injections of a slightly astringent or cooling nature, especially previous to connexion. 2. The precautions to be taken by a sound individual who exposes himself to the contagion, should consist in not prolonging the vene- real act, and in making water immediately after it ;* but the means which place the patient most indisputably beyond the possibility of contracting blennorrhagia, is the use of the condom. " This practice," says M. Ricord, " is not sanctioned, it is true, by nature, yet Astruc has long since recommended it, and in practice there are many cases in which the surgeon is forced to prescribe connexion once or twice a week, as he would do aperient pills. Although, therefore, a prac- tice not to be lightly sanctioned, I must recommend it in some cases, for without it the mucous membrane of the urethra would infallibly inflame." These, then, are the only means which a surgeon can depend upon or recommend, to place his patient out of danger of contagion. The host of other specifics which charlatanism has invented, I shall not here stop to enumerate. The Abortive Treatment.—It has been stated above, that one of our principal objects should be to shorten the period of the duration of blennorrhagia, and to check it at the onset. This we should attempt to effect in two ways, either by general, or local and direct means. * The use of injections into the urethra is prejudicial, as they serve only to push the contagious matter farther into the canaL BLENNORRHAGIA. 53 The following, or the abortive treatment, is, however, only applicable previous to the occurrence of the symptoms of acute inflammation— that is to say, during the first few days after the disease has declared itself. The general means will consist in abstaining from all irritating or heating food ; not, however, that we prescribe an entire abstinence. A moderate use of nutritious diet should be recommended, as we be- lieve general debility, of itself, tends greatly to produce a discharge from mucous membranes. Small quantities of fluids should be taken, and warm baths or any relaxing agent should be strictly forbidden, unless there be reason to expect that the complaint depends upon an irritability of the skin or the quality of the urine ; in these excep- tional cases alone, baths and copious drinks should be allowed. In addition to these precautions, rest and quiet of the affected parts must be strongly recommended. Internally, the surgeon should prescribe the use of the anti-blen- norrhagic remedies, which seem to act by their revulsive action on the intestinal canal, such as cubebs, copaiba, and turpentine. The doses in which they should be administered will be further alluded to, when mention is made of the particular forms of the complaint. When I say that their action is or ought to be a revulsive one, I do not wish to be supposed to recommend their use so as to produce gastritis. On the other hand, however, these preparations should be given in sufficiently large doses, and at short intervals, so as to pro- duce a sudden effect on the system. Various powerful quack medi- cines owe their efficacy as anti-blennorrhagics to this mode of action. The surgeon, however, in the use of these means, must not discon- tinue them too quickly, but gradually diminish the dose. By such means the cure will be found to be permanent. Externally, various revulsive remedies have been in vogue. In some cases, the Russian or vapor bath, which acts by determining to the skin, will completely cure a patient in a very short time. Blisters have likewise been employed with the same view, but, generally speaking, they are prejudicial. Direct or local means have been employed with the object of cut- ting short the affection ; under this head I may mention compression. This treatment has succeeded in some few cases, but, generally speaking, it is not only useless, but prejudicial. It is only in urethral blennorrhagia that we can employ it; and here it produces erections by day and pollutions at night, which again occasion congestions, the forerunners of inflammation. 54 BLENNORRHAGIA. Local baths are likewise to be avoided, as they tend to increase rather than to diminish the secretion. However, ice and cold washes (provided no reaction follow) may be attended with great benefit. Separation of the surfaces of the mucous membrane will be among one of the direct means from which the surgeon may derive much advantage ; for, as we have previously observed, one diseased mu- cous surface reacts on the other, and augments the mischief. In ad- dition to these means, great attention must be paid to cleanliness ; but, generally speaking, the greatest dependence should be placed upon injections of various astringents or tonic substances, the nature and strength of which will be spoken of again under the head of regional forms of blennorrhagia. Provided, however, these means fail in curing the patient, or if the surgeon be consulted at a late period, when symptoms of acute in- flammation are present, it will be in vain, and even dangerous, to pursue any longer the treatment above spoken of, as it would tend only to augment the mischief. It therefore must be given up ; and this leads me to speak of the third division. The Curative Treatment.—The first stage, or the acute form, par- ticularly if the inflammation be severe, may require general or local bleeding ; usually, however, M. Ricord recommends leeches, taking care to employ them in sufficient quantities, and never applying them on those parts where the skin is doubled on itself and maintained by a loose cellular tissue, such as on the scrotum, eyelids, or penis ; for although twenty cases might be cited in which no ill consequences have arisen, still the twenty-first is liable to be followed by gangrene or erysipelas ; and as equal advantages follow their application on the surrounding parts, namely, the groin, perineum, or temples, the surgeon should never expose his patient to the danger of these acci- dents. In virulent blennorrhagia, especial care should be taken that the leeches are not applied on a depending part of the body, other- wise, if the secretion falls, or comes in contact with the leech-bites, inoculation will result, and a distinct chancre will be formed on every leech-bite. I saw a case of this kind at the female venereal hospi- tal, where thirty chancres existed on the perineum, in consequence of the application of thirty leeches, prescribed by a sage femme. Leeches sometimes will produce an erythematous irritation and swelling of the neighboring glands ; therefore it will be well for the surgeon to apprize his patient that this is probable. Poultices and rest will, however, soon cure this affection. Baths.—In the preceding section I have condemned the use of BLENNORRHAGIA. 55 baths; but in this, the acute stage, they are of the greatest benefit, when employed of such a temperature as is agreeable to the patient's feelings. Provided no reaction comes on, the patient may continue in the bath for half or three quarters of an hour. In other cases their use should be omitted. Local bathing is prejudicial, as tending to cause congestion of the part. Injections are in some cases useful: in the vagina they wash away the secretions; but in a narrow canal like the urethra, they cause great irritation. Diluent drinks may be freely employed, as they tend to render the secretions less irritating. The composition of them must depend upon the taste of the patients, as it is the water they contain which is beneficial. The use of diaphoretics should be strictly forbidden, for reasons stated above. The state of the digestive organs should be attended to, as all mu- cous membranes sympathize with the stomach; constipation or diar- rhoea must, therefore, be avoided. In addition, the horizontal posture should be prescribed ; strict attention to diet, avoiding everything that can excite, particularly beer, asparagus, &c. This terminates what I have to say on the treatment of acute blen- norrhagia. I now, therefore, turn to the chronic form, which is called blennorrhoea. Treatment of Blennorrhoea.—The first point in the treatment is to omit the antiphlogistic remedies, as they have become useless the instant that acute inflammatory symptoms have subsided. In their place the surgeon should prescribe those remedies which were recommended under the head of abortive treatment. Warm baths must be now avoided ; the diet should be more nutritious, but not stimulating. In addition, a general revulsive treatment, combined with a local or direct one, should be prescribed ; for experience proves that, although a cure may take place when either mode is em- ployed singly, still, when conjointly employed, they act more surely and effectually. The revulsive general treatment consists in the employment of co- paiba, cubebs, turpentine, purgatives, diuretics, astringents, tonics, iodine, and cutaneous revulsives. I have arranged them in the order of their efficacy. Copaiba is placed in the first rank, for this oil has enjoyed a repu- tation for being a specific, or at least of having a special action on blennorrhagic affections. It is, in fact, one of the most powerful agents that we employ in the treatment of this disease. By some 56 BLENNORRHAGIA. surgeons it has been given in all stages of the complaint, and many have vaunted its virtues in the acute stage. M. Ricord states that he feels convinced it may occasionally be useful in this stage, but that it is usually inefficacious. The result of my experience on the admin- istration of this substance (continues M. Ricord) leads me to the fol- lowing conclusions on its therapeutic effects. In the acute stage of a blennorrhagia, it produces no amelioration ; on the contrary, it often gives rise to ill consequences which we should avoid, and in some cases aggravates the disease itself. Ad- ministered in the acute stage, it has this further disadvantage, that, if it produce no good effect, the surgeon is deprived of one of his best agents, as the stomach gets out of order and will not bear it at a later period. The action of copaiba is manifested in certain effects on the stom- ach, intestinal canal, skin, urinary organs, and, in some few rare cases, on the nervous system. The effects of the remedy are first evident on the stomach, as it produces a disgust; vomiting often follows, and this occurs to such an extent that we have known persons feel sick on coming into a room where the oil is kept. In cases where this unpleasant effect is produced, the surgeon may feel convinced that no good will result from continuing the preparation, as it will only tend to occasion in- flammation of the stomach, without diminishing the discharge. In cases of gastritis, which come on especially in persons predisposed, the other mucous surfaces will become sympathetically affected or inflamed. Usually the action on the intestinal canal is but slight—particularly confined to the small intestines. Sometimes, however, colic and diarrhoea follow. This we consider, when present in a slight degree, to be a good sign, as it by no means betokens inflammation, but shows that the revulsive action is taking place ; still the surgeon should watch carefully that inflammation does not succeed, or run too high. It has been stated that copaiba has a decided action on the urinary organs. It seems as if the specific good results arise directly from the action on the urinary organs ; for, unless absorption take place and the oil pass off by the urethra, the same good effects are not ap- parent ; and a further proof is, that this preparation is especially use- ful in gonorrhoea. Given in the other forms, it appears to produce little or no effect, viz., in blennorrhagic ophthalmia, blennorrhagia of the rectum, vagina, &c. BLENNORRHAGIA. 57 On the skin, the action of the remedy is no less apparent, produ- cing various eruptions, most frequently one which resembles measles, or nettle-rash ; eczema likewise sometimes follows its administration, as it does after eating seafish. To produce these complications—for such may these eruptions be called, there must exist some predisposing cause, which usually con- sists in a stomachic derangement: a moist state of the atmosphere, exposure, &c. These should be carefully avoided during the time that the patient is taking copaiba ; this is the more necessary, as the surgeon will be blamed for their occurrence. The eruption is usually preceded by a general lassitude and drow- siness, and sometimes by shivering, accompanied with a general itch- ing or irritation of the skin. The eruption will continue as long as the use of the copaiba is per- sisted in. Let the surgeon only cease to employ it, and in a few days every trace of the skin affection will disappear. Such an an- nouncement to your patient will free him from much anxiety. I have observed these affections to occur epidemically, particularly during spring and autumn. These have, by some authors, and Gibert among the rest, been stated to depend upon, or bear a relation to gonorrhoea, as secondary symptoms do to syphilis ; but we shall not here stop to prove the absurdity of such an opinion. Lastly, it has been stated that copaiba sometimes acts in an unu- sual way on the nervous system. During the same month, M. Ri- cord states, he has known the administration of enemata, containing six drachms of copaiba, followed, in the case of a female, by an apo- plectic attack ; in another case, likewise a female, by hemiplegia, which ceased on the breaking out of a rubeolic eruption over the whole body. The dose of copaiba must vary according to circumstances; for- merly, surgeons were in the habit of prescribing only a few drops ; however, Bell, Swediaur, and others, have given the oil in much larger quantities—that is to say, in doses of from 3j to gj ; and this last-mentioned quantity has been given without any ill consequences following. My practice (says M. Ricord) is to begin with a drachm, and gradually augment it until some visible good or bad effect fol- lows ; but I think that the dose should never exceed gj in the twen- ty-four hours, for fear of ill consequences. If we believe certain practitioners, one would be led to suppose that this remedy is more efficacious when administered by the rectum, as an enema, than when taken into the stomach. M. Lisfranc, especially, is one of the * 58 BLENNORRHAGIA. French surgeons who relies greatly on this form of administration. I have personally watched the treatment, but can not say I have been persuaded that it is a preferable plan, as it required a larger dose, and a longer time to cure the patient; and the quantity employed was enormous. I think that, as the beneficial effect is particularly marked on the small intestines, and not on the rectum, the copaiba should be given by the mouth; and this brings me naturally to consider the form un- der which it may be administered. Daily experience proves the truth of the following proposition, viz., that the efficacy of the preparation will depend upon the greater pu- rity in which it is given ; hence the superiority of those in which the oil is simply held in suspension. On the other hand results the inefficacy of many preparations which apothecaries have invented to cover the smell and taste of this drug. Among these, I may speak particularly of its combination with magnesia; a means of solidifying the oil, and thus administering it in pills. These hard balls pass through the intestinal canal without any effect. Latterly, the copaiba capsules have been introduced into practice. They consist of a little shell of gelatine or gluten, which encloses a small quantity of copaiba. The inventors assert that oil thus given produces no unpleasant smell or taste, nor do eructations follow. This, however, is not true ; the taste and smell are rendered less disagreeable, but, generally speaking, the characteristic taste of co- paiba remains in the mouth after taking them, though not to so great a degree. Many individuals are unable to swallow them, or the little shell may burst, or at once become dissolved in the stomach, and then all the unpleasant effects of copaiba remain. The capsules of M. Mothes are not so objectionable as the rest; they are smaller, and the oil is mixed with a very small quantity of magnesia : hence they have not the same tendency to break, but pass on into the duodenum, where the oil escapes without occasioning eructations. The dose is usually six or eight capsules in the twenty-four hours. As long as the copaiba gives rise only to slight colic or diarrhoea, without any accompanying symptoms of inflammation, these symp- toms may be allowed to proceed, provided the blennorrhagia gets bet- ter under its use ; but should no amelioration follow, the diarrhoea must be checked by combining the copaiba with opium, or some as- tringent preparation, such as the rhatany, &c. BLENNORRHAGIA. 59 Constipation should be relieved by gentle cathartics; when there is no effect on the urinary organs, it will be well to order a little nitric aether; if the stomach be irritable, great advantage may be de- rived from the use of the bicarbonate of soda. In employing, then, copaiba, we ought not to use exclusively any preparation, but prefer one or the other according to circumstances. I will now speak of another preparation, which has evidently anti- blennorrhagic properties, namely— Cubebs.—In appreciating the value of the powdered cubebs, it should ^be stated that it yields only to copaiba in efficacy; and notwithstand- ing the objections that have been urged against this remedy, I con- sider its use of great benefit. On the stomach, cubebs acts like the pepper tribe generally in ex- citing that organ. Its curative powers are exerted more especially on the small intestines; but, instead of producing diarrhoea, like co- paiba, cubebs occasions constipation. We must, therefore, combine it with purgatives. In some cases, this powder irritates the stomach to such a degree that gastritis ensues. The surgeon should be aware of this, and leave off administering it on the occurrence of the first symptoms. This is one of the reasons for preferring copaiba; an- other is, that cubebs is very liable to adulterations, which are not easily detected. M. Ricord states in his lectures that he has met with two very serious cases where he suspected an adulteration ; the dose given did not exceed six drachms, and the two patients obtained the powder from apothecaries in different parts of Paris ; yet, an hour after taking the medicine, vertigo, trembling of the limbs, dilatation of the pupil, together with convulsions, occurred.—In one case, ery- sipelas,, followed by gangrene of the thigh, came on, and the patient sank in twenty-four hours. The remainder of the cubebs was ana- lyzed, yet no adulteration could be detected; the papers, however, were not observed to be greasy, as they usually are. On the other hand, its cheapness, the fact of the stomach supporting its use, as well as the smell being less penetrating in the room in which it is kept, and, lastly, no eruptions following its employment, have made it a standard remedy at the venereal hospital, and in private prac- tice with M. Ricord. Notwithstanding, I believe copaiba to be the more efficacious of the two remedies for the cure of blennor- rhagia. The dose is usually from a 3j. to gii. of the powder; but among the out-patients of M. Ricord, I have rarely seen more than 3iij. pre- scribed during the twenty-four hours. He finds from experience that 60 BLENNORRHAGIA. it is better to begin with this quantity, as the stomach feels at once the effect of it, and does not habituate itself to its use, as happens when we order smaller doses and gradually increase them. The mode of administering this remedy is usually in powder, and when taken it should be mixed with water. In this state it is far more efficacious than in combination with other ingredients ; its ac- tion seems more direct. M. Ricord has found that the tincture, de- coction, or pills, are very inferior to the powder alone. Of late, chymists have contrived to enclose cubebs in capsules of gum, and the plan is a very good one. The combining cubebs with copaiba- is bad, as the effect generally is not so well marked, and we should prefer reserving the one remedy for cases which are rebellious to the other. It seems to act particularly on the urinary organs, as it gives a very peculiar smell to the urine ; and it is especially in blennorrhagia of the urethra that its good effects are visible. Cubebs and copaiba may, then, be said to be anti-blennorrhagics par excellence, although other preparations have been equally vaunted. The administration of turpentine, in the opinion of some surgeons, is attended with good effects ; but it should be ranked among the ad- juvants to a cure, rather than as a remedy. Tonics.—In the chronic stage, complicated with a lymphatic tem- perament or scrofulous constitution, the best results will often follow the administration of bitters and tonics, in conjunction with a reason- able quantity of wine and nutritious diet. Vapor baths, shower baths, and sea-bathing, are adjuvants which no surgeon should neglect in chronic cases. Blisters, placed as near the diseased parts as possible, particularly when the discharge depends upon a change of structure of the mu- cous membrane, deserve well the attention of the practitioner. Here I terminate my observations on the general treatment of blen- norrhagic affections, and shall now direct the attention of my reader to what may be called— The Direct Treatment.—This consists in checking the discharge by local applications, which form a numerous list, comprising solu- tions of lead, zinc, the protoioduret of iron, sulphate of alum, corro- sive sublimate, and particularly nitrate of silver. As I shall have occasion to speak of these various preparations at a later period, in describing the treatment of the various regional forms, I shall now pass them over, reserving the description of each of their properties and doses until then. Leaving the description of BALANITIS. 61 blennorrhagia, I shall pursue the plan I have previously laid down, and describe the disease as it may occur in one or the other sex, and in the different mucous membranes. CHAPTER II. BLENNORRHAGIA IN THE MALE. The forms of blennorrhagia peculiar to the male are balanitis and gonorrhoea; affections of very great importance to the surgeon, and which I shall successively describe at some length. SECTION I. BALANITIS. Synonymous Terms.—English writers have described the com- plaint here spoken of, under the name of balanitis, by the terms gon- orrhoea praeputialis, bastard clap, external gonorrhoea, &c. Of late years it has been generally known in France by the name of balanite, the equivalent term for which I shall employ in the following pages. Definition.—Balanitis consists in inflammation and patchy excori- ation of the glans penis and lining of the prepuce, accompanied by a muco-purulent discharge. Causes.—The predisposing cause of balanitis is undoubtedly the existence of the prepuce, for we do not meet with the affection in persons who have been circumcised. The exciting cause can be usually traced to the application of some irritating secretion, such as the menstrual fluid, blennorrhagic matter, &c.; but, although frequently of venereal origin, this affection often depends upon other causes than impure connexion. I have frequently occasion to see it in boys who are inattentive to cleanliness, and al- low the secretion of the glandulae odoriferae to accumulate between the prepuce and glans. ( I have been able to trace it to a discharge from the urethra, pro- duced by stone in the bladder, or by the passage of instruments. The surgeon should be aware of these facts, otherwise he may fall 62 BALANITIS. into the error of attributing to infection the simple effect of inattention to cleanliness. I might cite more than one instance where this has occurred. " The prepuce," adds M. Ricord, in one of his clinical lectures, " is an appendix to the genital organs, the use and object of which I could never divine ; in place of being of use, it leads to a great deal of inconvenience, and the Jews have done well in circum- cising their children, as it renders them free from one of the ills of humanity. The prepuce is a superfluous piece of skin and mucous membrane, which serves no other purpose than acting as a reservoir for the collection of dirt, particularly when individuals are inattentive to cleanliness." As I stated above, the disease may affect either the prepuce or glans ; part only, or their whole surface, may be the seat of the in- flammation. It is particularly liable to occur in the neighborhood of the fraenum. The symptoms of the affection are the following : a slight itching, which is soon after succeeded by heat and pain of the part, attended by an increased secretion of the glands, which becomes more or less purulent. The prepuce soon swells, in consequence of a tumefaction in the cellular tissue, which so largely enters into its composition, and this swelling may occur in a very short period. Not unfrequently an inflammatory or erysipelatous condition succeeds this oedematous state, and may be confined to the prepuce only. Usually no pain is felt in making water, nor does any chordee ex- ist. In a few cases, however, when the urine passes over the in- flamed prepuce, a scalding is felt, and in erection the glans may become too large for the swollen parts around ; a pain like that expe- rienced in chordee may occur, and it is very difficult, when phymosis exists, to decide whether the balanitis is accompanied with gonorrhoea or not. Balanitis is usually acute in its progress, but it may become chron- ic. Its termination is commonly favorable ; however, gangrene some- times ensues, as well as erysipelas, more especially if the surgeon applies leeches on the diseased and oedematous prepuce. The sur- face of the glans and prepuce frequently becomes irregularly excori- ated, resembling a blistered surface, as seen in plate III. Complications.—Balanitis, however, is not always the simple affec- tion I have here described. In some instances abscesses may form, in consequence of the collection of matter between the glans and prepuce, which is swollen or narrow, or a circumscribed inflamma- tion of the cellular tissue of the prepuce result, terminating in abscess. BALANITIS. 63 In either case, these collections of matter will point at the upper part of the penis, and gangrene will often attack the prepuce, and, destroy- ing it, the glans penis will become exposed, as seen in plate V., fig. 3. Gangrene rarely commences at any other point than this, and may destroy the whole penis, or be limited to the prepuce, as was the case in the individual from whom the drawing was taken. This tendency of the prepuce to become gangrenous at its upper part has been vari- ously accounted for. Some suppose it to depend upon the greater number of vessels in this situation ; but it more probably arises from the friction against the trowsers, to which it is subject in all the movements of the body. A very frequent complication is chancre, which, masked by a nar- row prepuce and purulent discharge, leads the surgeon to believe that the patient is suffering under simple balanitis. Secondary symptoms may become also a complication. Thus the mucous tubercle occurring on the prepuce, which is already the seat of a balanitis, will increase the disease ; it will likewise be one of the causes of it. Hence we have what is called, improperly, a syph- ilitic balanitis, for the complications produce or exaggerate balanitis, not in virtue of any specific poison, but as a consequence of the se- cretion, which is very acrid. Eczema, particularly in old people, will constitute a complication, and, like vegetations, will be more difficult to cure, in proportion as the surgeon is unable to expose the glans. Balanitis, without any complication of chancre, may cause a bubo. This, however, is rare, and we seldom find that buboes arising from this cause suppurate ; they are merely sympathetic, and when they do suppurate, never give rise to virulent sores capable of being inoc- ulated. Secondary symptoms never arise as a consequence of simple bala- nitis. Such is the result of M. Ricord's researches on inoculation. I have never heard a case of simple balanitis cited which was fol- lowed by secondary symptoms. M. Cullerier, who supposes that a simple gonorrhoea may give rise to them, says he has never seen a case of balanitis which he could trace as the cause of constitutional syphilis. M. Puch, one of the surgeons at the Venereal hospital, considers that simple balanitis may produce a chancre, and thus induce second- ary symptoms. He inoculated a patient affected with simple bala- nitis, unaccompanied by chancre, but in whom vegetations existed. The characteristic pustule was observed, and he had the kindness to 64 BALANITIS. show me the case, and concluded that simple balanitis, without ulcer- ations, may give rise to syphilis. This conclusion I can not adopt, for the following reasons : He admits, himself, that it is an excep- tional case to see the inoculation succeed ; he has observed it in two cases. M. Ricord has never met with similar results. It is, there- fore, natural that we should seek an explanation of it in some circum- stance beyond a simple balanitis. I believe that many circumstances may explain this occurrence. The patient, before entering the hos- pital, had connexion, and as his prepuce was long, the syphilitic virus may easily be supposed to have remained within its folds without producing chancres, as the glans was covered with mucous and smegma ; for we find that the virus does not produce its effect until it comes in contact with the mucous membrane or skin, or till an abrasion results, or it is introduced into a follicle. The virus may remain on the prepuce inert, provided there is a secretion which pro- tects it, in the same way that it may be kept in glass tubes, and yet at the end of the eighth day produce a chancre. I believe, then, that the true explanation of these exceptional cases depends upon some such cause. The diagnosis of balanitis is very easy, provided the surgeon can uncover the glans, and see in what state it is ; but when phymosis is present, the practitioner is often at a loss to know whether a simple balanitis exists, or if it be complicated with a gonorrhoea, chancres, or vegetations. In these cases, an induration may often be felt on the prepuce, and, on interrogating the patient, it will be found that a chancre existed before the phymosis took place ; but if no induration exist, and if the patient have not examined the penis, our diagnosis will be very imperfect. Still one means is within our reach—it is that of inoculation. The prognosis will depend upon the complications present, for sim- ple balanitis presents nothing unfavorable. The treatment of balanitis in uncomplicated cases is very simple. It consists in washing the parts, and separating the prepuce from the glans by means of a piece of lint; this alone will usually suffice to cure the patient. When all other local applications have been tried I have seen patients, whom other practitioners have had under their care for six months without benefit, consult M. Ricord, and this sim- ple treatment cured them in a few days. The piece of lint may be about an inch and a half long, and half an inch in breadth. Having washed and dried the affected parts, apply this piece of lint between the prepuce and glans at its base, and then draw the former over the BALANITIS. 65 glans, taking care to change the lint two or three times in the twenty- four hours. When an inflammatory condition of the parts exists, it will be well to pass a stick of caustic over them, simply to whiten the surface, which should be previously dried by lint; and during the subsequent days the surgeon should order a wash containing— Liq. Plum. Subac. 3i. Aq. Distill. ^viij. and dry lint to be constantly kept between the glans and prepuce. When balanitis is complicated with chancre, of course we must employ the treatment which the latter complaint may require, and which will be described in the second part of this work. The complication of phymosis presents some difficulties, as it is often impossible to act directly on the diseased parts. The first thing to be borne in mind is, that we must not operate on the prepuce when- ever we can avoid it, particularly if the phymosis be not habitual. Instead of slitting up the prepuce, M. Ricord's plan is to wipe away all the secretion, and introduce a stick of nitrate of silver between the glans and prepuce, and cauterize slightly the parts. The immediate consequence is considerable augmentation of pain, which may last for half an hour, but on the following day the amendment is very marked. Baths, and injections containing opium, are useful, but not so advan- tageous as cauterization : it is the best antiphlogistic remedy with which I am acquainted. If the surgeon, however, be consulted at a later period, when the gangrene is imminent, or has already commenced, the prepuce should be freely slit up without delay, so as to expose the part; and com- presses of cold water, or solutions of opium, should be constantly ap- plied. The indications for cauterization, or for incision, are sometimes obscure. When, however, the discharge consists of thick pus, we should cauterize, and the patient thus preserves the prepuce, for in a few days he is able to uncover the glans ; moreover, if there be a chancre, an incision is very prejudicial, as it most probably will in- oculate the divided surface. The indication for slitting up the prepuce consists in a discharge of ichorous matter, or when the skin is of a dark livid color. If the sur- geon do not operate in these cases, nature herself will form an opening. In cases of balanitis, the surgeon should be particularly cautious that the glans is not left uncovered, as inflammation and swelling may occur, and paraphymosis result. 5 66 GONORRHOEA. SECTION II. GONORRHEA. The next form of blennorrhagia I am about to describe, as it exists in the male, is gonorrhoea. Synonymous Terms.—M. Ricord calls it urethral blennorrhagia; some French writers denominate it venereal catarrh; in England it is vulgarly known by the name clap, derived from the French word clapier, signifying a filthy abscess ; and in France the common peo- ple call it chaude pisse. As the term gonorrhoea is generally accepted, I shall employ it, rather than change the name of the affection, and at once proceed to treat of the conditions which tend to its development. Causes.—The unnatural size of the male organ, as well as a large meatus, tend to augment the chances of contracting a gonorrhoea. A relative disproportion between the genital organ of the male and fe- male will be a very frequent cause of the development, of gonorrhoea. It is probable that the introduction of the gonorrhoeal matter takes place previous to ejaculation, and that it is the expulsive force with which the semen issues that washes away the contagious matter; for, unless such were the case, I am convinced that gonorrhoea would be still more common than it is. During erection, and previous to ejaculation, the meatus has a great tendency to open. The round form of the glans further promotes this tendency, as it is pressed laterally when passing the vagina, and this naturally separates the lips of the meatus. Some writers, not content with this explanation, believe that gonorrhoea does not occur from the introduction of the pus, but they suppose that absorption from the external part takes place, and that the virus is directly carried into the glands of morgagni, which are situated just within the fossa navicularis. I have sufficiently, I hope, under the general head of blennorrhagia, spoken of the direct causes of the affection ; I shall not here there- fore, return to the subject, but at once describe the situation of gonor- rhoea. Every part of the urethra has been successively considered as the seat of the disease ; in addition to the fossa navicularis the GONORRHOEA. 67 vesiculae seminales and the prostate gland have been by different wri- ters pointed out as the «parts from which the secretion takes place. My own opinion is, that any part of the urethra may become affected, but the exact point will in a great measure depend upon the time the affection has lasted ; undoubtedly the fossa navicularis is the point most frequently affected, as Cockburn stated long since. The symptoms of gonorrhoea consist in pain felt in the course of the urethra, particularly at the fossa navicularis. As M. Jourdan has observed, this point seems the rendezvous of all the morbid sensations of the penis, so this sign alone can not be of great value ; but when, together with pain, the surgeon observes a muco-purulent discharge coming from the urethra, he may at once infer that gonorrhoea exists. The pain which is felt is sometimes slight and of an agreeable kind —if this term may be applied to pain ; whence the belief that gonor- rhoea proceeded from the vesiculae seminales. More frequently, how- ever, the pain is severe ; patients speak of their urine scalding them, or that they feel needles pricking them, especially when the urine is loaded with salts, or when it is passed in a large stream. In the acute stage of gonorrhoea there is frequently a difficulty in making water, a circumstance which arises in part from fear of the pain which accompanies the passage of the urine, and in part, likewise, from the swollen state of the mucous membrane and the narrowness of the canal. These symptoms do not exist long without chordee, sometimes of so violent a nature that authors have spoken of a distinct variety {chaude pisse chordee), in consequence of chordee being the most prominent symptom. This chordee. depends upon an inflammation of the corpus spongi- osum, and a secretion of plastic lymph into its interstices. It conse- quently loses its elasticity, and in erections can not follow the corpora cavernosa in their varied movements ; hence the curvature in different directions, either downward, laterally, or otherwise. Chordee will be severe in proportion as the penis naturally varies in size between the quiescent state and during erection ; hence, in persons whose penis enlarges but little in erections, chordee is seldom present. Chordee is likewise a symptom which is more severe in proportion as the gonorrhoea has gained the deeper portions of the mucous mem- brane ; when the affection is confined to the orifice of the meatus, the chordee is proportionably slight. Various morbid sensations, such as cramp, pains in the testicle, a feeling of tension in the groin, pricking in the perinaeum, frequent 68 GONORRHEA. desire to make water, sometime incontinence of urine, or tenesmus of the bladder, are present, and may add to the severity of the case. These symptoms increase in proportion as the gonorrhoea gains the deeper portions of the canal; hence, Bell has described varieties which depend upon the presence of one or other of the foregoing symptoms. He has distinguished gonorrhoea of the bulb, prostate, neck of the bladder, and bladder itself. Instead of admitting these distinctions, I shall consider them only as signs that the gonorrhoea has reached certain portions of the canal; for example, the pain in the perinaeum causes us to suspect that the prostate participates in the disease—tenesmus, that the bladder is inflamed, and so on. The Diagnosis of Gonorrhoea.—Every tyro in medicine will at once distinguish what he calls a clap, by means of the symptoms above described ; but such a person may not be aware that a surgeon can not always decide at once whether a man is suffering under a gonor- rhoea or not, provided no discharge be observed, and the lips of the urethra be not inflamed, and no stains seen on the linen. M. Ricord gives the following instance of the occasional difficulty. He was or- dered by a magistrate to give an opinion whether a prisoner, said to have violated a girl, was laboring under gonorrhoea or not. The ac- cused presented no swelling of the lips of the meatus ; on pressure, no discharge came from the urethra, and there existed no traces of any secretion on the shirt. When interrogated, he stated he had made water six hours previously to the examination. As M. Ricord had some suspicion, he ordered him to pass his urine at once, and desired one of the jailers to watch his prisoner. In six hours after, M. Ricord returned, and then found undoubted marks of an existing gonorrhoea. The prisoner confessed that he had made water previ- ously to the first examination, and had taken care to remove the se- cretion as soon as formed, by a piece of lint which he concealed for that purpose. The diagnosis of gonorrhoea of the various portions of the urethra I have above spoken of, and shall not repeat what was then said, ex- cept to observe that these distinctions are of importance, as they lead the surgeon to foretell the probability of this or that complication arising; for instance, a swelled testicle, or inflammation of the blad- der ; and the patient is not thus taken by surprise, and does not ac- cuse the surgeon of bad treatment. The prognosis must be drawn from the general and local symp- toms, which it is unnecessary for me here to refer to. The complications which may occur are numerous. We mav in GONORRHOEA. 69, the first place, find abscesses in the fossa navicularis, and they exist more frequently than surgeons think. They commence in the small follicles, which exist in great abundance in this portion of the canal. Inflammation of the prostate gland is another complication. Haemor- rhage comes on sometimes as a consequence of rupture of the urethra when individuals wish to overcome a chordee, a practice formerly recommended, and occasionally followed by the unenlightened. Swelled testicle, as well as buboes, are among the complications which I may mention here, but I shall treat of this subject in full at a future period. With respect to buboes accompanying a mild gon- orrhoea, they are very rare ; we may estimate their occurrence once in a hundred cases of gonorrhoea ; they seldom suppurate, and are never of a specific nature ; they disappear under simple treatment. In scrofulous patients buboes occur, not in proportion to the severity of the gonorrhoea, but in virtue of the lymphatic diathesis ; and bala- nitis is not an unfrequent complication. Chancre may likewise occur in any part of the urethra, giving rise to what the French call a chancre larve. Of the existence of this complication, any one who has seen much practice must have had ample proof. M. Ricord has kindly furnished me with a drawing of a urethra in which chancre is seen in its whole extent. (See cut, p. 195.) Such cases, however, are very rare ; he nevertheless possesses two ex- amples. I shall not here stop to reconsider the manner in which the virus is introduced into the urethra, as it is similar to that described under the head of Introduction of Gonorrhoeal Matter, with which it is often combined. A knowledge of this fact, viz., that chancre may exist concealed from view, is of the greatest practical importance ; it at once explains a host of difficulties that previously did not admit of solution ; it points out the difference between a virulent and mild gonorrhoea, and explains those rare cases of secondary symptoms which follow, with various other points which it would be out of place to discuss here, but which are fully treated of in the second part of this work. Chronic Gonorrhoea, or Gleet.—The acute stage of gonor- rhoea, either in consequence of non-treatment, or when treatment is injudiciously employed, may degenerate into a chronic stage, which is known by a diminution of the scalding in making water. The dis- charge, which was previously purulent, becomes mucous, though it continues abundant. In other cases, no running is observed during the day, but in the morning the lips of the meatus are found glued 70 GONORRHOEA. together, and a very small quantity of discharge escapes ; on the linen it leaves a stain like that of gum. In some persons, no other traces of a discharge are found than various mucous flocculi, which resem- ble little bits of vermicelli; they seem to come from the follicles in the urethra and prostate, and are a very plague to hypochondriacal patients who are haunted with the venereal disease; and as they daily examine their urine, the existence of a thread of mucus of the size of a millet-seed causes them to post off to their surgeon to show him what they have found. All the acute symptoms have passed, as well as redness of the lips of the meatus ; but chordee often remains, for it will be readily un- derstood that the cause of this symptom is not so easily got rid of as the others, and it often requires a considerable period before the penis can regain its natural elasticity. In chronic cases of blennorrhagia, when the affection is seated near the entrance of the vesiculae seminales, nocturnal pollutions are frequent, attended with considerable suffering; here the chronic in- flammation causes the pollutions, and they react on the mucous mem- brane, thus forming a vicious circle, out of which it is very difficult to rescue the patient. M. Ricord states, that patients come to him, who, during the time that they are rapidly recovering from gonorrhoea, without having committed any excesses, find the affection suddenly return as bad as ever. On interrogating them, he often finds that the only explanation which can be given of the aggravation of the symp- toms, exists in the occurrence of nocturnal pollutions. Another frequent symptom of chronic gonorrhoea, is a difficulty in making water. Thus, after any slight excess in diet, ~** is *«. BLENNORRHAGIA IN THE FEMALE. 145 The chronic discharge may put on a rusty appearance, and become tinged with a larger or smaller quantity of blood. These secretions, whether in an acute or chronic stage, may have no smell; or, on the contrary, have a very unpleasant odor, particularly when the mucous papulae exist. The smell, sui generis, is often so decided, that it is characteristic in a great number of cases : under other circumstances, it resembles the smell of cancer, or that of feculent matter. The only differences which result from the particular seat of the blennorrhagia are, that the secretions which come from the uterus are always more mucous, thready, and collected into flocculi; whereas, those which escape from the urethra, vulva, or vagina, present a less tenacious character than the others. The Symptoms of blennorrhagia in the female do not present dif- ferences which always have a relation to the cause which has pro- duced it; these symptoms are more especially connected with the precise situation, or the degree of severity of the complaint. As the disease is, for the most part, purely local, be its exact seat what it may, we do not find general symptoms present; in a few cases, how- ever, sympathetic or constitutional symptoms accompany the affec- tion, particularly such as depend upon the circulation ; the nervous system may likewise participate, and the digestive organs may suffer. We have seen women affected with both acute and chronic dis- charges, and yet complaining of no pain, and would have been ap- parently unconscious of suffering from a blennorrhagia, were it not for the stains which they were unaccustomed to see on their linen, or in consequence of their husbands contracting the disease. Never- theless, an inconvenient sense of heat of the vulva, accompanied with itching, usually announces the commencement of the disease. To treat, however, the subject systematically, we must describe seriatim the affection as it occurs in the various parts of the genito- urinary mucous membrane. Thus the symptoms of blennorrhagia of the vulva consist in a swelled state and redness of the nymphae, to- gether with a good deal of irritation ; on separating the nymphae, the morbid secretion at once appears, which may be confined to the vulva alone, or may escape and become matted and harden on the hair of the external organs, forming thick and offensive crusts, which com- pletely cover the parts. Fat women are more especially subject to it. Patients laboring under this form find a difficulty in walking ; the y desire of sexual intercourse is often increased, but it is usually at- 10 146 BLENNORRHAGIA IN THE FEMALE. tended with pain. The discharge renders, of course, the diagnosis easy. In blennorrhagia of the urethra, there is pain in making water, but slighter than in the affection of the male, and in some cases no scalding is felt; therefore, the absence or presence of this symptom is of no great value as a diagnostic sign : dysuria sometimes accompanies the affection ; the introduction of a catheter is, however, seldom called for. The secretion does not at once meet the eye; in order to sat- isfy himself if really any is to be found, the surgeon should take the following precautions : Having introduced the first finger into the vagina, the pulp turned toward the symphysis pubis, let him press somewhat firmly the urethra against the bone, at the same time with- drawing the finger. In this manner, if pus be present in the canal, it will be squeezed out, provided the female has not lately made wa- ter, and she has a blennorrhagia of the urethra. We have by this means detected the presence of a disease that other practitioners have not suspected. M. Ricord estimates that the urethra is affected in eight cases out of every twelve females suffering from discharges of the genital organs. Blennorrhagia of the vagina is attended, in the majority of cases, with little pain : the disease seems to be very indolent, particularly when no foreign substance comes in contact with the mucous mem- brane ; we have, however, been unable to introduce the speculum in some cases without causing pain ; in others, the slightest touch be- comes insupportable, and consequently the act of going to stool is very painful. In cases of this nature, the surgeon will not immedi- ately perceive the discharge, as a narrow vulva may occasion an ac- cumulation of the secretion in the posterior part of the vagina ; large quantities of feculent matter in the rectum, or a full bladder, will tend to the same effect, and thus the discharge escapes only when the pa- tient makes efforts to go to stool or pass urine. The surgeon should be aware that the traces of a discharge are to be looked for, not on the front part of the linen, as in the male, but behind; and if a woman keep herself clean by frequently washing the parts, or retaining a sponge in the vagina, he will with difficulty ascertain whether she be diseased or not. Blennorrhagia of the uterus may be commonly recognised by the usual symptoms attendant on inflammation of that organ, viz., a pain- ful feeling of weight in the pelvis, a distinct sense of heat communi- cated to the finger of the surgeon placed on the neck of the uterus, great pain felt by the patient, when the uterus is pressed upon, from t BLENNORRHAGIA IN THE FEMALE. 147 the vagina, as well as from the hypogastrium, a sense of dragging in the iliac region, and derangement of the menstrual function : all these symptoms may, however, be absent, although there is an acute blen- norrhagia and free discharge from the uterus. Such an affection as this, which thus shows itself by a discharge from the external organs, we can not investigate without the aid of the speculum. The same may be said of the deeper lesions of the vagina, or of the neck of the uterus ; it should not be our object alone to ascertain the exact character of the discharge and the complaint which gives rise to it, but likewise to convince ourselves of the con- dition of the mucous membrane, the morbid states of which we have before described. Without any further remarks on the necessity of employing the speculum, as we feel convinced that time will overcome the prejudi- ces which exist in England against its use, more than any argument we can urge in its favor, we shall at once proceed to describe the in- strument that M. Ricord uses, and which, by personal experience, we can recommend to our readers as being of easier application for the surgeon, and less painful to the patient. It consists, as may be seen in the accompanying woodcut, of two valves united at about the mid- (The Speculum.) die point, allowing both extremities to be widely opened ; the narrow- est part is thus placed at the vulva. To each valve a handle is at- tached, by which means space is gained, and the light falls upon the interior uninterruptedly, and pressure on them causes a dilatation of the two extremities, which can be maintained, diminished, or in- creased, by means of a screw. It has the further advantage of being adapted to the young and the old ; one instrument serves alike for all, and the surgeon is not obliged to have a series, as happens when he employs the common speculum. Its employment is very simple, but, like passing a catheter, requires some practice. 148 BLENNORRHAGIA IN THE FEMALE. The patient should be placed on the edge of the speculum-chair, as seen in the annexed woodcut, or on a bed, with a pillow under the (Speculum-Chair.*) head and shoulders, the thighs bent on the pelvis, and the legs on the thighs, the feet supported on two chairs. The surgeon should place himself between the lower extremities of his patient, and requires no assistant—an important thing in private practice. The spedilum, previously warmed and greased with a white pomatum, is thus to be introduced : Holding the valves of the instrument firmly together with the right hand, the surgeon should separate the nymphae by means of the index and ring fingers, while, by the aid of the middle finger of the left hand, he depresses the lower part of the vulva. This should be done gradually, but gently; at the same time the extremity of the speculum should be introduced, the handles turned toward the left thigh ; the side of one of the extremities of the valve should press up*on the middle finger ; the other valve will necessarily * I here introduce to the notice of the profession a chair which answers admirably for nearly all surgical operations. Its recommendations are its simplicity, firmness, and general application to surgical purposes. It looks like an easy-chair in a library, and may be raised to a sufficient and convenient height. It embraces the latest improve- ments, and is particularly distinguished from all others by the inclination of its seat. I can not too strongly recommend to the profession the maker, Mr. Moon of Orange 6treet, who has so ably assisted me in its construction. BLENNORRHAGIA IN THE FEMALE. 149 be applied against the posterior surface of the meatus, along which the surgeon must pass it by depressing the instrument, without tear- ing or excoriating the mucous membrane. As soon as the speculum has passed the ring of the vulva, it should be directed in the axis of the pelvis, and the operator should separate the valves; by this means he is enabled to see the condition of the vagina and uterus, and, finally, the instrument will surround the neck of that organ. It is unnecessary for this purpose to employ a very long instru- ment, or push it on until the neck of the uterus is embraced, as this would expose the organ to laceration, and cause great suffering if the instrument should be caught in the cul de sac of the vagina, as often happens. To avoid this, we recommend that the situation of the neck of the uterus be previously ascertained by the toucher, so that the instrument may fall at once upon it, and the neck of the uterus will be recognised by the smooth condition of the mucous membrane, and by its color, which usually differs from that of the vagina. Use- ful indications for finding it may often be derived from the streaks of white-of-egg-like mucus, which flow from the uterus into the vagina. In spite of these indications and precepts, should the surgeon find the speculum entangled in the cul de sac of the vagina, instead of pushing it onward, let him gradually withdraw the instrument, at the same time that the valves are separated, and the neck of the uterus will at once come into view. This was the method which M. Ricord followed when he formerly had the care of the females, and such is the plan we have adopted when we introduced the speculum at the Hopital de L'Ourcine, and we have never met with any difficulty, although we were often called upon to employ it in cases of various deformities of the osseous system, &c. There are, however, certain counter-indications which should pre- vent the surgeon from introducing the instrument, at least for the mo- ment. These are, first, a severe inflammation of the vulva or vagina ; sec- ondly, the existence of the hymen, which the surgeon ought general- ly to respect; thirdly, the narrowness of the vagina in very young girls; fourthly, the occurrence of various bands of well-organized membranes, which are sometimes met with in women that have had children ; fifthly, during the period of menstruation, as it is then use- less. The speculum may be employed, even though a woman be pregnant, provided the surgeon thinks the case requires it, and if the instrument be employed with care. 150 BLENNORRHAGIA IN THE FEMALE. M. Ricord states that the French female in high life is now so reconciled to the use of the speculum, that he often receives notes requesting his attendance, and, in the postscript, a demand that he will bring his speculum. At the hospital, when M. Ricord took the service, in 1830, a revolution broke out, and a strike against the spec- ulum occurred ; however, a few days of bread and water quieted this revolt of the harem ; and now the women are so convinced of the benefit, that they think no more of its introduction than they do of having a blister dressed. They can, however, appreciate instantly the tact of one surgeon over another in introducing it. The Complications of Blennorrhagia.—We shall now proceed to describe these, more especially as their consideration will lead us in some measure to consider the diagnosis of the various forms we have above detailed. In the affection of the vulva, and as a consequence of want of proper attention to cleanliness, especially in fat women, erythema or eczema may appear on the thighs or external organs. and give rise to a muco-purulent secretion, thus assuming a form of external blennorrhagia, particularly in the groin ; such a state often precedes the breaking out of mucous tubercles. The vulva may like- wise assume an oedematous condition, by which means a species of phymosis of the nymphae occurs, and gangrene arises; this may be followed by an induration, which lasts a longer or shorter time, or an abscess sometimes forms, which, if not opened speedily, may extend to the perinaeum, and produce a fistulous opening, which it is very difficult to treat. Abscesses here often result from cysts, and are lia- ble to return, unless the cyst be entirely cut out. We have, in the Hotel-Dieu, seen a striking example of a frequent return of the com- plaint in consequence of this treatment not being followed. The inflammation of the urethra may extend to the bladder, giving rise to cystitis, retention of urine, dysuria, depending upon spasm or an inflammatory state ; in some rare cases there is haematury. The blennorrhagia of the uterus may be complicated with the vari- ous morbid general sensations we have previously described : to these we shall not now revert; but there is one which we believe is new to English practitioners, at least we do not remember having read of it in English works. We allude to an ovaritis, which bears an analogy with epididymis in the male. Thus a female suffering under uterine blennorrhagia may be seized with shivering and a feverish state of the system; vomiting may come on, together with pain referred to the iliac fossa, where more or less tension may be present (in no way resembling that superficial pain produced by peritonitis); pressure on BLENNORRHAGIA IN THE FEMALE. 151 the os uteri gives no suffering ; but if the finger be carried up the cul de sac of the vagina, and the patient desired to turn upon the opposite side, pain of a most acute kind will be felt. The blennorrhagia may cease for the moment, one ovary may be attacked only, or both simul- taneously, as in epididymitis : revulsion will explain the partial ces- sation of the discharge. Lastly, we believe that a great number of ovarian dropsies may re- sult from a chronic inflammation of that organ, the consequence of such complications. A frequent, complication of blennorrhagia of the uterus is the occur- rence of ulcerations. These may be either specific or simple. The specific ulcers may be usually distinguished by being isolated, although they may occupy any portion of the neck of the uterus ; they may be further distinguished by giving rise to the characteristic pustule, when inoculation is tried : the granulations which appear upon their surface rapidly heal, leaving, however, a considerable state of induration. Lastly, secondary symptoms will follow after some time. Simple ulcers arise as a consequence of inflammation ; they are seldom distinct: commencing at the interior of the uterus, they make their way outward, have a great tendency to throw out granulations, but seem little disposed to cicatrize ; by such signs the surgeon will usually be able to diagnose a simple from a specific ulcer. During its progressive stage, or after it has cicatrized, provided no induration follows, it is not easy to form an opinion ; but this is not important, as the treatment will be the same. The consideration of this subject naturally leads me to mention some points which present certain dif- ficulties for the surgeon. The medical adviser is often consulted to know if a blennorrhagia has been transmitted, or is transmissible ; or, in other words, if the disease under which the female labors be con- tagious, has arisen spontaneously, or be the result of a sexual inter- course with a diseased person ? The fact of a blennorrhagia having been contracted by sexual intercourse is, as we have before observed, no proof of the syphilitic or virulent nature of the discharge. On the other hand, a virulent discharge in a female may occasion a mild af- fection in the urethra of the man who has connexion with her, it act- ing not in virtue of its specific influence, but as a simple irritant. M. Ricord, in consequence of the various investigations he has made relative to this subject, is convinced that a female perfectly free from disease herself may communicate either a chancre or gonorrhoea ; that is to say, the virulent matter may be deposited in her vagina by 152 BLENNORRHAGIA IN THE FEMALE. one individual, and may be taken up by another in subsequent con- nexion, without her becoming affected by it—she is the reservoir simply ; this happens not unfrequently in girls of the town. Admitting, as we do, that various causes may occasion in the fe- male, as in the male, a blennorrhagia which is variously designated by the terms whites, fieurs blanches, still blennorrhagia, depending on these causes, is more uncommon than is generally supposed. In fact, those women who communicate the disease present, on exami- nation, some considerable lesion, such as we have described above ; hence, whenever a patient presents himself, complaining that a woman has infected him, the surgeon, in ninety-nine cases out of a hundred, will be right if he states that the woman with whom he has had con- nexion is herself diseased. Persons having connexion with these women do not, however, necessarily contract the disease, although it is probable that they will do so. Many persons have wished to distinguish the whites, or fieurs blanches, from blennorrhagia. This, however, they have been unable to do ; and it is not surprising that it is difficult to distinguish things which are exactly similar in form, and which only differ, if we may be allowed the expression, by an essence that we can not discover. There is nothing, either in the particular seat of the affection, nei- ther in the appearance of the discharge, nor in the alterations of the tissues, which can distinguish leucorrhoea from simple blennorrhagia. The only possible differential signs, in some few cases, might be drawn from a knowledge of the causes ; thus, in admitting, as some do, that the whites are those discharges which arise from the influ- ence of individual or general causes, then, under the head of blen- norrhagia, we should arrange all other discharges which arise as a consequence of mechanical, chymical, or virulent causes which have acted directly on the organs of generation. Such distinctions are, however, impossible in by far the majority of cases, in consequence of the little degree of confidence the surgeon can place in the stories of patients who deceive themselves, or wish to deceive him. The most important' task, then, the surgeon has to perform is to decide whether the blennorrhagia be virulent or not. If a chancre be pres- ent, no doubt can remain in his mind that the disease is a virulent one, and that it has been contracted from sexual intercourse. In other cases the diagnosis should be very guarded ; care should be taken in the wording of certificates that a medical man may be asked for. " After carefully examining Mrs. ----, I do not find she is la- boring under any syphilitic affection, but is subject to a discharge, . A ^S^Sl^zF -y >— ^ iiM : •■■'■. /oV) .7 0 / t i -^V V i >A- :^ BLENNORRHAGIA IN THE FEMALE. 153 which, under the influence of any exciting cause, may become ag- gravated, and thus transmit the disease to persons having connexion with her," is a good form. The Prognosis of a simple blennorrhagia of the vulva is not serious, except in a case of the occurrence of complications which abscess or fistula might give rise to. In urethral blennorrhagia the cure is usually rapid. The disease does not last so long as in the male. The vaginal blennorrhagia is usually the more difficult to cure, in proportion as the complaint is of old standing. When the disease has extended itself to the posterior portion of the vagina, it is next to impossible to cure ; like the uterine blennorrhagia, it is relieved for the moment only, becoming aggravated at the time of menstruation, and is thus interminable. In this last form women generally are bar- ren, for masses of thick, ropy mucus block up the os uteri, and pre- vent fecundation. Treatment.—With reference to the prevention of the disease, we have nothing to add to what we stated under this head when speak- ing of blennorrhagia in the male. In referring to the curative treat- ment, we shall divide it into the abortive, and the treatment of the acute and chronic stage. Here, as elsewhere, the abortive treatment should be employed ; but women seldom apply in time ; the medical man is never consulted during the first few days : this may be attributed to their modesty, or to a cause which (were I not afraid of maligning the sex) I should attribute to that unaccountable, but no less true statement—want of cleanliness with respect to the genital organs. In the treatment of the acute stage of blennorrhagia of the vulva, great benefit may be derived from warm lotions, containing opium or belladonna. If excoriations similar to those found in balanitis are present, the surgeon will find great benefit from cauterizing the sur- face, and keeping dry lint between the diseased parts. If no excori- ations are present, dry lint alone will usually suffice. When the acute stage has passed, astringent injections may be had recourse to with advantage. Blennorrhagia of the urethra, as it resembles that in the male, re- quires a similar treatment. Blennorrhagia in the vagina.—In addition to the ordinary antiphlo- gistic remedies, it is particularly important to use frequent injections, in order to remove all matter which may stagnate and produce a great source of irritation. These injections are best employed when the 154 BLENNORRHAGIA IN THE FEMALE. patient is in a warm bath. In cases where pain is felt, injections should not be persisted in. Further benefit may, however, be derived from injections—namely, as astringents. To this effect, the patient should be placed on a bed, the hips raised, and then the injection should be pushed gently, and allowed to remain. The tube of the syringe should be of an elastic substance. When the case is com- plicated with a granular state of the mucous membrane, a ball of lint, moistened with various substances, may be employed, attached by means of a thread which passes out of the vulva, to enable the patient to withdraw it at will. However, the greatest advantage is usually to be derived from slightly touching the parts over with the nitrate of silver. An augmented secretion usually follows this treatment, but soon ceases, and a cure takes place. Injections of nitrate of silver may be employed, but not with the same advantage as the solid sub- stance. When it is impracticable to introduce the speculum, benefit may still be derived from the application of the solid stick of nitrate of silver. In other cases we may derive great benefit from plugging the vagina with dry lint, which should be changed twice a day. Blennorrhagia of the uterus.—In the acute stage of the disease, in- jections into the uterus are dangerous ; leeches, likewise, should never be employed, or placed on the neck of that organ, as has been recommended: when placed on the groin, or opposite the spine, they have as good an effect, and they do not here cause inflammation, or produce virulent sores on the os uteri. In the chronic state, injections of nitrate of silver may be used (two grains to the ounce), and the quantity has been augmented to ten grains. This substance has suc- ceeded better than any other. Since my return to England, my late master (M. Vidal de Cassis) has called the particular attention of the profession to the subject of injections into the uterus ; and as I witnessed many of the cases treated in this manner, I may be allowed to subjoin my own opinion upon the subject, and make a few practical observations which I hope will be found interesting. It is certain that, if fluids be injected into the uterus in abundance, and with considerable force, on the dead subject, some portion of the liquid may pass into the peritonaeum ; this result, however, is by no means certain. When injections are em- ployed on the female during life, some practitioners believe that these same consequences ensue. Such is not, however, my own opinion. I have injected the uterus many times, when at the Female Venereal Hospital, with the happiest results, and have no reason to believe that fluid ever got into the peritonaeum; immediately after the opera- BLENNORRHAGIA IN THE FEMALE. 155 tion, the patient has occasionally complained of colic and pain in the loins ; these symptoms usually disappear in a few hours by warm fo- mentations, therefore I have had no cause to reject on this account a treatment which has the advantage of curing a very obstinate affec- tion. There are, however, some precautions necessary to be taken. A long tube is to be introduced into the os uteri, and a syringe con- taining a very small quantity of the solution may be firmly attached to it, and the fluid should be pushed on with but little violence; for it must be borne in mind that the cavity of the unimpregnated uterus is very small, and that large quantities of fluid forcibly impelled might possibly pass into the fallopian tubes, and thus escape into the cavity of the peritonaeum—consequences not very probable, but which might give rise to very unpleasant circumstances. Treatment of the complications.—Retention of urine rarely occurs in the female ; it may, however, demand the use of the catheter. In inflammation of the neck of the bladder, or in cystitis, the usual antiphlogistic means should be used, and great benefit is derived from cold clysters containing laudanum. When the complaint has resisted this treatment, the mucous membrane may be rubbed over slightly with nitrate of silver, by means of the instrument of Lallemand. In the male we have seen this treatment followed by success. Vegetations should be destroyed by excision when possible, but they are very liable to return. Stricture, from the nature of the female genital organs, is very rare ; perhaps it does not occur once in ten thousand cases. When abscesses form in the nymphae, they should at once be opened by large and free incisions, which ought to comprise the whole length and depth of the tissues, and cysts should be removed. Cases of fistulae, which arise previous to the surgeon having been consulted, or which occur in consequence of bad management, must be treated on general principles. Thus, the first object to be attained is to keep the sides of the fistula in contact, and this may often be attained (provided the fistula be recent) by means of position and pressure. At a later period, when the fistulous opening is lined with an organized false membrane, the solid nitrate of silver may be used in order to destroy the false membrane and produce an eschar; when this fails, pressure should be used on the sides of the fistula. The nitrate of silver may be often replaced with advantage by the nitric acid, particularly when the sides are indurated, or by means of the uretome the callous structure may be incised. Unfortunately, cases 156 BLENNORRHAGIC OPHTHALMIA. present themselves which resist all treatment, and it only remains for the surgeon to recommend cleanliness. In the oedematous state of the vulva, which we have previously spoken of, instantaneous relief will be procured by dividing the part which may be supposed to form the stricture. Bubo must be treated as in the male. Chancres require the same treatment here as when they occur in other parts. We refer our readers to that subject. The treatment of the various nervous and other complications which occur in uterine blennorrhagia must be conducted on general principles ; but the cure of the local disease will often cause them to disappear. Ovaritis must be treated by our most powerful antiphlogistic reme- dies, otherwise abscesses will form and open either into the vagina, peritonaeum, or rectum. CHAPTER IV. FORMS OF BLENNORRHAGIA COMMON TO BOTH SEXES. Having now described the forms of blennorrhagia which are pe- culiar to either sex, we come, according to the plan we have above laid down, to speak of those forms which are common to the male and female. In the first rank stands blennorrhagic ophthalmia. SECTION I. BLENNORRHAGIC OPHTHALMIA. Blennorrhagic ophthalmia, or what in England is usually term- ed gonorrhoeal ophthalmia, is not unfrequently seen ; yet it is a rare affection, in proportion to the vast number of cases of blennorrhagia which we have witnessed. Its exact situation is pretty regular : BLENNORRHAGIC OPHTHALMIA. 157 thus it usually occupies the palpebral surface of the conjunctiva, or the ocular surface may alone be diseased ; however, we most fre- quently find them both affected at the same time. The follicles at the commencement may be the seat of the complaint, or the substance of the conjunctiva, or the sub-mucous cellular tissue. Usually one eye is affected only at a time ; but, in new-born children, both are not unfrequently seen in a morbid condition. Causes.—On this subject there is much difference of opinion, and at the present day two doctrines divide the medical world; one class of practitioners insisting that the disease is a consequence of sympa- thy; another class asserting that it results from the blennorrhagic pus coming in direct contact with the conjunctiva. The supporters of this last opinion reject altogether the doctrine of sympathy ; on the con- trary, the advocates of the first doctrine admit that blennorrhagic oph- thalmia may be produced by direct contact. We shall now consider these opposite opinions, and first of sym- pathy. The authors who take this view of the subject consider that the affection depends upon a sudden suppression of a blennorrhagia, which, not knowing what to do with itself, passes by sympathy to the eye. Such persons have assumed two things as proved which we can not allow : First, that the discharge is suddenly driven into the sys- tem ; secondly, that there exists a sympathy between the eye and the urethra, vagina, &c. Observation proves, constantly, that the blennorrhagia of the genital organs continues, and is not checked at the time the ophthalmia breaks out; therefore there is no metastasis. There are no proofs, either, of sympathy between the eye and the urethra ; we have stated that it is a rare affection in comparison to the number of cases of blennorrhagia ; if it were a sympathetic affec- tion, we should expect it to occur much more frequently. Another reason which makes us believe that it is not a sympathetic affection is, that in women it is a much rarer affection than in men ; now, sympathy is usually supposed to act more powerfully in the former class, or at least equally so. One eye only is affected at a time in by far the majority of cases : how can sympathy explain this ? why does one eye sympathize more than the other with the genital organs ? These, then, form the reasons which oblige us to reject the doctrine that blennorrhagic ophthalmia is a consequence of metastasis or sym- pathy. 1.58 BLENNORRHAGIC OPHTHALMIA. We advocate the second opinion, viz., that direct contact of the blennorrhagic discharge is the cause of the ophthalmia, for the fol- lowing reasons : Observation clearly points out that matter directly applied to the conjunctiva will and can produce the ophthalmia; we are well aware that it is not always possible to trace the disease to direct contact, but are we consequently to reject the doctrine, and conclude that none has taken place, simply because we have not traced it 1 Certain circumstances, such as the temperature or humid- ity of the air, influence considerably the disease, rendering infection more probable, and aggravating the complaint. Age likewise has its predisposing effect: thus, children born of parents laboring under a blennorrhagic discharge are very liable to be- come infected, in consequence of direct introduction of the matter, and both eyes are usually equally affected. The period of infancy passed, all ages are equally liable. Sex, as we have above stated, has a marked influence in predis- posing individuals. The male is, in a tenfold degree, more liable than the female ; the reason is simple. In making water, the man is obliged to handle the penis ; curiosity also makes him wish to exam- ine the state of the discharge frequently ; thus his hands become soiled with the purulent secretion, which may easily come in contact with the eye. In woman, however, the contrary happens ; her fingers are rarely soiled, for she is lamentably neglectful of the ordinary duties of clean- liness. When one eye is affected, the probability of the other be- coming so likewise will depend upon whether the patient lies on the same side or not, thus favoring the discharge to come in contact with the sound organ. It will be rendered still less probable when the bridge of the nose is high, for the same reasons. Symptoms.—At the commencement, the symptoms are similar to those found in common ophthalmia; the patient feels as if a foreign body intervened between the body and the lid. Should the surgeon be called upon to examine the eye at this period, he will find that the lower eyelid is first attacked ; it is redder than usual, and presents a flocculent, red appearance; the disease does not remain, however, long confined to this spot, but spreads over the whole surface of the conjunctiva; there is considerable lacrymation, followed speedily by a muco-purulent discharge, which soon assumes a purulent charac- ter ; the follicles participate in the disease ; the mucous membrane assumes a granular appearance, and a sanguineous discharge, or even pure blood, appears on the surface. BLENNORRHAGIC OPHTHALMIA. 159 The secretions now form crusts around the lids, and are often so acrid that they excoriate the cheek and parts which they come in contact with; it, however, does not produce any effect on being inoculated. Granulations are so common in this affection, that it has been called granular ophthalmia; this proves that the inflammation has gained the body of the mucous membrane. The symptoms do not, however, stop here ; oedema of the lids takes place to such an extent that the patient loses all power of opening them, and they remain per- manently closed, causing the secretions to be shut up, as in case of abscess. The upper lid, allowing of a greater distension than the lower, covers it, and trichiasis often results; oedema of the cellular tissue of the conjunctiva occurs, and chemosis follows ; thus the cor- nea is surrounded with a mass of oedematous infiltration. Should phlegmonous inflammation occur, an induration will follow in conse- quence of lymph being thrown out. The other parts of the eye become successively attacked ; intoler- ance of light follows ; the cornea becomes clouded, ulcerates, and hypopium succeeds. The ulceration may result from the mere me- chanical effect of the pus, which by its acrid qualities macerates or softens the cornea; or it may ulcerate, from the circulation being in- terrupted ; hence, destruction of the parts follows from insufficient nutrition. These unfavorable symptoms follow one another so rapidly, that in twenty-four hours the eye may be lost. When the disease has ex- isted five days, and the use of the organ is preserved, the surgeon may hope to save it. When the acute stage has passed, the affection may terminate either by resolution, which gradually occurs, leaving a considerable hardness, or cicatrices of the cornea may result, or the iris may become adherent, or be covered with false membranes. Delitescence is a very rare termination. Diagnosis.—In this point of view it is impossible, by any of the signs taken singly, to satisfy one's self of the existence of an oph- thalmia which is the direct effect of gonorrhoea or blennorrhagia. We have before observed that the granular state of the mucous membrane does not prove the specific nature of the complaint, but shows only that the body of the membrane is the seat of the disease. The intensity of this form has been considered as a characteristic symptom, but the practitioner will find he can not depend solely on it, as other forms of ophthalmia have this sign in common. 160 BLENNORRHAGIC OPHTHALMIA. The coincidence of blennorrhagia is not conclusive, for any individ- ual may become affected with ophthalmia independently of gonor- rhoea ; the latter complaint does not prevent him from being affected with a simple conjunctivitis; when it occurs, however, it is a sign of importance, but not an unequivocal symptom of a specific disease. However, the coexistence of blennorrhagia of some of the mucous membranes, great intensity of the complaint, together with a granular appearance of the mucous membranes, will usually be sufficient evi- dence that the disease is blennorrhagic ophthalmia. In moist, damp weather, the surgeon should be on the alert to treat actively inflammation of the eyes in persons laboring under blennorrhagic affections. There is still another question which we should not leave unno- ticed. How can we diagnose a virulent from a mild blennorrhagic ophthalmia ? We positively affirm that no case has ever been shown us which we could call virulent; we have inoculated, but no pustule has been produced, and we are not aware of authors having cited ca- ses of it; we therefore believe that there is no virulent form, strictly so called. Prognosis.—There is no form of ophthalmia, the prognosis of which is more unfavorable than the one we are describing; conse- quently, when the surgeon has a case to treat, he should never take the whole responsibility upon himself ; the patient only ob- serves the slight redness, and if in twenty-four hours the organ is lost, his treatment will be blamed ; a second opinion should, there- fore, be called in. " To give an idea of the unfavorable nature of the prognosis," says M. Ricord, " when I was Dupuytren's interne, that distinguished pro- fessor never had a case that was perfectly cured, or a patient that re- covered his sight completely when once attacked with this complaint, and yet it was not from the fear of taking blood, for six or eight bleed- ings were ordered in as many days." Treatment.—To use the words of Lisfranc, in one of his clinical lectures, " you should tumble upon this complaint, the arm bent, and the mind firmly convinced that it is better for your patient to run the risk of losing all his force than his eye, for one can be recovered, the other is irremediable." But it is at the commencement that we may hope to be of the greatest service ; on the first appearance of redness, let leeches be applied to the temples, and the mastoid process, and let the patient be briskly purged. Should general inflammatory symp- BLENNORRHAGIC OPHTHALMIA. 161 toms be present, general bleeding may be called for. Without wait- ing, however, to allow the disease to gain ground and correct his diagnosis, the surgeon should at once employ the nitrate of silver in substance, not with the intention of its acting like a caustic, but sim- ply to change the character of inflammation ; for, as we have fre- quently had occasion to observe, this substance is endowed with anti- phlogistic properties. To apply it properly, the eyelids should be everted, and then the solid stick of nitrate of silver should be rapidly passed over the surface, so as to whiten it slightly; immediately in- ject cold water under the eyelids, and by this means the nitrate of silver will not touch the cornea. This treatment should be accompanied by that above mentioned, together with poppy-head fomentations, and great relief may be de- rived from belladonna placed in the nostril of the affected side. At a later period the surgeon will do well to prescribe a seton in the neck; by such means nature seems as if taken by surprise, and frequently the eye is at once relieved. The patient's head should be raised and turned to the affected side, to prevent the secretion coming in contact with the sound organ. When chemosis is present, the surgeon should not hesitate to cau- terize it, or, in case of that treatment not succeeding, he may readily, by means of scissors, cut off the swollen and oedematous cellular tis- sue. This will tend materially to unload the vessels of the part. When the chemosis is indurated, cauterization may be tried ; when, however, the circulation of the cornea is interfered with, the surgeon will do well to scarify it (the chemosis), as recommended by Scarpa. Supposing that the first cauterization does not succeed, it is by no means a reason for discontinuing it; in its reapplication, the surgeon should bear in mind the following rules : Cauterization is usually succeeded by a sanguinolent secretion ; this lasts some few hours-; if, at the end of that time, it does not return to its purulent state, if the eye becomes redder than before, the surgeon may with advantage reapply the caustic. M. Ricord has reapplied it four or five times under these circumstances. When, however, the secretion becomes purulent, and then serous, and the other symptoms of inflammation abate, no further application of the caustic is required; it is now worse than useless, and will tend only to excite the inflammation afresh. This constitutes the treatment which we have seen employed with the greatest success ; we shall not, however, quit the subject U 1 62 BLENNORRHAGIA IN THE ANUS. without saying a few words on some other remedies which have been used. M. Ricord is opposed to the use of mercury, as it often causes sal- ivation ; for, although the ptyalism might act as a counter-irritant, it is too near the seat of the affection, and causes only another disease, instead of curing one. Our opinion, from what we have seen of mercury in other affections of the eye, &c, differs greatly from that of our learned master, and in spite of his objections, we should feel called upon to use it in certain cases, and under certain restrictions. As regards the propriety of reproducing the original blennorrhagia, we have nothing further to add to what we stated in our general ob- servations on blennorrhagia, except to repeat that, though recom- mended by Baron Boyer, it is very dangerous, and does not produce the results he anticipates. SECTION II. BLENNORRHAGIA IN THE ANUS. It may be asked, Is there such a disease as this ? We answer, Yes. Nevertheless, it is very rare ; but in large hospitals, set apart for diseases of the genital organs, it is occasionally met with. We have seen some cases—one lately, which was clearly proved, as a police officer was witness of the unnatural crime, and the boy entered the hospital suffering greatly from blennorrhagia of the rectum, and presented the following symptoms. How far it may be common, it is not here for us to decide, but as a consequence of direct infection we believe it an unfrequent disease ; the error of thinking it so de- pends upon the following circumstance. A secondary symptom, which we call mucous tubercle, and which very often follows an in- durated chancre, is very common in the hospital: we have given a very good plate of it. (See Plate V., fig. 4, and PI. 7.) Hence M. Ricord interrogates the patient on this score, and exam- ines the anus frequently. Now, as the mucous tubercle gives rise frequently to a discharge, a superficial observer might suppose that the disease has been contracted by direct contact, particularly when the tubercles are ulcerated. After a careful examination of these BLENNORRHAGIA IN THE ANUS. 163 cases, and after inoculation of the secretion, &c, we have satisfied ourselves that we have only had to treat a secondary symptom. The symptoms of blennorrhagia of the anus are but slightly alluded to by authors, and yet they are of great importance, more especially in medico-legal inquiries, as we have more than once stated. Symptoms.—Pain and difficulty in going to stool usually accompa- ny the disease; however, such symptoms exist equally in haemor- rhoids and other affections of the rectum ; a discharge from the gut takes place, resembling that from the urethra. The lesions of the intestines may be similar to those we described in speaking of the vagina, and the pain is very often intense, in consequence of the faecal matter passing over the excoriated and inflamed gut, thus forming a severe complication ; chancres may occur, which, if accompanied, as they sometimes are, by a spasmodic action of the intestine, render defecation very difficult, or even impossible. The disease may assume either a chronic or acute character. When acute, the circumstances and complications render it very se- vere ; when it takes on the chronic form, the position and difficulty of local treatment render the cure very tedious. Buboes seldom fol- low, but abscess at the margin of the anus is not unfrequent; it does not, however, necessarily form a communication with the intestine, though fissures of the rectum may frequently result. The affection is usually seated just within the sphincter, and does not extend beyond the second curvature of the rectum. The cause is, as we have stated above, the effect of direct contact of the blennorrhagic secretion ; it can not be produced by swallow- ing the secretion, as some authors have pretended. The other gen- eral causes of blennorrhagia might give rise to the disease, but sel- dom do so. Diagnosis.—This is by no means easy, for we occasionally see blennorrhoid discharges from the rectum, and to distinguish such from blennorrhagia is usually impossible. Notwithstanding, the medical man is sometimes called upon to give evidence ; it is therefore of the greatest importance that he fully understand this subject, as the life and reputation of several individuals may depend upon his opinion ; and for these reasons we purpose examining some of the signs which have been given in books. M. Cullerier, one of the surgeons of the Venereal hospital, states, in an article he has written on this subject, that an opinion may be formed from the funnel-shaped appearance of the rectum. The case which we lately saw proved completely that this funnel-shaped ap- 164 BLENNORRHAGIA IN THE ANUS. pearance of the anus does not necessarily follow the commission of an unnatural crime ; no such appearance was there present. Those who have dissected phthisical patients must be likewise aware that this appearance will be often found, as it depends upon the absorption of the fat; an inflammatory affection may cause a swelling of the parts around the anus, and give the opening a funnel- shaped appearance; hence, then, we infer that the crime may have been committed without this pretended sign being present; and if it does exist, there is no reason to suppose that the crime has been per- petrated. Our readers will, therefore, appreciate the value of such a symptom. The color of the discharge has been cited as assisting the diagno- sis ; but taken alone this is of no use, for it gives the surgeon no in- formation as to the cause. In simple blennorrhagia of the rectum inoculation affords no assist- ance ; if, however, chancre be present, inoculation will then satisfac- torily prove that the complaint has been caught in an unnatural man- ner. The occurrence of buboes will not assist the diagnosis, as some have supposed ; observation clearly shows that they are often pro- duced by simple irritation. The antecedents of the patient seldom aid the diagnosis, as he rarely acknowledges that he has been guilty of such a crime. In fine, when no chancre exists, there is no one unequivocal sign that the complaint, which the surgeon is called to pronounce upon, depends on a disease contracted in unnatural connexion ; there is, however, a circumstance on which M. Ricord lays great stress ; we refer to a rent or tearing of the margin opposite the coccyx ani. peri- neum, which he has never found in persons unaccustomed to the crime. He further states, when this condition has been observed, that the patients, on being pressed, have avowed and confessed the manner in which the disease had been contracted. Prognosis.—This must be always unfavorable, as, during the acute stage, the passage of the faeces irritates the membrane, and may give rise to abscesses. In the chronic stage, if the disease have reached the deep parts of the rectum, we can have no hopes of speedily curing it, as it is difficult to apply local treatment. Treatment.—The first indication we have to fulfil is to empty the rectum, and to prevent constipation as much as possible ; this is best done by lavements. When, however, fissures of the rectum exist, the introduction of the clyster-pipe is difficult, and should not be contin- ued ; laxatives only should be used. Cubebs and copaiba are not VEGETATIONS. 165 only useless, but highly prejudicial, as they tend to irritate the rec- tum, and have no effect in checking the discharge. The direct means consist in keeping the parts perfectly clean, in employing injections of nitrate of silver of the usual strength, and, in some cases, advantage may be derived from the use of the tent. SECTION III. BLENNORRHAGIA OF THE MOUTH, NOSE, AND EARS. M. Ricord, in his immense practice, has never seen any disease or discharge which could be classed under this head ; he is therefore disposed to treat such descriptions as fabulous, and to attribute them to simple catarrhal affections. In the umbilicus, and in the fold of the groin, discharges may appear as the consequence of dirt, or the development of mucous tubercles ; the treatment must, of course, be founded on general principles and consideration of the cause. SECTION IV. VEGETATIONS. Under the general term of non-virulent affections I place vegeta- tions, which, though not necessarily, are frequently a consequence of sexual intercourse, and must therefore be considered. Vegetations are generally designated by the terms, warts, cauliflower excrescences, cockscombs, fyc. (PI. VI.) Pathology.—In color vegetations differ considerably; sometimes they are of a very vivid red or scarlet; this happens particularly when they are seated on the glans penis at the entrance of the ure- thra in the male or female, on the inner margin of a narrow prepuce, and, generally speaking, when they are not constantly exposed to the air. When seated on the skin they are much paler, and by exposure become even quite black. Their consistence and sensibility differ considerably : they may be quite horny, very little if at all sensible, and quite dry ; or they may Vy 166 VEGETATIONS. be moist, secreting a dirty and offensive fluid, flaccid, and sensible to the ordinary stimuli. Sometimes they are attached to the skin by a sort of pedicle ; at others, they have a broad base, and are flattened. In number and size the same variety occurs ; we meet often with one or two, very small and pointed ; in other instances, the male or female organs may be completely covered with them. They are more frequently situated on the mucous membrane than on the skin, although they are met with on the thighs ; still, however, they are found on those parts of the skin which are more closely allied to mucous membrane. Their growth depends apparently on the little pressure and the moisture which surround them ; for, if pressure be made, and if artificial means be employed to keep the parts dry, their growth is retarded. Their structure is very peculiar : a cluster of vegetations is com- posed of a number of granular bodies connected by a common base ; the size of the granules differs greatly, usually that of a small pin's head ; these granulations are more or less conical ; when not com- pressed, they are covered by epidermis or epithelium, which often becomes horny in exposed situations ; if a section be made of this cluster, it seems to consist of an hypertrophied dermis, which is much thicker here than elsewhere. Some authors believe vegetations to consist of the papillae of the skin, which from some cause are hyper- trophied, and lift up the epidermis covering them. Others believe them to depend upon an hypertrophy of the crypts, which form the exhalents on the skin, having assumed a conical appearance. What- ever views my readers may have upon the subject, let them be as- sured that their origin is deeper than is imagined; hence arises the difficulty of removing them, and the necessity of taking certain pre- cautions if we wish to cure them radically. They are plentifully supplied with blood-vessels, bleeding freely when cut; their sensi- bility differs greatly ; in some cases vegetations are nearly destitute of sensation ; when they have been much irritated, they become ex- ceedingly sensitive, and the secretion they give rise to seems to in- crease that sensibility. The causes appear to arise from irritation ; some persons believe them to be the consequence of venereal disease, and pretend to speak of syphilitic vegetations as distinguished from others. Observation leads me to the following conclusions : Any secretion which will oc- casion irritation of a surface for a prolonged period may produce vege- tations. We have often seen them in boys and adults affected with natural phymosis, or who pay no attention to cleanliness ; in such VEGETATIONS. 167 cases, it is the secretion of the glandulae odoriferae which produce the disease, for connexion has never been indulged in. Sir A. Cooper, in his valuable Lectures on Surgery, states two causes which prove that the secretion of warts is contagious, and he does not think that the blood of these bodies can become the infectious agent. I have met with similar cases, but I am not prepared to say that the matter they secrete is of any peculiar property, acting otherwise than as a simple irritant, which, as I have said, is alone sufficient to produce warts. In females they depend upon gonorrhoea or irritating discharges ; the secretion of chancres often produces them, not, I believe, in virtue of any specific action, but from its irritating qualities, and modern authors no longer consider them a secondary symptom. It is of no great importance in medical jurisprudence that these points should be properly appreciated. I may here mention an instance. A late interne at St. Louis' hospital was shown a child with these vegetations completely encircling the genital organs, which he in- stantly pronounced to be syphilitic ; and the mother immediately sus- pected an old man who was in the habit of playing with the child, who lived in the same house with her ; and the answers of the child appeared to corroborate these suspicions, or they were (as often hap- pens) tortured into an acknowledgment. The authorities were ap- prized, but did not think it necessary to take any measures. I ex- amined the child, and found that the vegetations existed in great numbers, of a dark and horny consistence ; there was a considerable quantity of serous discharge from the vagina. The child was puny, lymphatic ; and I could detect no marks of violence on its person. This circumstance induced me to tell the interne that he had come rather hastily to a conclusion on the nature of the vegetations. Their pale, horny, dark character showed that they had existed a long time, notwithstanding any statement of the mother, who seemed at all risks to tax the old man with rape. The discharge from the vagina, as I assured him, was often pres- ent in scrofulous children ; it existed in this instance, and its serous character showed that it did not depend upon recent infection. Now these appearances did not tally with the commission of rape, or the idea of infection contracted a few days before. I believed the man innocent; and I mention the case here, as the circumstances which attend it are peculiar, and I believe it be an instructive one. Complications.—Vegetations may exist alone, or be complicated with a variety of other affections : in the female we often find dis- 168 VEGETATIONS. charges which produce, keep up, and aggravate the complaint. Excoriation of the surrounding tissues is often likewise a complica- tion. Ulcerations, both of a simple and specific nature, frequently attend the complaint, and render it more difficult of cure. But by far the most frequent in the London hospitals is condylomata, and hence these two affections are often confounded together, and attributed to the same cause. In the female, the situation of vegetations often gives rise to a complication, particularly when they are of a very vascular kind and occupy the meatus, causing that affection which has been described by Sir C. M. Clarke and Sir B. Brodie. In the male, vegetations co-exist with balanitis, chancres, paraphymosis, phymosis, complications which are often severer than the original af- fection, and which it is necessary to remedy previous to treating the vegetations. The diagnosis of vegetations is generally easy ; there is, however, one affection with which they may be confounded ; I allude to con- dylomata. The practised eye will, in such cases, however, rarely be deceived. The former affection is pedunculated, the granules small, covered with epidermis ; their color is florid. The history of the case, and the existence of some irritation, help the diagnosis. In the latter affection the bases of the condylomata are large, the granular patch is flat, apparently destitute of epidermis, and covered with a whitish or yellow secretion, rarely occurring without other traces of secondary symptoms, probably the patchy excoriation of the tonsils, or a papular eruption on the body. When vegetations and condylomata occur together, the local characters I have above mentioned aid the diagnosis. The prognosis is favorable, although the patient should be made aware that, when destroyed, vegetations are very liable to recur. If not removed, however, they may create great local irritation, and produce very intractable sores, although possessing nothing specific. In some few cases I have witnessed, when vegetations are very ex- tensive, no sooner does the surgeon get rid of one crop than another appears ; the disease is hydra-headed; but under the treatment which I shall immediately recommend, this rarely occurs. Treatment.—When these bodies are few in number, it is only ne- cessary to remove the cause which keeps up the irritation, and they will disappear of themselves. Ablution with tepid water, or an astringent wash, will often suffice, provided dry lint be used to pre- vent the vegetations coming in contact with one another. They shrivel up and soon fall away, and are not reproduced. In such 2 7 J.V*»J7W>-? 7^" 'Tos-raM* Si Ji^A* *f y^f/cAI^v.JIJ J7* HERPES PR^PUTIALIS. 169 cases as these, any dry powder may be employed, and, as far as my experience goes, the simpler it is the better; and I should recom- mend hair-powder in preference to those stimulating ones in use, which, however, are not without their danger. I have often had oc- casion to witness vegetations surrounded with a hard crust composed of some powder mixed with the secretion, and producing an augmen- tation of suffering; hence I do not recommend them. When the patient will submit to the use of instruments, nothing succeeds so well as excision of the vegetations with a pair of curved scissors, taking care to cut them as close as possible to their roots. The incised parts bleed freely; but this should not deter the surgeon from cutting off as many as possible, placing dry lint upon them when the bleeding has ceased; the coagula and lint should be re- moved by the use of the warm bath, and the greatest attention paid to cleanliness, at the same time that means should be taken to check any discharge which may run over the affected part. If powders be used, the part should be carefully washed and dried previous to any more powder being applied. When these means fail, caustics may be employed, but the surgeon will find them very inefficacious compared to the other means. Nitrate of silver produces but little effect; its action is superficial, and it forms a hard cake on the vege- tation, which is irritating and does not fall off for some days, when the vegetations are often as large as before. The caustic potash is a very unmanageable preparation ; it extends further than is wished, and the black and decomposed substance is very irritating. How- ever, as an adjunct to excision, the employment of the solid nitrate of silver is beneficial; but the surgeon should not employ it to the bleeding surfaces : when the excised parts have ceased to pour out blood, and the part is washed, let the stick of nitrate of silver be applied to the centre, and the vegetations will not reappear. Gener- al means are of no benefit, unless they tend to check any discharge which keeps up the irritation. SECTION V. HERPES PRjEPUTIALIS. Among non-virulent affections is a complaint which pathologists have agreed to call herpes praeputialis. Willan and Bateman have 170 HERPES PRjEPUTIALIS. classed it among vesicular diseases. It commences by a cluster of small vesicles, seated on a patch of inflamed skin : the vesicles may become ruptured, and the secretion of the part may cause ulceration, and little sores are thus produced. The reader who is not familiar with this disease, will gain a very good idea of its characters by examining Plate III., fig. 3: the affection is there seen in all its stages. I think I can not do better than extract the following case from my note-book, together with the observations which I made upon it, as they comprehend whatever is known upon the disease. August 15, 1839.—My friend Dr. Fisher, of the Place Vendome, directed A. G-----to call upon me, and ask my opinion upon a sore on the penis, this morning. On the prepuce and glans there are several ulcerations presenting the following appearance : one is a small distinct ulcer, covered with a whitish secretion, the base is red, and gradually lost in the surrounding tissue ; close to it is a distinct vesicle filled with a limpid fluid; there are various others, which more or less resemble the two spoken of. On the right buttock there is a patch of vesicles of the size of a five-shilling piece, the base of each being as large as a pin's head; some are filled with a serous, others with a yellowish fluid. Close to the anus is another patch, which is completely covered with a yellowish crust, such as is seen on the face of children. The History the patient gives of himself is the following : he left England in consequence of bad health and indigestion, and is now returning from Geneva. On Thursday last, the 8th instant, having been three days in a diligence, he felt a singular pricking near the anus, and at that period the sore on the penis first appeared, but has made no progress since. Being interrogated on the subject of ex- posure to contagion, he states that he has not had connexion more than twice, the last one dated two years back. As to the probability of having contracted it on a water-closet, he states that he did sit down on one which was very dirty, a short time since. He adds, that had he reason to attribute the affection to contagion, he would willingly avow it, having no motive for concealing the truth. On again questioning him, he states that he is very subject to in- digestion and to eruptions ; lately he has been particularly inattentive to diet, eating at a table d'hote, &c. Such is the history of the case given by a very intelligent young man, who can have no reason for concealing anything, as he is very anxious to pursue his journey. He naturally asked me for an opin- ion on the sore, and this leads me to consider the diagnosis. The HERPES PRAEPUTIALIS. 171 circumstance of an ulceration on the pern's, presenting the characters above noticed, in a young man of twenty, is very strong prima, facie evidence that a chancre exists; but we are aware that the presence of a sore on the penis does not prove that it is a chancre, for other sores may appear on the penis, and chancres may appear on any part of the body. As to the characters of chancres, we have stated them to be those attending other ulcerations, and that other sores may put on the character of chancre. In young men, suspicion is excited because they are more exposed ; but any age is necessarily liable. Thus, then, as far as we have yet seen, the present case has as many cir- cumstances for supposing it to be one of chancre as not. Now if it be not a chancre, what is it 1 The prepuce is liable to other vesicular diseases. Thus, in addition to chancre, eczema and herpes praeputialis are not unfrequently seen on that part. Can the present complaint be any of these ? It presents a vesicle of a con- siderable size, seated on an elevated patch: these, we see at once, are not the characters of eczema, for by referring to this latter affec- tion it will be found that eczema presents a very small vesicle, in great quantities, thickly and irregularly sprinkled over an inflamed and reddened skin. Herpes praeputialis, like herpes labialis, usually appears in distinct patches of about some ten or twelve large vesicles on a red base, which, at the end of a few days, fade away and dry up of themselves, or, if the irritation continue, form little ulcers. They generally depend, not upon local irritation, but upon disorder of the digestive organs ; on the contrary, eczema usually accompa- nies, and is produced by, local irritation. So far, then, it will at once be perceived that we are in doubt whether this case be due to a specific cause or not. If it be a sim- ple affection of the skin, it can be only herpes praeputialis, and we exclude eczema, and come to the conclusion that it is either a chan- cre or herpes. As to the probability of its being a chancre, we should add, that our patient has not been exposed to contagion, and unless we allow that a chancre arise spontaneously, the present case does not depend upon a specific contagion. Is it probable that the present case is an herpetic affection ? We find on studying herpes, on the lips and prepuce, that it is usually preceded by general disturbance of the digestive organs; that it occurs in persons possessing a delicate skin, and such as are subject 172 ECZEMA. to skin diseases ; that it never exists except in patches, and that these patches may be numerous. Now these circumstances are all present in the case before us: the vesicles are not only present on the penis, but likewise on the buttocks, where there has never been an abrasion of surface ; hence inoculation could not have acted here, although it may on the sound surface of the mucous membrane. For these reasons, then, we have diagnosed the case to be one of herpes praeputialis, which from the moisture of the part has ulcerated. The prognosis is favorable, inasmuch as the course of an herpetic affection, when properly treated, is excessively simple ; we therefore gave our patient every reason to suppose that he would be perfectly well in a few days. The treatment we recommended, was particular attention to diet, advising him to live upon milk and vegetables, with meat and wine in moderation, avoiding all heating dishes. We prescribed aperients and bitters, and a local application of lint dipped in aromatic wine. August 18. This patient left Paris quite well. SECTION VI. ECZEMA. The surgeon is occasionally consulted on account of a severe affection of the genital organs which pathologists call eczema. This disease is generally spoken of only in treatises on skin diseases; however, as it occasionally is a consequence of sexual intercourse, I have thought proper to allude to it, and accompany the description with a plate which the reader will find in Plate IV., fig. 3. Causes.—Eczema can generally be traced to the application of some irritating substance to the skin. In cases which we are about to treat of, the blennorrhagic discharge is the usual exciting cause, together with inattention to cleanliness : hence we very frequently witness cases of the affection in prostitutes. In men, however, who work in a business where much powder or dust is disengaged, this affection of the genital organs is not uncommon, and of course quite independent of any venereal complaint. The surgeon should not forget that mere friction of the trousers will produce it; by itself it EXCORIATIONS. 173 is no sign of venereal disease. I have found it more frequently in persons who have red or auburn hair than in other individuals. Symptoms.—Eczema is characterized at its commencement by a feeling of itching, heat, and redness ; the parts become swollen, and these symptoms are followed by an eruption of small vesicles scat- tered over the surface : when scratched, a serous fluid exudes, form- ing little scales on the skin, and increases the irritation. The disease may assume the chronic form; in this state the drawing was taken : the skin is red and swollen ; the surface covered with the secretion above mentioned, which is hardened by exposure, and crevices are seen running between the little lamellae : from these issues, at first, a clear, and in the more advanced stages a sero-purulent secretion, giving rise to larger and firmer scales, and the disease is then called eczema impetiginodes. The diagnosis is easy, and does not require further allusion. The prognosis, in simple cases, is favorable, but in the severer forms no prospect of an early or speedy cure can be given, as this affection is one of the most obstinate. Treatment.—Great attention to cleanliness is frequently sufficient to cure the patient, at the same time that all exciting causes are carefully avoided. In the more advanced stages, local bleeding will be called for, and some emollient application, such as bran-water, goulard-water, poultices, particularly those made of potato-starch ; linseed-meal, by its rancidity, often exaggerates the complaint. When these means fail, it may be found advantageous to stimulate the part by rubbing the organ with nitrate of silver, when all irrita- tion has ceased, and employing dry lint to prevent friction. SECTION VII. EXCORIATIONS. Definition.—By the term excoriation, I here mean abrasion of the epidermis or epithelium, the result of sexual intercourse. We meet, in practice, with some few individuals who can not in- dulge in sexual intercourse without being subject to excoriations; such persons are not observed to have a particularly fine or clear skin : we have met with the affection in patients who on other parts of the body have a thicker cuticle than usual, and yet are very sub- 174 EXCORIATIONS. ject to abrasions in connexion. Excoriations, however, are more frequently met with in persons who naturally have a long and nar- row prepuce, and pay little attention to cleanliness. The number and position of excoriations differ greatly, but it is in the neighborhood of the fraenum that they are most frequently seen, and they often occur upon the patches of the glandule odorifere at the base of the glans penis. They may rapidly heal, or, if neglected, ulcerations may follow, and be kept up by the secretions of the part; these sores, as far as physical characters go, we are unable to dis- tinguish from chancres, to which thev bear a strong resemblance in situation, size, &c. The treatment is the simplest possible : washing the penis several times in the day with a little goulard-water, and when dried placing a small strip of lint between the glans and prepuce, will rapidly cause these excoriations to heal. When this object is gained, the surgeon, to prevent a repetition of the annoyance, may recommend some astringent wash, and engage his patient to partially uncover the glands ; by such means, together with strict attention to cleanli- ness, or washing the part daily with a little spirit, the abrasions of the skin will not reoccur, and the patient will be relieved from much annoyance and danger in promiscuous intercourse. PART II. SYPHILIS. CHAPTER I. PRIMARY SYMPTOMS. In the introduction it has been stated that venereal diseases may be naturally distinguished into two orders : to the first of these I have already sufficiently directed the attention of my readers. There, how- ever, remains the second division, no less important, if considered in relation to the primary symptoms it gives rise to, or to those general or constitutional results which modern surgeons believe to be a direct consequence of the primary. This second order, the description of which will form the subject of this part, has been styled— Syphilis.—Syphilis is a virulent affection, the essential character of which is its dependence upon a special cause, or a distinct virus. The term syphilis is derived, according to Fallopius and Swediaur, from ovv, with, and <£' y- y & ' FZiza'ric^its-? JJ,' sTa.r.Mi Sf ■■ZW-yJlyift-rX!,*, , ,r/jfaMfiA CHANCRE. 177 fourth to the fifth day the vesicle assumes a pustular character, and a distinct depression is seen in the centre, so that it represents very distinctly at this period the small-pox pustule, fig. 1, d. e. The red areola, which has been hitherto gradually augmenting in intensity, now as gradually fades away, and the cellular tissue, which was slightly oedematous, becomes infiltrated with plastic lymph. On the sixth or seventh day the pustule is observed to be wrinkled, in con- sequence of the contents becoming thicker, and ultimately a crust takes the place of the pustule, fig. \,f,g. If not interfered with, this crust assumes a conical appearance, increasing always at its base ; it ultimately falls of, leaving an ulcer seated on a slightly indurated base, in depth equal to the thickness of the skin : the bottom of the ulcer is covered with a whitish pulpy substance or false membrane, which adheres so firmly, that it is with difficulty wiped or washed off. The ulcer is generally circular, and appears as if made with a •punch, fig: 1, h. The margin, if viewed by means of a microscope, will be found dentated and covered with a secretion similar to that seen at the bot- tom of the ulcer. The border is slightly oedematous, or indurated, and the areola around it of a browner tint than at the previous stages : this oedematous condition of the border occasions a slight eversion of the edges, and hence the ulcer may assume a somewhat infundi- buliform appearance.* The surgeon, however, must not expect that the course of every chancre he meets with in practice will be similar to this artificial sore. Observation teaches us that primary sores may commence in either of the following ways. The matter from an already infected individual may introduce itself into the follicles which exist in such numbers on the glans penis, and as the opening closes, little ab- scesses or pustules form, which then go through the stages mention- ed in the preceding paragraph ; and a good idea of this form of chancre may be obtained from PI. IV., fig. 2. More frequently, however, the matter comes in contact with an abraded surface, together with mucus or some secretion which forms a sort of crust, and then the chancre is in the same condition as seen in PI. IV., fig. \,g ; provided no mucus be present, the abraded sur- face does not become dry, but presents the appearance seen in Plate * Provided the patient keeps his bed, is in a good state of health, and commits no excesses of any kind, the course of a chancre produced in the artificial manner above- described will pass through these regular phases, but under opposite circumstances the artificial sore may take on any of the varieties hereafter to be mentioned. 12 178 CHANCRE. IV.,fig.l.g. Chancres may commence in any of these ways, or the matter may be introduced under the epidermis or epithelium, by leech- bites, punctured wounds, &c. ; they will then follow the course of follicular or artificial chancres. Lastly, the absorbents may carry the matter along a lymphatic vessel, cause the ulceration of it, or of a lymphatic gland, and thus the chancre appears as a little abscess in the course of the vessel, presenting, when the scale falls off, the appearance seen in Plate V., fig. 2. If the pus of a chancre, such as we have described it, be examin- ed by the microscope, it will be often found to contain animalcules, particularly the vibrio lineola of Muller. The experiments of M. Donne have likewise proved that it may present either alkaline or acid properties, circumstances depending upon its situation, &c. It varies in consistence, but is usually of a thin, serous, and san- guineous character ; however, the peculiar pathognomonic character of the pus is the action which it has on the animal economy when inoculated ; for I may here state that no other secretion with which we are acquainted, or which I have seen employed, will produce similar effects. This pus will produce no such specific effects on animals, not- withstanding all the attempts which M. Ricord and others have made to inoculate them; hence, as far as experiments can prove it, its effects seem to be confined to the human species. Progress of Artificial Chancre.—If the sore be kept clean, it shows very little tendency to increase, and may remain a considerable time in statu quo, provided no excesses are committed ; the disease has a very mild character, quite at variance with those symptoms usually attributed to it. Weeks may pass, and the chancre not be larger than a split pea, although the areola may become somewhat more livid. The anatomical characters of the ulcerative period are not, however, always so simple as we have above described them; in consequence of circumstances to be mentioned hereafter, the chancre may assume various appearances, which are considered by M. Ricord sufficiently distinct and characteristic to deserve particular attention. I shall consider these varieties under the following heads. 1st Variety, or Phagedenic Chancre.—Every chancre may be strictly said to be phagedenic, that is to say, it destroys the tissues which are in contact with it, but in simple, uncomplicated cases, its progress soon becomes checked and limited by the infiltration of lymph which sometimes surrounds it, and which Hunter considered CHANCRE. 179 as one of the features of a genuine chancre. When there is an ab- sence of this induration, which, when occurring in a slight degree, I shall call healthy, we may observe the 2d variety of chancre, which I shall call Diphtheritic Phagedenic. Chancre, an example of which is given in Plate V., figure 1.* Its form may be various; it has a ten- dency to extend rather in breadth than in depth, in consequence of the skin or mucous membrane offering but little resistance to it. The surrounding parts are but slightly swollen, or if any swelling be pres- ent, it has rather an oedematous or phlegmonous character than the specific induration ; in size such ulcerations cover a large surface, and secrete a thin, darkish colored, acrid pus. 3d Variety : Indurated Chancre.—I have not thought it neces- sary to give a drawing of the indurated chancre, a form which Hun- ter described ; it is rarely met with either in London or Paris. The cases which I believe Hunter meant, were chancres as seen in Plate IV., figure 1, h, provided they had an indurated base and sides, or what I should now describe as a simple chancre on an in- durated base. This sore and the following is the one spoken of by Mr. Carmichael as giving rise to the scaly venereal disease. 4th Variety : Indurated Phagedenic Chancre.—The simple super- iicial sore will occasionally become indurated to a considerable ex- tent, and plastic lymph be deposited in the cellular tissue around and beneath it in large quantities. In these cases the centre of the in- duration is observed to assume a dark appearance, and what M. Ri- cord calls an interstitial gangrene results, which gains by degrees the whole surface ; commencing at the centre, it reaches the circum- ference, and then becomes limited; it seems as if this gangrene re- sulted in consequence of insufficient nutrition from compression ex- ercised by the induration upon the vessels. A good idea may be formed of this chancre from Plate V., fig. 2. I have lately seen under Mr. Lawrence's care at St. Bartholomew's hospital several cases of this description. The cicatrix of a previous sore became cartilaginous and quite transparent; in a few days red streaks were observed running through it; these became darker until the whole indurated mass lost its transparency, and assumed the peculiar char- acter seen in Plate V., fig. 2. 5th Variety : Gangrenous Chancre.—In addition to the form of phagedenic chancre last mentioned, the result of excessive indura- ration, there is likewise another, the consequence of excessive mflam- * This is the form of chancre which Mr. Carmichael considers as giving rise to the phagedenic venereal disease, and has by him been named acute phagedena. 180 CHANCRE. mation, which I shall call gangrenous chancre. Violent inflamma- tion may attack any simple chancre as it does other parts of the body, and gangrene of the chancre follows, succeeded by a grayish or blackish slough, which, on falling off, leaves the surrounding tissues in an infiltrated state, but no induration remains. The secretion ap- pears of a very acrid, irritating character, and consists rather of liquid tissues destroyed by the gangrene, than of pus or any secre- tion from the blood. (See Plate V., fig. 3.*) Period of Reparation.—Under whichever of the forms above de- scribed chancre may have first appeared, the reparative process is ushered in by the appearance of healthy granulations on the surface of the sore, the margin, which was slightly elevated, becomes on a level with the ulcerating surface. The cicatrix extends from the cir- cumference toward the centre ; finally, the indurated base becomes absorbed, and a perfect cicatrization, level with the surrounding skin, occurs. When the chancre has existed on the skin or mucous mem- brane, a slight cicatrix only will remain ; but on parts where the cellular tissue is not in abundance and lax, as on the glans penis, or neck of the uterus, a depression will often result. A stain long re- mains on the spot where the chancre has existed ; at first of a livid hue, it gradually grows paler, until the cicatrized point ultimately be- comes whiter than the surrounding skin. The reparative stage, like the ulcerative, has its varieties. Thus, instead of healing rapidly, and from the circumference toward the centre, various points on the surface begin to cicatrize, or on one side only of the chancre. In other cases the sore cicatrizes, but no sooner does this happen than it begins again to ulcerate, or as the cicatrix commences on one side the ulcer enlarges on the other; thus we have a chancre lasting an indefinite length of time. The granulations may likewise be slightly or very much raised above the level of the surface ; in the latter case forming the ulcus elevatum of some writers. Such a sore, however, has usually lost its specific properties, and the secretion it furnishes is no longer inoculable. In some cases the ulceration in cicatrizing becomes indurated; instead of forming a healthy cicatrix, we observe a callous thickening, which, on the slightest cause, breaks out again into an ulcer of a very un- healthy character, as occurred in Plate V., fig. 3. Lastly, a chancre will become changed into what I shall hereafter describe as a mucous tubercle. In this case, instead of being gradually covered by a * Different varieties of chancre, and their different positions are shown in Plate IX. 5, SzAtf yfr.r.f CHANCRE. 193 stances ; thus, climate, constitution, age, plethora, debility, bad air, insufficient clothing, &c, are so many causes which will tend to pro- duce the varieties of chancre. An attentive examination of the varieties of chancre has enabled us to enumerate some of the causes which appear to give rise to them ; thus, bad food, insufficient clothing, intemperate habits, expo- sure to cold, local stimulating applications, are a few of the causes which make a simple chancre take on the diptheritic character. Young plethoric persons, who use great exertion, or who are addicted to the abuse of spirituous liquors, at the same time that they expose themselves to vicissitudes of the weather, or who change suddenly their diet or climate—such, we say, run a great risk of the chancre assuming that variety which we have called gangrenous pha- gedenic. Scrofulous individuals, or old men who have led a dissipated life, or men subject to the diseases of hot climates, persons with skin dis- eases, and constitutional complaints, whose health has been ruined by several courses of mercury, as well as those whose chancres have been treated injudiciously, will be found to present the serpiginous variety of chancre. Lastly, we arrive at the indurated variety. Here the cause is by no means clear, yet it is the one which we are most interested in dis- covering. The indurated chancre may appear in a variety of con- stitutions. The one delineated in plate V., fig. 2, occurred on the penis of a young man of a clear, transparent complexion, of short stature, but who could not be said to present very evident marks of scrofula. In the case of Mr. H., detailed at page 188, the constitu- tion was good, though somewhat lymphatic, and he was subject to hypochondriasis. Sex seems to have some influence; it is most common in males, yet we have seen various cases in women. Situation apparently interferes but little, as chancre may, in any situation, take on this character, although an ulcer situated on the prepuce is most frequently indurated. We have been unable to connect induration with any peculiar mode of local treatment; we have seen persons affected with the most obstinate forms of indurated chancre, who had not been treated either locally or generally ; on the other hand, the most simple and judicious local management of a sore, immediately after its commencement^ has not always prevented the occurrence of this character, which deserves so much attention from the practitioner, as it betokens a 13 194 CHANCRE. peculiar liability to secondary symptoms ; the relation between the two we can only observe, and not account for ; it is one of those primitive facts (as M. Andral calls them), the solution of which science, as it at present exists, does not permit us to a tempt, and of which a more or less probable hypothesis can only remove the diffi- culty one step farther back. The Diagnosis of Chancre.—In describing artificial chancre, con- sidered in reference to its chymical, physical, and microscopical characters, as well as the local effects produced on the economy when the secretion is introduced into the system, we have given the diagnosis of chancre. But it may not be uninteresting to consider practically the subject, and allude to such cases as present difficulties. A case is presented to our observation at its origin; that is to say, we are consulted for a pustule, a small abscess, or an excoriation, such as seen in plate IV., figs. 1 and 2. How is a correct diagnosis to be formed in this case ? A rational diagnosis may often be founded on the appearance, situation, history, and course of this stage of chancre, but only a rational one. The value to be attached to each circumstance we shall consider in detail. 1st. The Appearance.—It is a fact which no one who has seen much of venereal disease can contest, that a primary sore presents characters which are very striking, and there are many surgeons who rely principally upon them in forming an opinion on the nature of a sore. M. Velpeau has assured me that he lays great stress upon it. This opinion will be corroborated on referring to plate IV., figs. 1 and 3, with its accompanying description. But though a primary syphilitic sore has generally a peculiar physiognomy, still it is iricon^ testable that other sores, not of a specific nature, may assume all the aspect of real chancres. If, for instance, a piece of corrosive subli- mate be placed between the glans and the prepuce, a sore, in every physical character resembling chancre, will follow ; hence we con- clude, that the appearance of the chancre is only of relative value in the diagnosis. In further illustration of the difficulty which attends the diagnosis, when a surgeon judges of the nature of a sore from its appearance, I may mention that many of the most eminent men in our profession, both in England and France, differ in opinion upon the diagnosis of the disease represented in plate IV., fig. 2. Several of those to whom I have submitted it, say, " Your diagnostic sign of inoculation was unnecessary ; we should have judged it syphilitic from its appear- ance." I have met with many who have stated the contrary, and CHANCRE. 195 ridiculed the notion of chancres existing on the leg. " These sores are chronic ones, such as you may see in my hospital any day," said a learned surgeon, lately, when I showed him the original drawings. If, however, a primitive sore usually assumes the characters above- mentioned, it is no less certain that in some few instances it presents no peculiar features, yet it is no less a chancre. Thus, then, the mere presence or absence of certain appearances can not alone enable us to decide upon its nature. 2.. The Situation.—As inoculation has proved that chancres may occur on any part of the skin or mucous membrane, the mere situ- ation of a sore will in no way assist our diagnosis, unless as urging us to examine more carefully those parts which are most likely to conceal them from our view, such as the deep portions of the vagina, uterus, urethra, rectum, mouth, &c. 3. The History of the Sore.—If there is any one circumstance which has led, or leads surgeons frequently to form a false diagnosis, it is the history. Thus, supposing that a patient avows that he has exposed himself to infection, and a sore follows, the simple fact of exposure only gives presumptive evidence that a sore is syphilitic, inasmuch as this sore may have been produced by simple irritation, or by abrasion. It is not sufficient to know that connexion has pre- ceded, but it is likewise necessary that a reasonable time only has elapsed between the act of coition and the real, not the reputed appearance of the sore. We are well aware that the space of time before a chancre appears may be considerable, as occurred in the case of Mr. H-----. (See note, page 188.) Here, probably, the pus introduced itself into a sebaceous follicle, and only came into action when it had destroyed the epithelium, and thus acted directly on the cellular tissue. But allowing the possibility of this fact, which is rendered probable by the experiments of M. Ricord, we must not give credence to all such statements, or suppose that chancre has appeared six weeks after connexion; for we find, on interrogating the patient, that through inattention or some other cause, he has not examined whether, during the interval which has elapsed between the last coition and the period at which he first observed the chancre, a sore existed or not; and it will often be found that a chancre, of a supposed week's duration, has in fact existed a month. Wrhat surgeon is not well aware that patients complain of buboes or other symptoms, and deny ever having had primary sores ?—yet, on uncovering the glans, he shows the patient a chancre, of the existence of which the latter was ignorant. 196 CHANCRE. The history, then, like the situation, aspect, fyc, is, alone, insuffi- cient to found a diagnosis on ; but if it is deceitful when the patient is desirous of telling the truth, how often may the surgeon be misled when the patient has reason for concealing his antecedents. In the female it is next to impossible ever to attain the truth. The irritation of the menses, or some other cause, is alleged to explain the ulcer- ations about the genital organs. We have mentioned elsewhere* the case of a female who suffered under ulcerations around the rectum, yet at first strenuously denied that they could possibly be syphilitic; although, at last, she was obliged to admit the fact. We might cite numerous cases to prove that an absolute reliance can not be placed on the history of patients. 4. Various Complications.—It is certain that buboes occurring with sores are prima, facie evidence of their being syphilitic. But we should recollect that any simple irritation in scrofulous habits will give rise to them, and perhaps such buboes are more difficult to treat than any others. Similar observations may be made on other com- plications. In fine, we may state, that these circumstances, when present, can only furnish a rational diagnosis. 5. The Course.—It is very true that chancre frequently has little tendency to heal, but on the contrary, gradually progresses; these are, however, characters not peculiar to chancres. There are various sores, which, in scrofulous and scorbutic constitutions, spread and heal very slowly. On the other hand, some true syphilitic sores heal in twenty-four hours ; but it is no less certain, that although such exist, they are of rare occurrence. When these characters are absent, it by no means follows that the sores are not syphilitic, and it is from the ensemble, and the greater or less probability, that our diagnosis (a rational one) must be formed. The Absolute Diagnosis.—In obscure cases, and when it is abso- lutely necessary to decide upon the nature of a sore, more especially in medico-legal inquiries, evidence such as we have mentioned would be insufficient. There remains, then, inoculation, which, although one of its greatest advocates, I would not unnecessarily employ; it will, however, at once decide upon the nature of a sore. Here, neither ignorance nor deception on the part of the patient, nor want of experience or observation and deduction on the surgeon's part, will interfere with the conclusion. The accu- racy of the test, the certainty of arriving at the truth, and the * Lancet, Nov., 1839, page 354. CHANCRE. 197 reputation of the surgeon, will counterbalance all objections to the operation.* Diagnosis of the Reparative Stage of Chancre.—The surgeon is not only called upon to give an opinion during the ulcerative stage, but he may be consulted at a later period, when the sore is healing, or when induration alone remains ; or lastly, when all traces have * The following cases, taken from a paper I read before the Parisian Medical Society, show the utility of inoculation:— " In the bed of No. 10, in the second ward of the venereal hospital, lies a patient, thirty-two years of age, a shoemaker by trade, of fair complexion. He states that from the age of thirteen till his eighteenth year, he was liable to ulcers on various parts of his body, the cicatrices of which are still visible; from the last-mentioned period he has enjoyed good health. About fifteen months since a bubo appeared, which suppurated and healed in about six weeks. " About five weeks ago the patient observed a chancre on the prepuce, four days after connexion; soon afterward several chancres appeared around the corona glandis, and he consulted M. Ricord as an out patient. During the time he was following the treatment prescribed, a vesicular eruption made its appearance on the inner part of the left leg, which he distinctly remembers having scratched, and from that moment, the sores began, and increased in size. '• Present state—Chancres still exist on the penis, which discharge freely; on the inner part of the left leg there are twelve ulcerations of different sizes, but assuming all the characters of primitive syphilitic sores. Inoculation with the pus of these sores was made, and the characteristic pustule was produced. See plate IV., fig. 3 a. " This, then, instead of being a case of secondary syphilis, which was inoculable, is simply an eczema which was inoculated by the nails of the patient, soiled with the secretion of the primitive sore on the penis. " On the 27th of February, 1838, a man presented himself at the out-patient room, complaining of chancre at the root of the penis, and accidentally, as it were, showed M. Ricord a sore on the frenum of the tongue. The characters of it were sufficient at once to arouse some suspicion as to its nature, and this patient was immediately admitted. Inoculation of the secretion on the sore in the mouth was made, and a characteristic pustule followed. All doubt was now removed, and the avowal of the man additionally proved that this was a primitive syphilitic ulceration. " A boy, fifteen years of age, of puny stature, lymphatic temperament, and not, apparently, arrived at the age of puberty, so slightly were the organs of generation developed, entered the seventh ward, suffering under an ulceration of a suspicious character, in the left groin. He gave the following account of himself:— " Had never had connexion with any females, or frequented their society; about three weeks previously the sore appeared on the groin, but it could not be ascertained if it commenced as a bubo or a sore. "As this sore presented all the character of chancre, except as to its history, inoculation of the secretion was performed, and a well-marked characteristic pustule followed. On these data the boy was interrogated more closely, and M. Ricord then found that he was in the habit of sleeping with a fellow-workman who presented chancres on the penis, which had existed some weeks. Both parties denied any unnatural practices; and whether the virus dropping on the sheets inoculated the scratch previously existing, or whether a scrofulous bubo preceded, which was caught by contact of the contagious principle, it is not here my object to inquire ; but I cite this case, to prove that without inoculation the case would have remained very obscure."-Lancet, 1. C pp. 354, 533. 198 CHANCRE. passed away. In the first and last cases it can be of little conse- quence to ascertain the nature of the affection ; if it should be, particular caution must be used, and a rational diagnosis is still more difficult than in the first stage. Called upon to give an opinion when induration alone remains, the surgeon whose eye and touch are accus- tomed to syphilitic induration, will rarely fail to decide upon the specific and peculiar cartilaginous feel, particularly when seated in loose cellular tissue, as on the prepuce; in other situations it will be very difficult to decide upon it, particularly when placed in the deeper portions of the canal, &c. But we shall return again to this subject. In these last instances we must wait patiently for the results, for, if the induration be specific, secondary symptoms will inevitably appear in a short time, and thus clear up any doubt. Prognosis of Chancre.—In the definition of chancre, we have stated that at its commencement it is a local disease, and that it gives rise, under circumstances we can often appreciate, to symptoms of general infection. We shall, then, in the following pages, con- sider the prognosis under two heads :— I. The prognosis of chancre as a local disease. II. The prognosis considered in reference to the probability of general and constitutional infection or secondary symptoms occurring. I. Prognosis of Chancre as a local disease.—In describing simple or artificial chancre, we have mentioned that in a good constitution it has a regular and constant course ; beginning as a pustule, abscess, or excoriation, it becomes an ulcer; granulations are produced; cicatrization follows, and it heals perfectly, without treatment, in a space of time which varies between three and five weeks; therefore we may unhesitatingly state that the prognosis of simple chancre is favorable. In a practical treatise, however, it is not sufficient to state this ; the surgeon should consider the prognosis under a variety of points of view, for in practice he is daily called upon to decide on the prog- nosis of this or that form of chancre. It is to facilitate this often difficult task that we propose devoting the following pages, founded on the strict observation of a number of cases. What probability is there of a chancre, which is simple at its com- mencement, assuming one of the varieties which we have described?— On this subject the surgeon can only be guided by a knowledge of those circumstances which seem to dispose to their production, viz. : If the patient has been exposed to bad or insufficient nourishment, has resided in an unhealthy situation, or has led a dissipated life, it is CHANCRE. 199 probable that the chancre will assume a diptheritic phagedenic char- acter. If the digestive organs be disordered, or provided irritating substances are, or have been, applied locally, particularly in scrofu- lous subjects, a serpiginous sore will possibly result. Should the chancre occur in young plethoric persons addicted to excesses of any kind, particularly to the use of spiritous liquors, at the same time that they employ much the part affected, we may anticipate the occurrence of the gangrenous phagedenic sore. Lastly, as to the probability of a sore assuming an indurated appearance, we must acknowledge our ignorance, for, although we have witnessed it in persons of lax fibre, or in others of clear com- plexion, still we can give no indications, as hitherto we have been unable, to associate it with any one temperament or constitution. What will be the probable duration of the chancre?—Simple chancre, when left alone, usually heals in a space of time varying from three to five weeks; when properly treated, perfect cicatrization may be obtained in from eight to ten days ; there are, however, circum- stances which have great influence in retarding the cure—among others we may mention the situation; thus a chancre situated on the frsenum, or margin of the prepuce, when a natural phymosis exists, will be prevented from healing by the rupture of the cicatrix when erection occurs. Chancres in the urethra, bathed as they con- stantly are by the urine, or when situated at the margin of the anus, or within it, will be so irritated by the distension of the gut, during the passing of faeces, that cicatrization will be often unusually retarded. Other instances might be given to show that the situation of simple chancre must influence the prognosis. The size of simple chancre must necessarily modify our prognosis, as to its duration ; for a large surface generally requires a longer time to cicatrize than a small one ; yet large ulcerations sometimes heal as quickly as small. The number of chancres might be supposed to influence the prognosis, yet practice teaches the contrary. Patients presenting several chancres are as speedily cured as those who have but one sore : cicatrization going on with equal rapidity in all. The duration of a diptheritic chancre can never be foretold, yet we may be guided, in some respects, by the state of the constitution, for, in proportion as it improves, we observe the sore to present a more favorable aspect. When we are called upon to give an opinion on the probable dura- tion of a Serpiginous Sore, we can not be too guarded ; it is true that, 200 CHANCRE. by rest and proper treatment, many such sores will speedily assume a healthy appearance ; but others resist, and require years to cure, and, when on the point of cicatrizing, again resume all their former virulence. In respect to the gangrenous phagedenic chancre, we may be more confident, as, by judicious treatment, the gangrene may be confined to the parts it has already attacked, and a speedy cicatrization be expected. Lastly, the indurated sore will, if left to nature, remain in statu quo, or, if it cicatrizes, a cartilaginous nodule will remain, unless general and local treatment be employed, and even then it will dis- appear very gradually. What probability is there of any of the affections termed complications occurring ? Did .we enter on this subject, we should only repeat what we stated when treating of the complications ; we therefore refer our readers to that section. In diptheritic chancre, we should remember that haemorrhage is often to be dreaded, as well as fistulae, their situation depending upon the tissues and parts affected. In gangrenous chancre a large and rapid loss of parts is always to be apprehended ; but although deformity results, it is not so great as the state of the sore would lead the surgeon at first to suppose. In respect to complications, the serpiginous and indurated sores present nothing remarkable. What renders the occurrence of successive accidents* probable ? —" Successive accidents," says M. Ricord, in his Treatise on Inoculation, " are a consequence of the extension of the disease [de proche en proche), or a simple extension of the primitive local symptom, as, for instance, the production of new chancres, simple or virulent abscesses, virulent or simple adenitis, &c. Is a bubo likely to follow ? This is a question which the patient suffering from a chancre often asks. Without entering, however, at length, into a discussion of all the causes which occasion the develop- * By successive accidents, we mean such affections as are only a gradual continuation of the same disease, for instance, the production of new chancres, the development of sympathetic buboes or abscesses, from extension of inflammation ; and the occurrence of symptomatic buboes produced by the transport of the syphilitic virus. Whenever, then, the secretion of a chancre is retained in contact with the tissues which secrete it, or comes in contact with such portions of the body as are susceptible of inoculation, we have reason to dread the formation of successive chancres; hence, chancres of the anus, of the prepuce where a natural phymosis exists, or of the four- chette in the female, often produce successive accidents. Besides, whenever a solution of continuity in the neighborhood of a chancre exists, subsequent sores are probable, from contact with the virulent secretion. CHANCRE. 201 ment of buboes, we shall here mention such as refer particularly to chancre. The mere existence of a simple chancre does not neces- sarily cause bubo ; in the female, for instance, bubo is rare. We have never seen artificial chancres on the thigh, of the male or female, followed by them. But if chancres on particular parts are seldom followed by buboes, there are likewise other situations which exercise the greatest influence on their formation : it will be found that in every one hundred men suffering under bubo, at least eighty have presented chancres around the fraenum or inferior part of the glans or prepuce. When bubo occurs in the female, the chancre will be found most probably at or around the meatus. This fact, of the situation of the chancre and occurrence of bubo, may be reasonably explained by the connexion which exists between the part primarily affected and the gland, by means of a lymphatic vessel which carries the virus directly to it. And it also proves that the theory of exclu- sive venous absorption is not tenable : but it seems in accordance with the doctrine of imbibition. In answer to our patient, we must be guided principally by the situation, not the size or the variety of the chancre; but we shall re- turn to this subject under the head of bubo. The fact of the tendency which buboes have to follow chancres situated on the fraenum, further shows the surgeon how cautious he should be in attributing buboes to this or that treatment; in all such calculations, we should take into consideration the position of the sore. We may here add, that bubo rarely follows any of the varieties of chancres, unless they be situated in one of these particular spots.* Does the treatment alter the prognosis ? In the preceding pages this question has been already answered : but to resume. A simple uncomplicated chancre will heal without treatment in about from three to five weeks, when properly treated in eight or ten days—the varieties, by judicious management, in longer or shorter periods, de- pending upon the causes which give rise to them. Is the chancre or sore contagious ? To this the medical man should answer peremptorily, yes or no. By allowing connexion, let the practitioner remember he is an accomplice, be it through ignorance of the consequences, or out of deference to his patient. Let him re- member that a sore which is about to heal, or which has just cicatri- zed, is very liable, under the slightest irritation, to inflame, ulcerate, and present any or all the varieties above described: thus, the patient * See Ricord's edition of Hunter. 202 CHANCRE. may by ignorance or imprudence lose the organ. On the other hand, who will state that a sore which is not perfectly cicatrized is incapa- ble of transmitting the infection ? It should not be forgotten that it is impossible to say how little virus is sufficient to infect an individual; the edge of a sore which is still unhealed may contain the quantum, and such a permission of the surgeon may lead to the greatest afflic- tions in more than one family, and the innocent child may suffer for its parents' credulity, or from the surgeon's ignorance of the laws which regulate the secretion of the virus.* H. Prognosis considered in reference to the probability of general and constitutional infection, or secondary symptoms. It is not our intention here to trespass upon the interesting subject of secondary symptoms, as we shall hereafter treat of them at great length ; but there are some considerations which so directly relate to chancre and its prognosis, that we shall here consider them. If it be an undoubted fact that secondary symptoms are a direct consequence of chancre, it is no less certain that they do not in every case ensue. The following facts, drawn from observation, may per- haps assist the practitioner in giving an opinion on the greater or less probability of their occurrence. 1. Stage of the Sore.—When the chancre has proceeded beyond the vesicular form seen on the third day, we can never guaranty an absolute indemnity from secondary syphilis ; the symptoms may ap- pear during the ulcerative or reparative stages, provided these are retarded by any circumstance. 2. Duration of the Chancre.—As secondary symptoms are the consequence of chancre, it might be reasonably supposed that the longer it lasts, the more subject is the individual to their occurrence. * The importance of the great discretion which it is necessary for the surgeon to show, has been lately impressed upon me by the following case : An old fellow-pupil of mine at St. Bartholomew's hospital, now established in a distant part of the country, treated a young man for some venereal affection and secondary symptoms; when he was nearly well, this patient asked the sanction of my friend to a marriage which he was about to contract. The penis was free from disease, as my friend believed.no sore being apparent, though a few blotches remained on the trunk. On such authority the marriage was solemnized, and in a few months the disease broke out again in both parties, and presented the well-marked coppery blotches. On interrogating my friend, he assured me of the correctness of the statements of both parties, and their honorable conduct; but in the conversation he accidentally alluded to a stricture of a very obsti- nate nature which his patient had previous to marriage. The views of M. Ricord on the existence of chancres in the urethra were unknown to him, and he agreed with me in the possibility of such an occurrence, and no longer admitted that secondary symptoms were transmissible, which opinion this isolated case had induced him to believe, con- trary to his views. CHANCRE. 203 This, absolutely speaking, is true, and is a reason for locally destroy- ing the virus, which is a constant secreting focus ; but the practitioner will be wrong to suppose that secondary symptoms only follow chancres which have existed a long time. Experience proves that they follow a chancre which has healed without treatment, in a few days; and we have witnessed cases of chancres which have existed eighteen months and two years, without producing these consequences. 3. The Number and Size.—The preceding observations apply equally to these circumstances ; it is not on such data as these that we can alone found our appreciation of the prognosis. 4. Situation of Chancres.—Chancres on any part of the body, viz., on the mouth, finger, penis, or anus, &c, will be followed in an equal proportion by secondary symptoms. If, however, secondary importance can only be placed on the stage, duration, size, number, and situation of primary sores in forming an opinion on the probable occurrence of general infection, the same does not hold good in reference to the varieties. Daily experience teaches us that the serpiginous and gangrenous sore is rarely followed by con- stitutional symptoms ; the phagedenic diptheritic occasionally gives rise to them ; the indurated almost always. It is well known that Hunter was so imbued with this opinion, that he denied a sore to be syphilitic, unless it presented an indurated base. M. Ricord lays so much stress upon it, that when a patient enters his wards, presenting an indurated chancre of six weeks' duration, and when no secondary symptoms have yet appeared, he puts him on a " traitement ex- pectant^ and few days pass before the occurrence of the well-known characteristic symptoms of general infection. M. Ricord never al- lows a patient to leave his hospital when the slightest induration even of the cicatrix exists ; should he, in spite of admonition, quit, he is told that secondary symptoms will result, and the prediction is found to be too true. Let us now inquire how far the complications can assist our prog- nosis in reference to the occurrence of secondary symptoms. We may erase from the list, gonorrhoea, paraphymosis, and phymosis, as they can have little direct influence in disposing to constitutional syphilis. The circumstance of the existence of bubo demands a separate consideration. A-priori reasoning would lead to the supposition, that when a bubo co-exists, there would be a greater probability of constitutional syphilis following, than when chancre alone appears. Experience on a large scale, however, contradicts such an opinion; 204 CHANCRE. bubo, as we shall hereafter find, is but an internal chancre, and by no means proves that the virus has entered the system ; and we do not find that absorption takes place more rapidly from this chancre in the gland than from an open chancre. This circumstance, more- over, seems to prove that the venous system plays an important part in occasioning the general infection. Lastly, we shall speak of the local treatment of chancre, in as far as it may lead to the probability of the occurrence of secondary symptoms. In the first place, let us again repeat that secondary symptoms will follow when no treatment is employed; they may (though in a far less proportion) succeed the most judicious local treatment. On the other hand, secondary symptoms may not occur, although the chancre be allowed to proceed without treatment. Secondary symptoms do not necessarily follow, although the local treatment of the chancre has been injudicious. In respect to general treatment, the same observations hold good. Secondary symptoms do not necessarily follow when general treat- ment has been neglected. The best and longest-continued plan of general treatment will not, in all cases, insure your patient against their occurrence. These facts at once show the absurdity of some persons' reasoning, who attribute to the effect of treatment what in fact is only the natural course of the disease ; it is from want of acquaintance with the natural history of the complaint, that unjust blame or injudicious encomiums are heaped upon so many therapeutic agents. Preventive Treatment.—The legislature of France, finding venereal affections very common and very severe, in 1498 and the following years, proposed means of checking them, by confining those that were diseased in a species of prison or hospital in the faubourg St. Germain and at Bicetre, flogging them very severely before and after incarceration. We find, however that these coercive measures were soon relaxed, and the law became a dead letter, inasmuch as its execution was, generally speaking, impossible ; secondly, the per- sons affected with the disease were too highly connected, and the disease, notwithstanding the punishment, had increased, and become aggravated to such an extent, owing to the concealment of the primary symptoms, and the impossibility of receiving so many patients, that it was ultimately given up; and who that calmly con- siders the subject can be surprised, or would propose such a.punish- ment, or cause the infraction of the liberty of the subject at the CHANCRE. 205 present day ? Our modern legislators have, I think, fallen into the opposite error. They imagine that the odium tacitly attached to the disease by society, will suffice to deter persons from exposing themselves to contagion, and that government ought not to interfere, or take any steps to check it, as it would be encouraging vice, appa- rently forgetting that neither religion, nor the laws, nor a knowledge of the consequences, will deter men from exposing themselves to syphilis. Is the medical man to remain a silent spectator of the ravages of the disease, as some sensible but short-sighted individuals are inclined to wish him to do, because any success which attends the precautions he recommends will tend to act as a premium upon dissipation ? Were it proved that this apathy of the surgeon was attended with a moral effect on the community, the question might bear a different complexion ; but daily experience and the history of the past prove the contrary. Let no one accuse the medical practitioner of immorality, if, in the discharge of the duties of his profession, he can suggest any preven- tive means against a disease which is frightful in itself and in its consequences ; for the surgeon well knows that immunity from dis- ease does not any more lead a libertine to continue his dissipated habits, than do successive syphilitic diseases check those propen- sities. On the other hand, a first fault may, by the non-observance of those precautions, render a whole family miserable, and entail disease which it may be impossible to cure. Guided by these principles, which we trust will not be misinter- preted, we shall now consider if there be any means of prevention of chancre. Is it possible to prevent the occurrence of chancre ? If chancres do not arise spontaneously, and we trust we have convinced our readers that at least at the present day they do not, then we think we are justified in stating that we can protect an individual from them ; but if it be possible, what means can we recommend for this purpose 1 In other words, what is the prophylactic treatment of chancre ? Syphilis at the present day is widely diffused; although it no longer presents the dreadful appearance that it did in the last centu- ries, still it exists, and is liable again to break out with redoubled violence, if the circumstances which favor its development occur. It becomes, then, the legislature to put a check to it as far as it lies in its power ; and we are of those who think it possible that it might be effectually destroyed, although we feel convinced that this will not k 206 CHANCRE. occur, as the disease must be better and more generally understood before such a universal extinction can take place. The French, more than any nation, are advancing in the way which is most likely to eradicate it. Who has not read the work of Parent Duchatelet 1* Who is not aware that this distinguished phy- sician and philanthropist has, during a long life, done more perhaps than any other individual to check syphilis ? He has given us the natural history of prostitutes ; he has pointed out the means of legis- lating for these unhappy creatures, who form, in fact, the focus of chancre ; and until means be taken in other countries to subject this class to some sort of control, it will be in vain for us to hope for a diminution of the evil; not that we pretend to say that even in France all has been done which might or should be attempted, although we do not mean here to criticise French treatment. Did other countries follow in their steps, Europe would have cause to rejoice. As general prophylactic means, the institution of hospitals and dispensaries for the gratuitous treatment of these complaints, is of the highest importance ; and M. Ricord thinks it would not be use- less to make the following preservative means known wherever a man exposes himself to contagion ; he has likewise suggested that a capable person be attached to each brothel, so that both males and females who expose themselves might be examined. This measure, by no means impracticable, would tend greatly to diminish the fre- quency of the disease. These are a few of the general prophylactic means which would tend to the object a community has in view. We shall not stop here to examine the feasibility or legality of them, as these subjects have so fully been discussed by Parent Duchatelet, but proceed to speak of the Direct Prophylactic Treatment of Individuals.—The surgeon may be consulted under two circumstances: 1st, by a female or prostitute who runs the risk of communicating the disease. In this case an examination of the external organs is not alone sufficient; the employment of the speculum is of the greatest aid in discovering the existence of internal disease. The practitioner should likewise recommend frequent ablution, as, without producing the disease, the virus may be contained in the vagina, but not act in consequence of a layer of mucus; hence the recommendation of the use of injections after connexion. " If women," says M. Ricord, " were only more attentive to cleanliness, * See his book, " Prostitution in Paris," translated from the French—Otis, Broaders, St Co., publishers, Boston. CHANCRE. 207 and took more care of themselves, venereal complaints would be less common." If consulted in the case of a person who is afraid of transmitting the disease, or when connexion is dangerous on account of a sup- posed infection, the chlorine washes, soaps, and the other means of more effectually cleansing, disinfecting, or chymically acting upon the morbid secretions, ought to be employed; the more the parts are rendered clean, the less we have to dread infection. The preceding observations relate particularly to those women of the town who are constantly exposing themselves to the virus. 2d. The surgeon may be consulted by a person who wishes to know what precautions he should take if he exposes himself to con- tagion. From the previous description of the accessory conditions of the tissues which are necessary to the action of the virus, the reader may at once infer the necessary general prophylactic means; however, there are several points which deserve a separate consider- ation. Thus, frequent washing the parts liable to be exposed to the virus, with astringent substances, will, as it were, tan the parts, and be a powerful means of prevention of the disease. But if this plan be advisable, the use of alkaline or chlorine washes immediately previous to. connexion is very prejudicial, as removing any mucus or smegma which might serve as a defence against actual contact of the virus; a person should carefully examine and guard against any abrasion, and, if any such exist, connexion should not take place. The observance of the few preceding recommendations would pre- vent, we are sure, a multitude of diseases. " There is," says M. Ricord, " a means, which the final cause of all sexual intercourse rejects, which morality has always blamed, but which necessity and certain circumstances may occasionally tolerate —I mean the condom." The condom, which permits only mediate sexual intercourse, is frequently, as Astruc has so well remarked, only an illusive guarantee ; it is sometimes torn ; in other cases, the substance of which it is made is pervious; or, again, in consequence of having been previously used and not properly washed, it may be contaminated; lastly, though it be made of good materials, and remain perfect, it only pro- tects those parts which it directly covers ; the root of the penis, the angle of the scrotum, as well as the groin, remain exposed. In con- clusion, the condom, even under the most favorable circumstances, can only guarantee an individual from contracting a gonorrhoea. Coition should not be prolonged, and ejaculation should take place, 208 CHANCRE. as this will frequently prevent the occurrence of urethral chancre, the sperm acting as a cleanser of the canal. Some persons believe that infection is more likely to occur after ejaculation ; this we see no reason at all for believing. After coition, the greatest care should be taken in washing the exposed parts ; for this purpose, alkaline and weak chlorine solutions are preferable, as they have the property of cleansing and decompo- sing any contagious matter, without producing local irritation. Any abrasion or lesion of continuity should be immediately cauterized; and it is useless to hesitate or attempt a diagnosis between the con- sequences of friction and that of the virus : it is better to cauterize unnecessarily than to exposethe patient to the chances of infection. Curative Treatment.—In spite of these precautionary measures, or in consequence of no attention being paid to them, a chancre may become developed in a follicle, an ulceration or abrasion of the sur- face may appear, or an abscess or pustule follow. 1. When a pustule is formed, or when a mucous or sebaceous follicle is observed through the skin, filled with pus, as may be well seen in Plate IV., fig. 2, it should be opened, and a stick of nitrate of silver, cut to a fine point, introduced and passed around the little ulcerated base and sides ; we prefer this to the plan of excision with scissors, which may be employed when the pustule is seated on the prepuce ; but as patients do not like a surgeon to employ instruments, and as we have more reliance on the nitrate of silver than on ex- cision, we recommend its general adoption. 2. In cases of abrasions or ulcerations, the stick of nitrate of silver should be passed slightly over the surface, our object being to destroy only the surface. From ignorance of the reasons of employ- ing the caustic, we have seen the local irritation increased, and con- siderable escars form from the profuse employment of this substance, a plan that can not be too much condemned. In the first instances, it is very often unnecessary to reapply the caustic ; usually, however, the parts should be cauterized as often as the eschars fall off, and the ulcerated surface does not put on a healthy, granulating appearance ; when this commences, the granula- ting portions of the sore should be left to themselves ; but whenever the surgeon suspects that the sore, or any part of it, secretes the virus, he should continue the application of the nitrate of silver. It is, however, not only necessary to destroy the virus which is secreted, as well as the parts which give origin to it, but the practitioner should endeavor to check as much as possible its CHANCRE. 209 secretion ; this is best done by employing the aromatic wine,* which experience shows to have that property, as well as the no less advantageous one of hardening the surrounding tissues, thus preventing them becoming inoculated, and increasing the size of the sore. Let the patient wash the sore four or five times during the day with this wine ; a small piece of lint soaked in it may be laid upon the sore, and the whole may be covered with a piece of oiled silk ; thus the lint is kept constantly moist; it will be found well to wet again the parts before removing the lint, as it might become ad- herent, and cause the sore to bleed if detached with any violence. The patient must keep quiet, but it is by no means necessary to maintain the horizontal posture, or be confined to his bed; his diet should be light, but nutritious. When perfect cicatrization has been obtained, and no local disease remains, the patient may be allowed to resume.his usual occupations, and sexual intercourse may be permitted. Under this treatment, simple, uncomplicated chancre will be cured in a very short space of time, and may be considered as a purely local disease, requiring no general treatment, and followed by no secondary symptoms. Let us, however, now turn the attention of our readers to the treatment of the varieties of chancre above spoken of under the term of anatomical characters. 1st. Treatment of Phagedenic Diptheritic Chancre.—As this variety of chancre depends upon certain peculiarities of constitution, 01 general causes, such as bad living, low unwholesome situations, and frequently a disordered state of the digestive organs, the first duty of the surgeon should be to remove them, and he will place the patient in the best condition for recovery. A good nutritious diet, and change from the close confined air of a damp house, to the well-ventilated ward of an hospital, have been often sufficient to change the aspect of very unhealthy sores. We have frequently seen a warm bed and a stimulating purgative, or an astringent wash, cause, in a few days, the most aggravated forms of the complaint to take on an improved appearance ; sores which were locally irritated by stimulating prep- arations have, under the influence of opiates, become quite healthy ; the same sores, previously treated by mercury, have become healthy when that substance has been left off: hence we can lay down no general law; we must attempt to discover the cause of the variety, * This is a preparation of the French pharmacopoeia, composed ot species aromatic* |iv., vinum rubrum lb. ij., alcoolatum vulni rarium |ij. As a less expensive wash I use Decot. ducrc. ^viij. Tinct. Catech. |ss. 14 210 CHANCRE. and remove it if possible ; this being done, the greatest benefit may be derived from employing lint dipped in a concentrated aqueous solution of opium, which should be kept constantly applied on the sore, covered by oiled silk ; the sore should not be dressed too often, as it is liable to irritate it: this form of dressing must be continued for some time, and absolute quietude should be enjoined ; the diet should be nutritious, and wine or beer may be allowed if the patient's general health does not counter-indicate them, or if he be in the habit of drinking to excess. The use of opium at bed-time may be attend- ed with the best results, when there is a good deal of local or general irritability. Constipation or diarrhoea should be treated on general principles, and tonics may be given with advantage. The use of ointments of all kinds will be usually found prejudicial, more especially as these sores secrete a great quantity of pus ; and the greasy substances rarely come in contact with the diseased surface. When, under the treatment recommended above, the chancre is getting better, the aromatic wine may be employed, and any superabundant granulations should be cauterized, and the edges of the ulcer, if very thin, or if undermined, may be excised with instruments, or destroyed by caustics ; but it will always be advisable to wait until all inflamma- tion has subsided before this is attempted. The use of local bleed- ing we have not seen followed by good effects, although it might, in some cases, be found beneficial, as well as general depletion: such cases we believe to be rare. 2d. The gangrenous phagedenic sore, the result of acute inflamma- tion which has terminated in gangrene, can seldom be checked at once, occurring as it does in young persons addicted to drinking; here, bleeding, either local or general, is exceedingly prejudicial: in the early stages these means are very useful in checking the prog- ress of the inflammation ; but when the gangrene has commenced, and the parts are struck with death, it is useless to suppose that bleeding will restore vitality, or will check the ravages of the disease. Instead, then, of venesection, let your patient keep his bed, attend t.o the state of the bowels, let his diet be of the mildest kind, and let lint dipped in the aqueous solution of opium be constantly applied to the gangrenous part; cooling drinks may be given, particularly lemonade. The gangrene will, in spite of this treatment, destroy the parts which are most acutely inflamed, but it will not extend further ; consequent- ly, during the few following days, a serous looking ichorous dis- charge of a very offensive smell comes away, mixed with the detritus CHANCRE. 211 of the tissues ; this gradually diminishes in quantity until it subsides altogether, and the surgeon is surprised at seeing but a slight deformi- ty result, comparatively to the severity of the disease; a simple sore follows, which should be treated in the usual manner, and the sur- rounding oedema which occasionally remains may be advantageously combated by compression with strips of adhesive plaster. If, in this or the preceding sores, any fistulous openings follow in consequence of the disease extending any depth, care should be taken that the escape of fluid be favored by position, otherwise, if it stag- nate, it may considerably aggravate the disease ; it will be, there- fore, well to employ a small syringe to cleanse the part. 3d. The Serpiginous Variety of Chancre.—We have already spoken of several indications which should incline the surgeon to prefer this or that local treatment; in this variety, however, we are obliged to admit, that we can give hardly any rules. Having observed every possible treatment employed that the experience of M. Ricord has suggested, we have seen cases continue in statu quo, and, after months have elapsed, get well by the unaided powers of nature. On the contrary, we have seen cases get well under a line of treatment which a month previously aggravated the disease, and yet the sore apparently presented the same characters. Such being the case, the surgeon should be careful how he attributes the cure of this variety to any local or general application; let him not be too sanguine ; we have been witnesses of cases like the following, under the influence of some simple or complicated treatment; a serpiginous chancre is rapidly getting well, when, without any assignable cause, the granula- tions disappear in a few hours ; the cicatrix, which was nearly per- fect, is destroyed; and the sore recovers its original size, or even augments, then returns to its chronic state, and defies all means of treatment, when we are suddenly surprised at the promising aspect it assumes, which, perhaps, is only deceptive. Notwithstanding, it must be allowed that few sores present this character ; usually, if the state of the bowels be attended to, if the diet be changed, if the local treatment be guided by general indications, a cure may often be attained ; thus, cauterization may be attempted, or general stimulants be employed, provided the sore assumes a chronic form; should the serpiginous character seem to depend upon the stimulating local treat- ment, an opposite one may be often tried with advantage. We have lately seen such sores benefited by employing compression with straps of the emplastrum vigo, not in all its stages, but when granulations appear; but if this practice has succeeded in some cases, it has 212 CHANCRE. signally failed in others, particularly when no granulations exist. Among other treatment, the sore has been sprinkled with starch, a layer of tallow has been laid upon it, as it was supposed that the action of the air had an injurious effect upon it; but if successful in some cases, in others it has only aggravated the disease. In hospital practice it is impossible to recommend change of air, but we feel convinced that a better diet, in a warmer climate, to- gether with tonics and sea-bathing, by improving the health gene- rally, would be more advantageous than any local treatment we could prescribe. 4th. The Indurated Variety of Chancre.—Unacquainted with the causes which give rise to indurated chancre, we are unable to prevent its occurrence, or to avoid those circumstances which predispose to, or keep it up: but, as we stated under the head of Prognosis, it is a very unfavorable circumstance, and one which we should attempt to remove as speedily and effectually as possible. In the first place, it predisposes to molecular gangrene, giving rise to the variety of chancre so well drawn in Plate IV., fig. 6, which extends in propor- tion to the quantity of induration. In the second place, it is of very serious consequence, as showing that the system is already, or is about to be, constitutionally affected. Experience has enabled M. Ricord to state, that secondary symptoms will follow indurated chancre in eighty-six out of every hundred cases. We have hitherto spoken of chancre as a local disease, and have not recommended any peculiar general treatment, further than such as was necessary for improving the general health, or treating any peculiar symptom ; we shall now, however, speak of the general treatment, which we shall show to be as advantageous, in this variety > as we think it to be prejudicial in the last. Local Treatment of Simple Indurated Chancre.—If, in spite of cauter- ization and the employment of aromatic wine, a chancre becomes in- durated, the first means should be laid aside ; or if consulted for an indurated chancre, cauterization should not be attempted, as the very fact of the occurrence of the induration shows that the disease is no longer the simple local affection above spoken of. If we even destroy the local disease, we have every probability of a constitutional infec- tion ; cauterization is, therefore, not only useless, but we run the risk of being accused of causing secondary symptoms by our treat- ment. When, however, induration follows the cauterization of a chancre, and did not exist previously, the surgeon should not too hastily sup- CHANCRE. 213 pose that the induration is of the specific nature above spoken of, inasmuch as cauterization will, in some constitutions, give rise to it. An experienced eye or finger will, however, usually distinguish one from the other, and a few days' quietude will prove whether it depend upon syphilis or not, as the real induration as gradually increases as the false one diminishes. (See Case, note p. 188.) If the indurated chancre suppurate freely, it may be washed several times a day with the aromatic wine : this is not unfrequently attended with some pain, which soon, however, passes away ; the sore should then be wiped dry, and a piece of lint, spread with an ointment com- posed of Calomel, gr. xxiv. Pulv. opii, ?j. Adipis suis scrofae ?j. This should be changed twice a day, and the sore may then be washed with the aromatic wine ; care should be taken in removing the dressing, otherwise bleeding is likely to occur from the wound. Under this treatment the chancre will usually heal; but as the in- duration remains, the sore is very liable to break out again on the slightest cause, and assume the phagedenic form we shall presently speak of. At other times perfect cicatrization takes place, but a cartilaginous nodule is left, which remains in statu quo, or, increasing in size, ruptures the cicatrix and gives rise to an unhealthy ulcer, which is not inoculable, but is most intractable. Indurated chancre, then, will heal without any general treatment. The employment of mercury is not absolutely necessary, but, if not had recourse to, we run the risk of a simple indurated chancre as- suming a phagedenic appearance. M. Ricord, at page 234 of his Re- searches [Doane's translation), states, " If, like the physiological school, we date the cure of a chancre from the period at which the ulcer is cicatrized, without regarding the consequences, the cure will appa- rently be more rapid under simple treatment: and in hospitals the patients are less time under treatment. But if, in order to call a patient cured, we wait until all hardness has disappeared, we shall find an enormous difference in favor of a mercurial treatment. " The induration remains in the first case a long time, even up to the period of the appearance of the secondary symptoms, which are of such frequent occurrence. For myself," continues M. Ricord, " while I allow that other remedies, besides mercury, possess curative properties ; yet, as one of the most powerful and the most sure, I have recourse to a mercurial treatment whenever a certain degree of 214 CHANCRE. ' induration accompanies a chancre, prevents its cicatrization, or remains after its superficial healing, and more especially when by its excess it gives rise to phagedena." When it has been decided, then, that mercury snould be used, a no less important question arises, as to the preparation, the dose, the period required for saturating the system, the indications for leaving it off, &c. There is no subject on which so much difference of opinion exists, perhaps, as on this. In the following pages we shall be guided by what we have seen, rather than by what we have read ; but for further information we refer our readers to the treatment of secondary symptoms, where we shall dwell more at length on the action of mercury. In indurated chancre we prefer a preparation which unites the good effects of iodine and mercury, known under the name of proto-ioduret of mercury. M. Ricord usually gives it in combination with henbane, and orders it in one-grain doses, in form of a pill, to be taken every night, five hours after the last meal. The effects are not at first apparent; it does not produce colic, like corro- sive sublimate, nor does it purge like calomel; at the end of a week or ten days he increases the dose, and orders a pill to be taken night and morning. The first visible effect of this remedy is observed on the induration, which diminishes in size and hardness: the surface becomes healthy and covered with granulations, and a cicatrix fol- lows. Provided these favorable results continue, it is not necessary to augment the dose, and the sore usually heals, and all traces of in- duration disappear. The pills should not, however, be immediately left off; let them be gradually discontinued. However, it is always well to continue their use some time after the disappearance of the induration ; no general rule can be laid down, for the surgeon must be guided by the circumstances of each case. We do not recollect having seen a patient salivated in order to cure an indurated chancre, which is one of the greatest recommendations of this preparation. Far from thinking it necessary to produce salivation, we purposely avoid it; and those who are familiar with the practice at the Venereal hospital will agree with us in stating that salivation is of a very rare occurrence ; if it should happen, ushered in as it is by an unpleasant taste in the mouth in the morning, a red and puffy state of the gums, with an increased flow of saliva, a fetid breath, a loaded tongue, disordered bowels, loss of appetite, and general feverish state, the mercury must be immediately left off; quiet and repose ordered, with a light and nutritious diet; and a gargle containing muriatic acid will, usually, soon put a stop to all local and general symptoms ; or CHANCRE. 215 if the state of the gums require it, they may be brushed over with a little muriatic acid, by means of a piece of lint. When all the symptoms of salivation have passed, the use of mercury may be again resorted to. It will at once be seen how different is the treat- ment we recommend to that usually followed. Strongly opposed to the general or indiscriminate use of mercury, we highly approve of it in indurated chancre; but we do not recommend a certain dose, which every person should take, be his complaint cured or aggrava- ted ; neither do we think that the mercury should be continued uVitil the constitution shows signs of becoming affected by soreness of the gums. We, consequently, can not agree with those who believe that salivation should be kept up several weeks ; on the contrary we are guided by the state of the induration and the appearance of the sore, considering them to be the only sure guide : after the experience we have had on this subject, we may say that this is the only criterion by which the surgeon can judge. Such treatment will not only cure the local disease, causing the chancre and induration to disappear gradually, but will likewise, in the great majority of cases, guaranty the patient from secondary symptoms—we say in the generality of cases, for we do not put this treatment forward as an absolute protection, believing that no method, however long continued, will absolutely protect the constitution from secondary symptoms. The mild and rational one we have recom- mended has, however, this decided advantage, that if secondary symptoms follow, they will be of a mild form ; the constitution, not being injured by mercury, will bear it a second time ; but of this we shall again speak, when treating of constitutional syphilis. Excision of the indurated chancre has been recommended ; but when it is remembered that this is often impossible from the situation of the parts ; that it is usually impracticable to remove the whole, for, if the smallest quantity of the virus be left, the whole wound assumes the character of a large chancre ; when, moreover, it is recollected that it has already ceased to be a local disease, and lastly, that if it were possible to remove the induration, the surgeon would lose one of the best guides for the administration of mercury—we reject the plan as prejudicial and useless. The Treatment of Indurated Phagedenic Chancre.—As the phage- dena in these cases depends upon an excessive induration, the most rational treatment consists in curing the induration which gives rise to it. This is best done by employing the treatment above recom- mended ; not that we think mercury good in phagedenic sores gen- 216 CHANCRE. erally, but only in such as depend upon induration ; here, sublata causa tollitur effectus; it is from not paying sufficient attention to these different species of phagedena that so much difference of opinion has existed on the use of mercury in these affections—we trust we have in some measure reconciled them. It is upon general treatment alone that we must, depend, as the sore is often very irri- table, and there is a good deal of general nervous excitement; the use of the opium solution locally, as well as the internal employment of fnorphia at bedtime, are often very beneficial. These compre- hend the principal means in use for the treatment of indurated chancres, as well as the other varieties; we shall therefore now pass to The Treatment of the Varieties of the. Reparative Stage.—When the chancre remains, as it occasionally does, in a statu quo, any stimulating ointment may be employed ; but, above all things, rest and quietude on a bed or sofa will be of great service ; this alone will be sufficient to attain our object. When an irregular cicatrization occurs, or when the borders of the ulcerations are livid, thin, and bleed on the slightest pressure, great advantage may be derived from destroying them with caustics, or they may be removed with scissors; a considerable haemorrhage results, but the chancre will assume a healthy character ; the cicatrization will commence and proceed from the circumference, and the ulceration completely dis- appear. When cicatrization appears in various detached points, it will be well to touch the sore with nitrate of silver ; when the gran- ulations are large, soft, and bleed on the slightest cause, a superficial cauterization will cause them to take on a healthy action. When the chancre puts on the appearance of the ulcus elevatum, and the gran- ulations are exuberant, and very red, let the parts be fairly cauter- ized, and when this has been repeated once or twice, cicatrization will commence. In these various varieties we have found the greatest success attend compression by means of strips of diachylon, which may be changed every other day, if there be but little suppu- ration ; or applied daily, when the sore discharges freely. Such local treatment, combined with a tonic and nutritious diet, will usually cure these sometimes troublesome cases. Treatment of the Complications of Chancre.—We have hitherto spoken of the treatment of simple chancre, or of its varieties ; we now turn to that of the complications, which may demand a special treatment, not in respect of syphilis, but in consequence of situation, or the co-existence of some other disease, which marks or changes CHANCRE. 217 the primary affection, or induces the surgeon to modify the treatment above spoken of. The existence of chancre of the urethra is now put beyond doubt ; we give an example of it situated at the meatus in the annexed wood- cut; it likewise shows that chancre may occur along the whole course of the canal, which becomes the seat of an irregular ulcera- tion, secreting the virus and extending rapidly. The case is described at page 274 of M. Ricord's work on inoculation. (Chancres iu the Urethra.) The symptoms are the following : During the few days following exposure to contagion, no unusual phenomena occur, but some irri- tation is soon felt at the entrance of the urethra, for it is this point which is usually the seat of the affection, followed by a slight dis- charge of a purulent character, tinged with blood, particularly when the canal is pressed ; the urine in its passage occasions some pain, but this at first is slight; pressure, however, on parts of the canal causes suffering, and induration occasionally is felt, confined to a par- ticular point. On separating the lips of the meatus, a chancre may be perceived, presenting all the characters above given, and the secre- tion of which produces, on inoculation, the characteristic pustule. Should it occur in an irritable, bad constitution, the chancre may increase in size, gain the orifice, or destroy the surrounding cellular tissue, form abscesses, or, at a later period, fistula, giving rise to all the unpleasant consequences which usually result; or the chancre may, by the irritation of the passage of the urine, become phage- denic, gain the deeper parts of the canal, form abscesses in the pros- tate, and even reach the bladder, which may be destroyed. Such a condition of the parts can not occur without acting on the system ; marasmus and a hectic state ensue from the local disease ; infiltra- tion of urine takes place ; haemorrhage occurs from vessels which the gangrene has opened, and the patient sinks. In other cases, and 218 CHANCRE. these, happily, are the most frequent, the secretion diminishes by degrees, and the chancre heals altogether, or leaves an indurated point, which causes a diminution in the calibre of the canal, forming one of the varieties of stricture which is followed in from six to eight weeks by the occurrence of secondary symptoms. Hence gon- orrhoea has been accused of causing constitutional syphilis, whereas, in fact, the patient has never had aught but chancre in the canal, the secretion of which has been mistaken for that of gonorrhoea. The diagnosis of this complication may be founded on the follow- ing considerations. The chancre in the urethra may be often detected by the eye ; it usually gives rise to a secretion from the canal on the sixth, eighth, and even twelfth day after connexion ; it has a sanious appearance, and inoculation produces the pustule ; pain is felt at a particular portion of the canal, usually close to the meatus. When induration exists, it is likewise confined to a point, is well defined, and cartilaginous. In gonorrhoea, redness is merely observed at the meatus ; the dis- charge from the canal usually follows exposure to contagion imme- diately ; serous at first, it becomes purulent, but rarely sanguinolent, and when blood is -found in it, it is rather bloody than streaked, as in chancre. Pain, at first confined to a point, extends along the canal; there is scalding and chordee, the induration which may follow is not distinctly limited, but occupies any part of the canal, particularly the deeper portions, and is deficient in the cartilaginous feel so characteristic of chancre. The prognosis is usually favorable, except when the sore assumes a phagedenic form; it is then one of the severest diseases the sur- geon is called upon to treat. The treatment consists in depriving the urine of its irritating prop- erties, by ordering abundance of liquids ; subduing any local irrita- tion by rest and antiphlogistic means ; introducing a pencil of nitrate of silver into the canal to cauterize the sore ; recommending injec- tions of aromatic wine, and the nightly employment of camphor in form of pills, to prevent the occurrence of erections. These will be sufficient to cure the majority of cases. When abscesses form, they should be at once opened, as fistulae are less likely to result, and cauterization be had recourse to immediately; if fistulous openings occur, they may be treated in the manner recommended at page 140. Induration will be best combated by general treatment; but, above all things, let the surgeon be careful how he employs bougies, as they only tend to irritate the canal, and have no effect in removing the CHANCRE. 219 stricture. We believe that such cases have been the cause of odium. being thrown on dilatation by some authors. Chancre situated on the frenum is frequently a complication, as in erection any cicatrix is burst, and it is difficult to cauterize the part; consequently it is better to divide the fraenum, if the chancre has not already done it, and treat the sore in the usual manner. Balanitis is another complication, a disease which is well shown in plate II., fig. 1 ; when it occurs in persons who have a wide pre- puce, enabling the surgeon to uncover the glans easily, and treat at once the chancre and the balanitis, it is of little importance ; but should a chancre occur on the inner portion of the prepuce, and be attended with balanitis, at the same time that a narrow opening pre- vents us from exposing the glans and treating directly the disease, the case assumes quite a different aspect; the secretion of the chancre, thus confined in the species of sac formed by the prepuce, causes inflammation, additional chancres ensue, so that the lining of the prepuce may become an ulcerating, virulent surface; the loose cellular tissue of the prepuce becomes oedematous and inflamed; a phlegmonous or an erysipelatous state succeeds, which often termi- nates in gangrene; a dark spot appears on the prepuce, usually on the upper part; an eschar forms, falls off, and the glans is observed appearing through the ulcerated opening ; a fetid discharge oozes out, composed of the detritus of the gangrenous tissues. In some cases destruction of the prepuce only occurs; in others the glans partici- pates, and a great portion may be destroyed ; the vessels of the sur- rounding parts are exposed, ruptured, and haemorrhage follows, which it is often difficult to check. Such are some of the consequences of this complication, the treatment of which we have already described under the head of balanitis. When there is a natural phymosis, and the surgeon is consulted at a late period, swelling, redness, and oedema having occurred, the same treatment may be pursued, and the patient usually recovers, but the phymosis remains ; it then becomes a question whether an oper- ation should be performed or not. If the surgeon be consulted at a later period, and gangrene be inevitable, we have seen a director passed between the glans and prepuce, and the parts slit up with a bistoury; considerable haemor- rhage follows, which seems to unload the vessels ; but this does not always check the gangrene, which destroys a greater portion of the prepuce. When a case presents itself, in which the prepuce is already destroyed, and the glans exposed, M. Ricord is in the habit 220 CHANCRE. of applying the opium solution, and letting the disease take its course ; a gangrene usually performs the part of the knife, and a complete circumcision results. He considers that an incision can not be of service, as no part is strictured, and the tissues divided present a puffy, lardaceous character ; he therefore prefers waiting till all inflammatory symptoms have passed away, and then removes by the knife any portions which inconvenience the patient. There is a complication of chancre depending upon its being seated at the opening of a narrow prepuce; here the chancres assume a linear form, like fissures, or chaps, and are very difficult of cure, in consequence of the cicatrix being torn asunder during erec- tion, and from the urine excoriating them ; quietude, cleanliness, and the use of an ointment of calomel and opium, are very beneficial. Having cured the local disease, the next question is to treat the phy- mosis, provided it be permanent. (Circumcision, as performed by M. Ricord.) If the patient will submit to an operation, the following mode, as delineated in the annexed woodcut, in our opinion, is the best one. Without employing any traction, we trace in ink a line on the pre- puce, which follows the circumference of the base of the glans, and is a little in front of it. This being done, the prepuce should be drawn forward and fixed between the blades of the forceps placed in front of the glans, and behind the line of ink traced on the prepuce ; let the forceps be then held in this position by an assistant. Let that portion of the prepuce which is in front of the forceps be now drawn forward by the left hand of the surgeon, while, at the same time, he with the right divides it in the oblique direction of the for- CHANCRE. 221 ceps, which thus protects the glans. In this operation the skin alone is removed ; the mucous membrane is not drawn forward with the prepuce and remains intact; if we do not wish to see a phymosis recur, this portion of mucous membrane must be removed. To effect this, M. Ricord employs a pair of scissors, slitting up the thin layer of mucous tissue as far as the base of the glans ; the two portions should then be successively held apart by a pair of forceps, and removed by dividing them at the base of the glans, as far as the fraenum, which is divided the last. M. Ricord prefers the employ- ment of torsion in these cases to check the bleeding ; lint dipped in cold water is then applied, and it may be advisable to administer an enema containing opium in the evening, or to prescribe camphor pills to prevent erections. A perfect cure takes place about the twentieth day, and the result is very satisfactory ; there is no deformity, nor have we to dread a consecutive paraphymosis. Paraphymosis is another complication which the surgeon is often called upon to treat. Many patients have an idea that chancres of the glans and pre- puce should be exposed ; hence they keep the glans uncovered for a long time, and employ force in doing so. Should there be much inflammation, an oedematous and swollen state of the prepuce follows, and the patient is incapable of reducing the paraphymosis. When the surgeon is consulted at an early period, applying cold to the penis, and the employment of gentle pressure, are sufficient to reduce the parts to their normal position ; but if, as often happens, there is not only paraphymosis, but ulceration, and the stricture of the glans is considerable, when there is risk of gangrene coming on, or when a paraphymosis has succeeded a natural phymosis, M. Ricord is not in the habit of attempting reduction, which is always attended with great pain, is often impossible, and if effected would only convert a paraphymosis into a phymosis. He passes a narrow-bladed knife underneath the portion of the prepuce which forms the stricture, and slits it up full an inch beyond the glans ; should there remain any bands which keep up the stricture, they should be successively divided, as well as the oedematous fold of mucous membrane in front of the strangulated parts ; cold may then be applied, and the patient will soon recover, but flaps of the prepuce may remain, which it will be well to remove at a later period, as they greatly inconvenience the patient. The surgeon must not be surprised at seeing the incised wound take on a chancrous appearance, which, however, must be treated on the principles of chancre in general. In thefemale,ihe situation of chancre may form a serious complication. 222 BUBO. SECTION II. BUBO. M. Ricord has divided the first stage of syphilis into two parts ; in the former he describes the primary, in the second the successive symptoms. The meaning of the former term has been already dwelt upon; by the latter denomination, or successive symptoms, I mean those which are the extension of primary symptoms by continuity of surface (<2e proche en proche) or a simple extension of the primary local symptom. Under this head I might consider fresh chancres, inflammatory or virulent abscesses and buboes. As the former sub- jects have been already described, it remains for me now to speak of bubo, which I consider as the type'of the successive affections, to the description of which this section will be devoted. Definition of Bubo.—In the following pages we shall imply, by the term bubo, a circumscribed swelling of a lymphatic vessel or gland, with or without suppuration. By the term venereal bubo, we understand a bubo which follows sexual intercourse. Syphilitic bubo is a term applied to those swellings which are the consequence of primary symptoms, or may arise from constitutional disease, generally termed lues venerea. In the present section we shall treat more especially of syphilitic buboes following primary symptoms ; the other forms will be only allu- ded to here, inasmuch as they tend to the illustration and diagnosis of syphilitic ones, and as appropriate sections will be devoted to their further description. Anatomical Characters of Syphilitic. Buboes.—The first appearance BUBO. 223 of the affection is frequently the occurrence of an inflamed lymphatic vessel, commencing at the chancre, and extending itself along the trunk of the vessel, attended with spelling, and presenting to the finger the sensation of a chord ; this is seen in the annexed cut. In other instances, there is no swelling of the lymphatic vessel, but the lymphatic gland, which is connected with the chancre, becomes swollen and red, and increases gradually in size ; at first it is per- fectly moveable, and unconnected with the surrounding tissues ; soon, however, the tumor is found to be attached to the deep-seated parts; at a still later period the skin becomes connected with the tumor, forming, together with the superficial and deep-seated glans, one uni- form swelling. Among the working classes it is at this period that attention is first paid to the affection, from .the pain and inconvenience felt. In consequence of the enlargement of the gland, the circula- tion may be impeded, and a varicoseJ"*ate of the limb result, or oedema may come on, and cause great al»m to the patient. The termination of the disease may hi various ; among the rarest we may mention delitescence; in such case, the swelling and other symptoms abate, the parts take on their acqustomed function, and are restored to their original state. Resolution, again, is one of the tewj^ations ; in this case the tumor becomes moveable on the surrounding parts, and slowly assumes its natural size and form. Suppuration often occurs ; this stage of the affection is announced by shivering, by the sense of fluctuation detectable by the finger, when the pus is seated in a superficial ganglion, although, when it occurs in a deep-seated gland, fluctuation's very difficult, if not impossible to be detected. Many young sjrfgeons may be deceived in the sensation of fluctuation, the elasticity of a swollen gland being liable to be mistaken for fluctuation ;?.on the other hand, when pus is bound down by a hard mass of condensed Cellular tissue, fluctuation is very obscure. In such cases it is useless to attempt to discover its presence by pressing from before backward ; the surgeon should press horizontally, or from without invteird, and by this means a more accurate opinion may be arrived at.~*"Should the abscess be left to itself, the skin covering it becomes'oedematous, discolored, gangre- nous at one point, and the pus escapes by a fistulous opening; the surrounding skin assumes a livid huej^s thin, and detached to a considerable extent, or is perforated with*several fistulous openings. In other cases, the bubo, when formei-does not proceed to suppu- ration, but takes on an indolent character} becomes indurated, and is 224 BUBO. unattended with pain ; it interferes, however, with the functions of the part, and may terminate in scirrhous degeneration, provided there is any predisposition on the part of the individual. Syphilitic buboes may likewise become scrofulous, or be complicated with scorbutic affections, or attended with haemorrhage, hospital gangrene, or present ulcerations in every respect similar to the varieties of chancre which we shall not here stop to describe, for bubo is but a chancre of the lymphatic vessel, or gland, as we have above stated; consequently, its secretion, parietes, &c, resemble those of chancre, and are regulated by the same laws. On the other hand, a syphilitic bubo, commencing as above stated, may enlarge to a certain extent, and then gradually subside, and ulti- mately disappear; or it may suppurate, and like any simple abscess, go through the different phases of suppuration, ulceration, and cica- trization, and present nonAof the characters which we have termed virulent when speaking ofwhancre, from which it differs in its essen- tial feature. \ Causes of Syphilitic Bubo.—In our definition of syphilitic bubo, we stated it to be a consequence of a primary symptom or chancre ; let us now inquire how this cause produces bubo. To do this, how- ever, let us recall to the atfcntion of our readers the anatomical struc- tures which are implicated. M. Cruveilhier found that the lymphatic vessels commence on free surfaces by a sort of excessively fine net-work. Their connexion with each other is seen in the annexed cut. His investigations, confirmed by the experiments of M. Panizza of Pavia, as well as those of M. Fohman, show the distribution of vessels on the sur- faces exposed to chancre. These experiments also prove that the lymphatic vessels, when injected with mercury, proceed onward to the glands, accompanying the superficial veins, anastomosing one with another, but not. incteasing in volume. Having reached the lymphatic glands, the vessels are lost in the substapce of that organ. Each lymphatic vessel is composed of a lining membrane, which BUBO. 225 bears a close analogy to that of the veins, and an outer one which is said to be fibrous, and gives the vessel a great power of resistance. From the experiments of Abernethy on the larger animals, the lymphatic glands are found to be composed of a spongy cellular tis- sue, in which the lymphatics dilate as they enter, and again pass out at the other side of the gland, to assume the same character and size which they had on entering them. Of course it is not here our object to show that these vessels are endowed with absorbing powers ; of this there can be no question; but as to the properties these vessels have of selecting the substances they take up, we must be silent, being completely unenlightened at present on the intimate nature of the function of secretion or absorp- tion ; but it is not a mere hypothesis to state that the absorbents do not, during life, take up indiscriminately a]} substances, and it would seem pretty well established that the lymphatic vessels often absorb the elements of substances rather than the substances themselves, although, under certain circumstances, it seems that they aBsorb sub- stances which at other times they appear to have a repugnance to. It is on such a supposition as this, that modern authors have attempted to explain why pus is often absorbed without any unpleasant consequences, whereas, in other instances, the absorption of a little pus gives rise to such fatal effects. To return, however, to the subject of this chapter—it would seem proved that syphilitic virus, on an ulcerated surface, does not neces- sarily give rise to successive phenomena, for the occurrence of bubo is rare in proportion to the number of chancres the surgeon is called upon to treat; hence, we shall presently consider the circumstances which favor or prevent the occurrence of bubo. When, however, the syphilitic virus gives rise to bubo, the investi- gations of M. Ricord induce us to believe that it may act in one of two ways. 1st. By absorption. 2d. By irritation. In the former case the virus is directly taken up by the lymphatic vessels, and carried along them, and, under some influence with which we are unacquainted, deposited on the sides of the lymphatic vessel, which it destroys ; it then acts on the cellular tissue in the same way as when introduced into a follicle, and produces a chancre, which causes destruction of the tissues, until it appears at the sur- face, or, if unchecked, it may be carried along the whole course of the vessel, until it reaches the gland ; here it becomes developed, 15 226 BUBO. destroying the surrounding parts, and eventually appearing at the surface, as above described. 2d. The syphilitic virus may not be absorbed, but give rise to an irritation and inflammation of a simple kind, as any other irritant may, not acting in a specific manner. This irritation may extend along the whole course of the lymphatic vessel, until it reaches the gland, giving rise to the chord above spoken of; or, by a sympathetic action which the extremities of canals have, the intervening portion of the lymphatic may apparently be free from disease, and the simple irritation of the surface be communicated to the gland, on the same principle that in cases of stone in the bladder no pain is felt along the urethra, but the irritation at the neck is accompanied with severe suffering and irritation at the glans penis. We well know, likewise, that tickling the palate causes vomiting. These various ways in which the syphilitic virus may act, do not rest upon hypothesis. Inoculation of the secretion of bubo has clearly proved that a great many buboes exist which secrete the syphilitic virus ; thus proving that absorption must have taken place, and that it has been brought in contact with the gland. A case illus- trative of this is related in M. Ricord's work, at page 143:— " A patient presented himself, suffering under syphilitic bubo, attended with considerable suppuration. I opened the abscess, but after the pus had been evacuated from the cellular tissue, I found in , the middle of the abscess a lymphatic ganglion of considerable volume, and presenting the feeling of fluctuation in the centre. I punctured it, and inoculated the patient with the pus which it con- tained, at the same time that I inoculated likewise with the pus taken from the surrounding parts. While the pus taken from the ganglion produced a characteristic pustule, that from the cellular tissue remained without any effect. I made, in consequence of this case, a series of experiments which no longer left any doubt on the results of inoculation." Predisposing Causes of Bubo.—If chancre be the cause of syphi- litic bubo, it is a fact admitted by all observers, that it is only the direct or exciting cause ; in order that bubo follow, there must be some predisposing influence, otherwise bubo would be more frequent than it is in proportion to the number of chancres. We therefore propose now to speak of those circumstances which appear to pre- dispose to bubo. Age has an influence in producing bubo. Infancy is comparatively free from their occurrence ; we have not witnessed any cases, but BUBO. 227 M. Ricord has mentioned one in a child of a month old; in spite of this exceptional instance, we may say that the quiet life and light nourishment of children predispose very little to the occurrence of buboes. Old age predisposes but little to buboes, in consequence of less exposure of the subject, and sluggish absorption ; but it is by no means exempt. We have witnessed buboes occurring in old people, and we have at present under our care a female, of a very advanced age, suffering under a severe form of syphilitic bubo. It is at the adult age that the lymphatic system seems most liable to absorption, and as exposure to the chances of contagion are at this period most common, we do not feel surprised that there exists a greater liability to buboes. The sex appears to play an important part in predisposing to bubo. Statistics show that the male is more susceptible of bubo than the female. It might be imagined that this circumstance depends upon the greater fatigue to which the male is exposed, compared to that undergone by the female ; such an opinion, however, is not true, for experience proves that women employed at the public markets, and who carry great burdens, are rarely affected with bubo, and in a far less proportion than in males who, from their social position, do not exert themselves. There would seem to exist some other circum- stance beyond that of occupation, to explain the greater frequency of bubo in the male. Temperament may be considered as a predisposing cause. The lymphatic temperament appears to be more liable to bubo than any other, inasmuch as it predisposes to absorption ; we have not been able to connect the more frequent occurrence of bubo with the other temperaments. The hygienic conditions of the patient, particularly fatigue, irrita- tion of the part, &c, predispose to the occurrence of bubo more than any other circumstances. The situation of chancre in predisposing to bubo must never be lost sight of by the surgeon ; while the artificial chancre on the thigh has never, in the numerous experiments we have witnessed and made, been followed by bubo, chancre situated around the fraenum, meatus of the female, or at the ischium, is seldom unattended by bubo. Whatever be the explanation of the fact, there can be no doubt that in the last-named situation bubo follows very frequently. The size of the chancre does not seem to have the same influ- ence ; we have seen very large chancres existing during a long 228 BUBO. period of time, and yet unattended with bubo ; on the contrary, a small chancre, if situated at the fraenum, is very often followed by bubo. Treatment of primary sores has been repeatedly stated to predis- pose to bubo, many surgeons believing that, by locally treating the chancre, the virus is driven into the system. There is not in surgery a more incorrect opinion than this, and we feel disposed to lay down the contrary principle, namely, that the more speedily and effectually a chancre is destroyed, the less will be the probability of the occur- rence of bubo. It is true that irritation of a chancre predisposes to bubo, but as the nitrate of silver does not irritate, but, on the con- trary, acts as an antiphlogistic agent, its use can not be said to pre- dispose to bubo. However, we do not pretend to state that the use of the caustic will always prevent the occurrence of buboes ; but though it will not, in all cases, succeed in preventing them, it will nevertheless render their occurrence less probable ; and when bubo follows the employment of the caustic, it is usually not virulent, and yields readily under*proper treatment. The idea that when a primary sore is treated by mercury, there is less disposition to the occurrence of bubo, has of late years fallen into disrepute, as it has been found that buboes occur during and after the use of mercury ; and even Hunter states that mercury sometimes occasions bubo. It is our opinion that mercury has no effect either in preventing or predisposing to the complaint. Symptoms of Bubo.—The earliest symptoms usually show them- selves during the second week of the existence of chancre ; we have rarely met with them during the week following contagion. They are often ushered in by shivering, or the first indication of a bubo is afforded by a pain in the part, attended by heat and swelling, increased by motion ; there is occasionally fever, and the affection may take on an acute character, presenting all the local appearances described under the head of anatomical characters; or it may assume a chronic form, and become of a very indolent nature. Diagnosis of Syphilitic Bubo.—Did the limits of the present work permit, we would treat of the diagnosis of bubo from aneurism, ex- ostosis, and the affections which may be confounded with bubo, as well as from hernia, when the tumor is situated in the groin ; but we are obliged to pass over this very interesting inquiry, and to call the attention of our readers to the diagnosis of syphilitic from the other forms of buboes. The opinion of a surgeon may be asked previous to or during the BUBO. 229 suppurative state; we shall, therefore, consider the points on which the diagnosis may be founded in these two stages. 1st. Diagnosis of Syphilitic Bubo, previous to Suppuration.—In such a case the surgeon can only arrive at a rational diagnosis, as it is impossible, before suppuration to give a decided opinion upon a point which, though of great importance, has hitherto puzzled the most celebrated authors. When a bubo appears during the second or third week of chancre, or during the period of cicatrization, particularly if the ulceration be seated at the fraenum, at the meatus urinarius, or on the ischium in the female—if it be confined to a superficial gland—if, moreover, it rapidly goes on to suppurate—the surgeon will be usually correct in calling it syphilitic, particularly if all these characters are present in one individual. The diagnosis is not always easy ; there are many conflicting opinions, so that it is difficult to decide upon the true nature of the case. Some have advanced that your diagnosis should be based on the antecedent history of the case, so that when a patient has exposed himself by sexual intercourse with a prostitute, and a bubo follows, it must necessarily be syphilitic ; in this opinion we can not agree, for, as we stated in speaking of chancre, every ulceration which follows promiscuous intercourse is not necessarily syphilitic, for the same reason every bubo is not syphilitic ; although, then, we may rationally consider a bubo syphilitic which follows a sore contracted in promiscuous intercourse, we should not so stigmatize every bubo which follows connexion, unaccompanied by chancre. This brings us to the consideration of a point of great importance, viz., what is the nature of a bubo following connexion, though not preceded by chancre ? Observation of a great number of such cases leads us to the following conclusion—that impure connexion may produce inflammation of the glans or prepuce, causing gonorrhoea praeputialis, excoriations, or gonorrhoea, and will subsequently pro- duce venereal non-syphilitic buboes, which, consequently, may be readily distinguished from the virulent forms. There are, however, cases in which it is sometimes difficult to distinguish syphilitic buboes from what the French call bubon dbemblee. Patients present themselves suffering under bubo, yet denying they have had chancres, or any affection of the genital organs, this is what is called dbemblee. Now, in the majority of such cases on carefully examining the vagina, neck of the uterus, rectum, glans, or urethra, a chancre, or traces of it, will be observed, clearly 230 BUBO. proving that the bubo is a syphilitic one ; but if this happen in the majority of instances, it is no less certain that there are cases which seem to merit the term d'emblee; thus buboes occur in persons who have neither object nor wish to deceive, without our being able to trace them to chancre, or any local affection. Are we justified in calling them d'emblee ? We think not, as the following case proves : M. Ricord inoculated from a superficial chancre, and on the following morning the characteristic pustule was evident, but the chancre from which the pus was taken he found completely cured ; now had a bubo followed, it would have been called d'emblee, as no traces of existing disease would have been found ; yet we see how incorrect this conclusion would have been. The few remaining cases of bubo d'emblee, may, we think, justly be attributed to scrofulous enlarge- ments of lymphatic glands, produced by any local excitement, as connexion, &c. That this is the case, is further rendered probable by the constitution of the individuals, by the indolent character of the swelling, and by its rarely suppurating ; further, by several glands being the seat of the disease, and by their never having fur- nished inoculable pus, although the experiment of inoculation has been often repeated. It is on a consideration of the circumstance relative to each case that the diagnosis must be founded ; but if the preceding observations are borne in mind, the surgeon will not often fall into error. Diagnosis of Syphilitic Bubo in the Stage of Suppuration.—We have stated that an open bubo is in every respect analogous to chancre ; hence, it would be useless to repeat what we said upon the diagnosis of chancre, and we refer our readers to that chapter. It is only when a syphilitic bubo suppurates that we can decide if the bubo has been produced by the absorption of the" virus, or by irritation. Prognosis of Syphilitic Bubo.—Many surgeons believe that the mere existence of bubo is a very unfavorable occurrence, as show- ing that the disease had made great inroads on the system ; but our readers will at once observe, that the prognosis of bubo may depend upon a variety of circumstances ; the mere existence will not throw any light on the prognosis ; and our opinion must be founded on other data. To this subject we demand the especial attention of our readers. In forming a prognosis, we must first decide whether a sore exists which may have caused the bubo ; if so, we should ascertain if it be a chancre ; on the other hand, if the patient has suffered or is suffering under gonorrhoea, or any simple non-virulent affection, then BUBO. 231 the prognosis will be always favorable ; but if we have reason to believe that the bubo is a syphilitic and not a sympathetic one, the next question to decide is, if it be a virulent bubo, or merely a con- sequence of irritation ; until this has been decided, it is impossible to form a prognosis. The prognosis of bubo, however, is favorable, inasmuch as it is found by statistics, that in every hundred cases twenty only are syphilitic, and that only a portion of these will suppurate. The prognosis of bubo, preceded by or accompanied with chancre, is, generally speaking, unfavorable, inasmuch as it is probable that the bubo is a virulent one ; but let it not be supposed that other bu- boes are not likewise very unfavorable as to their prognosis, particu- larly scrofulous ones, which are extremely indolent. A bubo, how- ever, which is a consequence of gonorrhoea or simple wound, usually soon disappears. The surgeon will therefore see how necessary it is, on the subject of prognosis, to arrive at an accurate diagnosis of the disease which has preceded the bubo, as well as of its nature; for he will thus be able, not only to allay the fears of his patient, but save his reputa- tion, by predicting whether a bubo will suppurate or not. The probability of the suppuration of a syphilitic bubo will depend upon the period at which the surgeon is consulted. If at a late pe- riod, when the skin is red and inflamed, and the bubo assumes an acute character, whatever may be the treatment employed, suppura- tion may be expected. In a good constitution, when treatment has been employed early, although a chancre has preceded the bubo, great hopes may be entertained of preventing suppuration. The opinion of the surgeon is often asked upon the probable dura- tion of a bubo. Any opinion that may be given should be very guarded, and must depend upon a mature consideration of the cir- cumstances which have preceded. Thus, every prospect of a speedy cure may be held out by the surgeon, when called in early, when there are no acute local symptoms, in a good constitution ; but when the bubo is suppurating, and you have reason to consider it a virulent sore, or when it occurs in a bad constitution, it is impossible to pre- dict the period of the cure. On this subject, however, we must refer our readers to the prognosis of chancre, as it is rather the latter com- plaint that we have to consider. The termination of bubo in induration depends, in a great measure, on the nature of the primary sore; thus, if it be already cartilagi- nous the bubo will probably become likewise indurated. Should a 232 BUBO. bubo occur in a lymphatic individual, our prognosis will be always very unfavorable, more especially if the bubo is indolent, for we have always equally to dread the consequences of a very acute or chronic bubo. With reference to the probability of the occurrence of secondary symptoms after bubo, we must repeat, that as the tumor is only syphilitic twenty times in every hundred cases, secondary symptoms could follow bubo only in the same proportion ; experience proves, moreover, that secondary symptoms do not even occur in that pro- portion, thus showing what is well known with respect to primary sores, viz., that every chancre is not followed by them. Observation on a large number of cases has likewise shown that virulent bubo, unattended with induration, is not followed more frequently by sec- ondary symptoms than is simple chancre ; a virulent bubo, however, attended with induration, like indurated chancre, is almost invariably followed by secondary symptoms ; consequently, in the prognosis the surgeon must be guided by the same principles that were laid down under the head of indurated chancre; constitutional infection being observed as frequently in cases of external as of internal chancres. Treatment of Syphilitic Bubo.—The prophylactic treatment, or the means of preventing the occurrence of bubo, merits our first atten- tion. This is best accomplished by considering the causes, both direct and indirect, which lead to bubo. As speedy a cure as possi- ble of the primary sore is of the utmost importance ; for although, as we stated above, bubo does not always occur, although a primary sore may exist several months, nor after the existence of large sores, still, as bubo is a direct consequence of chancre, it should be our object to cure the latter as soon as possible, as no individual can be guarantied from bubo as long as a chancre exists ; and our readers, we hope, are convinced that the speedily curing chancre by local means does not render the occurrence of bubo more imminent. But the surgeon must not depend alone upon a speedy cure of the primary sore; he should consider and choose that treatment which is least likely to irritate it, and this is undoubtedly the use of the caustic in cases of simple chancre. To persons unacquainted with the action of nitrate of silver, it might seem paradoxical to state that its action is antiphlogistic, but we have already, we hope, proved that this is its true mode of action. On the contrary, we should avoid all stimulating applications, or lay them aside if they have been used; absolute repose should be recommended, or if the patient's occupa- tions do not permit this, we must enjoin him to use as little exercise BUBO. 233 as possible, recommend a suspensory bandage if the sore be on the penis, and use the other means recommended against the occurrence of the complications of chancre. If, in spite of these precautionary measures, or if the surgeon be called to treat a bubo at its com- mencement, it is indifferent at this stage, as far as the treatment is concerned, to diagnose accurately the nature of the bubo; cold water, ice, repose on a sofa or bed, with slight clothing, are among the most potent means for bringing about delitescence of the swelling which has lately commenced; cold applications, however, should not be persisted in, provided they cause pain, or when, as in some few cases, they tend to augment the swelling. Under these circum- stances, or if an individual will not submit to any restraint, the best means of treatment is the employment of compression, either by means of graduated compresses of linen, fixed in their proper posi- tion by the figure-of-8 bandage, or a bandage or truss of an oval shape, which was invented by a pupil of M. Ricord's, and which he constantly employs with the most signal success. 'russ for compressing Buboes.) It consists, as seen in the woodcut, of a pad of an oval form ; to the inner part of this oval pad is fixed a strap, which passes around the thigh, and then goes through a pulley on the external edge of the pad ; it is then brought back and passed around the loins, and having 234 BUBO. gained the front of the abdomen, and then the groin, is ultimately attached by means of a buckle to the pad, thus enabling the surgeon to employ compression to any extent. The application of the bandage will be readily understood with the aid of the accompanying woodcut. Employed at an early period, and in the way above recommended, compression will be found a very advantageous treatment, and will often occasion the disappearance of these swellings, or effect what the French call their abortion. Abortive Treatment.—The surgeon, however, is often consulted when the bubo has already made considerable progress ; there is red- ness of the skin, considerable heat and swelling, but no inflamma- tion is perceptible ; at this period the usual antiphlogistic means must be employed and vigorously followed up, viz., general bleeding, the use of tartar emetic internally, the local application of leeches, the employment of cold washes or ice, &c. If fomentations be em- ployed, they should be continually changed, and thus warmth and moisture constantly maintained ; in place of poultices of linseed meal, the common arrowroot made from the potato, and prepared as a poultice by the addition of boiling water, is far preferable ; it is not liable to become rancid and thus irritate the skin, it never becomes hard, and has the further advantage of causing continually an oozing of moisture; during the night it is particularly advantageous ; during the day we prefer lint dipped in warm water, and laid on the bubo, taking care to cover it with oiled silk, and to change the lint every hour ; by these means we have obtained the happiest results in speed- ily and effectually relieving all local inflammation. It nevertheless happens that although the acute symptoms are removed, a sub-acute state continues, or the surgeon is called to treat an indolent bubo; in the practice of the venereal hospitals we have met with many such cases, and we have seen the following treatment followed by success : During the daytime, let the swelling be covered with an emplastrum vigo cum mercurio and compression by means of the truss be made, as recommended in the preceding pages; in the evening let the bandage and plaster be removed, and let a drachm of blue ointment be carefully rubbed on the swelling before a fire during a quarter of an hour, and place an arrowroot poultice over it; on the following day the compression and frictions may be repeated, until all swelling has subsided. In case of the failure of these means, recourse must be had to a more vigorous treatment. It is at this stage that we have seen much benefit derived from covering the tumor with a blister, and BUBO. 235 when the epidermis has been thus removed, gently placing the blue ointment on the parts, which may be covered with a poultice ; when the blistered surface has healed, a second and third blister may be applied, and the same dressing repeated. The mercury, in all these cases, is employed rather as a local resolutive application than as a specific remedy, consequently it is our object rather to place the ointment on the tumor than to occasion its absorption from the chancre, and thus make it pass through the affected gland—the point that Hunter seems to have had in view; of course, should salivation ensue, the employment of mercury should be instantly laid aside, and the usual means of treating ptyalism be had recourse to. In all the plans previously recommended, it will, we hope, have become apparent that it is our object to cause the resolution of the tumor by absorption, and prevent suppuration ; experience, however, proves that these much-wished-for ends can not always be attained. When bubo follows a chancre, and when, consequently, we have every reason to suppose that absorption of the virus has taken place, and has been carried into a ganglion, all our endeavors to promote resolution will too frequently fail; still, under such circumstances, it is better to act as if the bubo were caused by irritation, and not de- spair of dissipating the swelling, for we are no longer living in the good old days of humorism, when it was supposed that that surgeon was the best, who by all the means in his power would assist nature in chasing all the peccant humors from the body. For this purpose, in place of dressing a blistered surface with the blue ointment, let a piece of lint dipped in a solution containing twenty grains of corro- sive sublimate to one ounce of water be applied, and kept on the de- nuded skin for two hours, or a shorter time if it cause great suffering to the patient (a circumstance almost constant) ; let a poultice on which some laudanum is poured, be applied and frequently changed ; in consequence of this caustic application an eschar will be formed, and when it falls off, the caustic may be again employed according to circumstances. Under this treatment, indolent buboes will get rap- idly well. When employed in virulent swellings, the pus is often seen oozing through the cauterized part, and on the separation of the eschar the true nature of the virulent bubo is at once seen, forming, in fact, a chancre which is brought into view by the destruction of the walls of the abscess. Blisters, then, and caustics, may be said either to promote absorption, if that be possible, or to hasten the opening of a virulent abscess, before it has had time to undermine the surrounding structures. There is, however, a great objection to 236 BUBO. the use of the blister and the corrosive sublimate ; they cause great pain in their application, and leave considerable cicatrices, which are indelible marks of the disease ; consequently, the surgeon should use them with discrimination, and only in cases where all other means have failed. When a patient presents all the signs of fluctuation in the swel- ling—when the skin is thin, livid, &c.—the methods recommended above are worse than useless, by the loss of time occupied in their employment;. the virus within extends itself on all sides, and, when opened, the abscess will be found very extensive. To avoid these consequences, the surgeon should open the abscess on the very first symptoms of the occurrence of pus ; provided the case be virulent, an opening should be made, for it would be useless to expect absorp- tion. The incision should be made in the direction of the greatest diameter of the -tumor. In the inguino-crural region, it is in the direction of the inguino-crural fold ; in the case of suppuration of the vertical glands of the thigh, it is in the direction of the axis of the limb that the incision should be made. Incisions on these principles do not expose the patient so much to subsequent burrowing or secon- dary abscesses, or cause crucial incisions to become necessary at a later period. If it be an important question to decide on the proper direction of the incision, it becomes a no less one to consider its length ; in small abscesses, a simple puncture is usually sufficient, particularly if there be no reason for supposing that it is not a virulent bubo ; in such cases a large incision is unnecessary, but when there is a large quan- tity of matter, when the skin over the abscess is livid, blue, and thin, when we suspect its virulent nature, and that it has undermined to a considerable extent the surrounding parts, a free incision is absolutely requisite; for in such cases we can not expect that the skin will become attached to the parts below. The same principle holds good, likewise, in cases of fistulous openings which extend on either side ; they should be freely opened, for unless this is done, cicatrization will not take place. It is quite unnecessary to press out the pus; such pressure gives rise to pain, and the use of the tent is only requisite in cases of non-virulent buboes, as in others the virus will inoculate the cut surfaces, and prevent closure of the opening. Treatment of Suppurating Syphilitic Bubo.—When the surgeon is consulted at this period, or when a bubo has been opened, the treat- ment must vary with the circumstances of the case. In the majority of instances, the treatment is similar to that recommended for chancre BUBO. 237 and its complications. Should inflammation, phagedena, or gangrene, be present, the specific nature of the bubo should be lost sight of, and the usual treatment of those affections employed ; this having been effected, we should turn to the treatment of the specific disease ; care should be taken that the virus does not remain in contact with the surfaces which secrete it; this is avoided by the use of baths, washing the part often, and the employment of the aromatic wine ; position may often be useful in allowing the secretions to pass away. Such treatment, combined with cauterization of the abscess, will usually succeed in bringing it to a happy termination, and cicatriza- tion will follow, healthy granulations filling up the cavity of the abscess. This, however, will occasionally be retarded by an indolent state of the bubo, by the skin presenting livid, thin edges, or being under- mined by the disease ; in the latter cases it is useless to expect that granulation will spring up as long as these portions of the skin remain around the abscess ; their removal is therefore indispensable. This may be effected by snipping them off with a strong pair of curved scissors. Patients have often a great objection to the use of instruments, and they may be very reasonably replaced by employ- ing the Vienna paste,* which, by virtue of its caustic properties, not only removes the superfluous portions of skin, but likewise causes the surrounding parts to take on a healthy action. When the edges of the suppurating bubo ulcerate, when it extends daily, or remains stationary, M. Ricord fills the abscess with the powder of cantharides, and orders a blister on the bubo ; the follow- ing morning, if induration exists, the edges of the blistered surfaces are dressed with lint, on which mercurial ointment is spread, and the abscess is washed with aromatic wine; should it be a simple bubo, common dressing or applications of white wash to the blistered sur- face, and the aromatic wine to the abscess, are sufficient. This treatment, with the powder of cantharides, is not so painful as might be imagined ; healthy granulations spring up, and the whole character of the sore is changed, and it will be often necessary to check the exuberance by the nitrate of silver ; in consequence of the extent of the disease, cicatrization will often take place imperfectly or irregularly ; the usual means of lightly passing the caustic over the surfaces will be found advantageous ; when the cicatrix is livid and indurated, it should be destroyed by repeated and partial applica- * The Pate de Vienne is composed of five parts of caustic lime, and six of caustic potash, with sufficient spirit to make a paste. 238 BUBO. tions of the Vienna paste, and a more healthy surface will be the result. Should induration of a specific kind follow a bubo, the general con- stitutional treatment with mercury must be had recourse to, and be guided by the same principles as were laid down in speaking of indu- rated chancre. In scrofulous constitutions, the tonic and general treatment must be had recourse to. Change of air, a nutritious diet, tonic medicines, particularly the various preparations of iron, together with local stim- ulants, should successively or conjointly be had recourse to. Lastly, in chronic indolent swellings of the superficial or deep- seated glands, neither local nor general treatment will suffice to remove the swollen state, or to remedy the various obstructions to the venous and absorbent system. In such cases recourse must be had to the pale de Vienne; a superficial layer is laid on, and when the eschar falls off, another and another may succeed; replace it, until at length the whole mass of enlarged glands has disappeared. This process is often indispensable, although very painful, and is far preferable to excision, as recommended by some authors To maintain poultices or dressing on the bubo, or even to employ compression by means of lint, I can strongly recommend a bandage, invented, I believe, by Messrs. Evans and Perkins, of Mortimer street, London ; its application is well seen in the annexed woodcut. (Inguinal Bandage.) SECO>iDARY SYMPTOMS. 239 CHAPTER II. SECTION I. SECONDARY SYMPTOMS. Definition.—Under this term we comprehend those various morbid phenomena which appear on the skin, mucous membranes, or in the eye and testicle, the consequence of absorption into the circulation of syphilitic virus, giving rise to a constitutional affec- tion which is hereditary, or, in other words, capable of transmission from the mother to the child, but incapable of inoculation. Synonymous Terms.—Secondary symptoms have been variously, designated by different authors. Some writers group under the term syphilis, not only what we now understand as primary, but likewise secondary symptoms, without distinguishing them either from one another, or from other diseases. This is not surprising when the difficulties attending the subject are considered, or when the erroneous notions then entertained upon medicine are weighed. The same observations apply to syphilitic affections, a term which includes indiscriminately everything which resembles the disease we are describing, and one which, as at the present day, has often no very definite meaning. Morbus pustularum, la verole, la grosse verole, are likewise sy- nonymous terms ; more modern writers have spoken of lues, constitu- tional syphilis, accidents secondaires, or constitutionals, as distinguish- ed from the local, primary effects of syphilis. We shall employ the term secondary symptoms, as it enables us at once to classify the various effects which we are about to describe ; and it has the ad- ditional advantage of being generally accepted. We shall, however, attempt to give a more distinct character to the affection we are about to treat of, and avoid that vagueness of expression which has dis- tinguished some writers on this interesting division of syphilis. 240 SECONDARY SYMPTOMS. History of Secondary Symptoms.—If we admit that primary symptoms were described and known to authors long before the dis- covery of America, &c. (as we have elsewhere wished to prove), we might naturally expect that secondary symptoms likewise existed; and from the description in the Bible, as well as in the Arabian, Greek, and Roman authors, little doubt remains that they formed the major part of the diseases of the. skin then so prevalent; we may, however, add that they do not seem to have been attributed or be- lieved to bear any relation to primary symptoms ; or, if known, they were confounded together in an unintelligible manner. It was toward the close of the fifteenth century that we find second- ary symptoms described as depending upon syphilis ; the light at once thrown upon the diseases in question may be accounted for by the existence of predisposing causes, which, as at the present day, are found not only to aggravate, but change altogether the physiog- nomy of the disease. We owe to Fernel, however, in 1556, the first accurate description of secondary symptoms : he first pointed out the relation that second- ary symptoms bore to the primary, and it is this distinction which has so greatly assisted and contributed to an accurate knowledge of the former. In 1784, Hunter, adopting the classification of Fernel, further sub- divided secondary symptoms into sympathetic and virulent. The virulent he again classed under two heads. 1. Those which appear during the early period of the constitutional infection. 2. Those which are observed at a much later period. In the former he placed eruptions on the skin and affections of the mucous membrane ; in the latter, diseases of the periosteum and of the bones. It is, however, M. Ricord who has recently introduced a classifica- tion of constitutional syphilitic affections, which we are confident our readers will consider the most perfect hitherto proposed. Following Fernel, he has separated primary from secondary symptoms, and has shown us how to distinguish them; adopting also the views of Hunter in some points, he has differed from and improved upon that eminent surgeon's classification, and the second division of Hunter he has preferred to place in a separate order, and called them ter- tiary symptoms. The reasons for this deviation from the doctrines of our great master will be given in their proper place. General Observations on Secondary Symptoms.—Previous SECONDARY SYMPTOMS- 241 to describing secondary symptoms, it will be well to devote a few pages to some general considerations. In our definition we have stated them to be the consequence of absorption into the circulation of the syphilitic virus, or to depend upon a poisoning of the animal economy by the virus, which we have described in the first chapter of this part. It might appear that this opinion, now generally received, is capa- ble of demonstration. Such, however, is not the case ; no one, to our knowledge, has ever attempted to inject the virus into the circula- tion. The probable consequences of such an experiment would be so severe that no medical man would undertake it, nor would any one be justified in thus experimenting upon his fellow-creatures ; and as the syphilitic virus has no perceptible effects on animals, we are deprived of two of the most valuable adjuncts in our investigations. Medical men have been content to collect such observations as daily experience furnish, to prove that secondary symptoms are the result of absorption of the virus into the general system. A long-continued observation, and accurate inquiry, in a large hospital, as well as extensive private practice, lead M. Ricord to state that a case of secondary symptoms, d'emblee, never occurs. The excep- tional cases depend upon hereditary infection, or from inattention on the part of the patient to his antecedent history, or to his ignorance of what chancres are, &c. In every case in which he has been con- sulted, chancre either existed, or some traces of it could be seen ; in fact, the exceptional instances may be reasonably accounted for, as in the bubon d'emblee. This is now so generally admitted, that we shall not stop to prove it further, but take it for granted that secondary symptoms are always preceded by a chancre situated in some part of the body. It is no less true, however, that every chancre is not fol- lowed by secondary symptoms ; were this not happily the case, they would be still infinitely more common than they are. Predisposing Causes of Secondary Symptoms generally.—Observa- tion of many thousands of cases shows that these consist in circum- stances not immediately connected with the individual, or apparently dependent on his constitution. It can not have escaped the observation of those of my readers who have seen much of syphilis, that the temperature of the air has a con- siderable influence on the production of secondary symptoms. Rapid changes from heat to cold, as witnessed in persons leaving the warm wards of hospitals for their own damp cold dwellings, place this be- yond doubt. Travellers state that the passing from, cold to warm,. 242 SECONDARY SYMPTOMS. and from warm to cold climates, produces a great disposition to the same effect. Clothing, particularly such as is slight and insufficient to maintain an equable temperature, has been accused, with reason, of predispo- sing to secondary symptoms. The use of spirituous liquors, highly savored or insufficient food, excitement of all kinds, moral or physical, are some of the most fre- quent predisposing causes. Amono- the circumstances appertaining to the individual, we may first speak of age. It rarely happens that a child is born of a mother suffering under secondary symptoms, without becoming affected at birth, or soon after, particularly if exposed to cold. When the pe- riod of infancy has passed, as the child is seldom exposed to conta- gion, the occurrence of secondary symptoms is very rare. From similar circumstances, and the torpid state of the lymphatic system, they are rarely met with at an advanced period of life. Sex.—It is hardly necessary to say that men are more liable than wo- men, in consequence of the former exposing themselves to the chances of contagion more frequently ; but we think the statement is no less true, that if the same risks were run by the two sexes, the female is less predisposed than the male. This assertion is supported by the cases we have observed in the Parisian institutions. In the male hospital, cases of secondary syphilis are very common; in the hos- pital of l'Oursine (the female one), during our duties there, out of four hundred in-patients, we observed few cases of secondary affec- tions. The same remark we made in visiting the foul wards at St. Lazare, devoted to the treatment of the prostitutes of Paris. The reason, we think, is the following : the female, though frequently the subject of chancre, is yet, from her sedentary and quiet life, less ex- posed than the male to the causes mentioned above. We are further borne out by the fact, that common prostitutes are much more fre- quently attacked with secondary symptoms, than that large class of unfortunate females, consisting of poor married women, to be found at l'Oursine. Temperament.—Its influence, as a predisposing cause, is very evi- dent, and some authors state that the lymphatic is the one which most particularly disposes to them. That this is often the case is true, but those who have attended to the subject must be aware, that the same individual, in the course of the year, may contract chancres ; the first will pass away, the second may be often attended with sec- ondary symptoms, or vice versa. Again, how often do we see the SECONDARY SYMPTOMS. 243 strongest men attacked, and the feeblest escape; it must, however, be allowed that a great portion of secondary symptons occurs in per- sons who have been reduced by illness, or some other cause. Sur- geons who are called upon to treat secondary symptoms can not but have remarked the number of their patients presenting that clear complexion which has been attributed to scrofulous subjects. I do not, however, assert that secondary symptoms are confined to such individuals ; but on being consulted for primary sores by patients with dark hair, clear brown complexions, or that beautiful transpa- rency of skin, I have too often predicted the occurrence of indura- tion, and the subsequent train of secondary affections. The reader will not forget, that in speaking of the various anatom- ical characters of chancre, and of their prognosis, we stated that the simple chancre, as well as the gangrenous and phagadenic ones, were rarely followed by secondary syphilis ; on the contrary, that the indurated chancre would be attended by it in ninety-nine cases out of one hundred. We stated, however, that the virus being always the. same, the difference in the form of the chancre must depend upon the nature of the constitution. What this may be, we are unable to say; observation alone shows that the constitution or condition of surrounding tissues, or the unknown element which causes indu- ration, is analogous to that which subsequently produces secondary symptoms. The importance of this, as indicating a line of treatment, has been already noticed, and further researches, it is to be hoped, will clear up these doubts. In the absence of anything certain, we will not speak of the conjectures which the subject has given rise to. If secondary syphilis, in consequence of the predisposing causes above referred to, arise from absorption of the virus, by what system of vessels does the process take place ? To this question we think observation may furnish a satisfactory reply. When the virus is taken up by the lymphatic vessels, as we remarked under the head of bubo, it is either carried along the vessel into the first lymphatic gland, or, being checked in its course, it occasions the development of a lym- phatic or glandular bubo. We stated, moreover, that under either of these circumstances, the virus remained unchanged, as is proved by inoculation. What prevents its further progress 1 Why can it not pass beyond the first gland, and what decomposition or change does the virus then undergo ? We are at a loss to decide, unless, as some have advanced, the elements of, and not the virus is absorbed. This view is not improbable, but is a simple hypothesis ; nor shall we in- quire if a bubo be the means of expelling from the system the peccant 244 SECONDARY SYMPTOMS. virus. One thing is certain, that bubo in no way betokens the prob- able occurrence of secondary syphilis. Often have we observed persons afflicted with the largest, most acute, or chronic buboes, without ever after being subject to secondary symptoms. On the other hand, we daily witness secondary syphilis coming on in per- sons who, we are certain, have never had buboes. It is true that the secondary disease often comes on during the existence or after the cure of bubo. In such cases, we think we are far from justified in attributing them to the bubo, as observation on a large scale shows that there is no direct relation between them. If, then, our opinion be correct, that the lymphatic system does not absorb the virus, and carry it into the economy, we necessarily must suppose that absorption is effected by the veins. The experiments of physiological writers have clearly proved these vessels to be endowed with the function of absorption: veins, we believe, have no power of selection (if we may be allowed the expression), as the absorbents have, nor do they tend to alter the qualities of substances, as the lymphatics evidently do. Lastly, the effects produced on the system by the absorption of the virus bear a great analogy to the deleterious effects produced by the injection of poisons into the veins. At the present day the comparison is feeble, but in the fifteenth cen- tury, when that famous epidemic reigned, we learn that livid patches appeared, that the ulcers on the skin were haemorrhagic ; everything in fact bespoke a liquefaction of the blood, such as is occasionally witnessed even at the present day. In the absence of experiments, all must be conjectural as to the quantity, quality, and period neces- sary to produce the contamination of the system above alluded to. The period at which secondary symptoms appear after the occurrence of the primary ones, deserves to arrest our attention. It is impossible to limit exactly this period. The earliest period at which they may occur, is eight days after the appearance of primary sores. M. Ri- cord relates such a case. It happened in a tailor, who, at the end of the week after the occurrence of chancre, had well-marked second- ary symptoms. M. Cullerier has likewise mentioned a similar case. Excepting, however, such instances, which are rarely met with at the present time, although we believe them to have been very com- mon in the fifteenth century, secondary symptoms usually show them- selves about six weeks or two months after the appearance of the primary sore. Of the importance of knowing this fact we have been more than once convinced : patients come into hospital six weeks after the occurrence of an indurated sore; mercury is given, and in SECONDARY SYMPTOMS. 245 a few days a brilliant display of secondary symptoms breaks out, oc- casioned, as some think, by giving mercury. M. Ricord has often shown us the natural course of the disease by abstaining from any treatment, and the well-known secondary affections soon appear. Can this period be delayed ? It can, as we have had ample oppor- tunities of observing. When due precautions are taken, no excesses or exposure to cold submitted to, weeks may pass over, and no second- ary symptoms appear; but, under the influence of predisposing causes, they suddenly break out. The employment of mercury in insufficient or injudicious doses appears to have the same effect; the disease is retarded, and we have seen it appear some months later, and have been unable to attribute it to any other cause. It results from the preceding observations, that the absorption of the syphilitic virus induces a syphilitic temperament, a peculiar state of system which care holds in abeyance ; the germ exists, but some extraneous cause develops it, and must call it into action ; as a fall on the knee, or inflammation of the chest, develops white swellings or phthisis, so does exposure of the surface to cold, or insufficient diet, cause the development of one of the forms of secondary syphilis, which we shall presently describe. The length of time that this syphilitic temperament may exist without giving any evidence of its presence by the occurrence of the disease, we are unable to decide ; but let it not be supposed that we belong to that school who think that secondary symptoms may break out twenty years after the cure of the primary affection; all we can say on this point is, that care and non-exposure to the predisposing causes, or an insufficient mercurial treatment (we shall hereafter state what we mean by this term), may retard the development of seconda- ry syphilis. M. Ricord states that the exact period of this suspen- sion of the disease, or incubation, can not be limited; but he has not met with a case which ever led him to suppose that syphilis can break out after a lapse of years ; and as those who state that this has occurred do not furnish us with their observations, as the chances of self-deception are great, and as no such cases have been personally observed, without absolutely denying the possibility, he is little dis- posed to credit them. In our definition we stated that the term secondary symptoms was employed to designate the morbid phenomena which appear on the skin, mucous membrane, eye, testicle, &c. Let us now direct our readers' attention to each separately. The researches of modern anatomists have proved beyond a doubt, 246 SECONDARY SYMPTOMS ON THE SKIN. that there exists a great analogy between the skin and the mucous membrane. Physiologists have likewise established analogy of function between them, and modern surgeons, in a variety of their rhinoplastic operations, have proved on the human body, what was long known to the comparative anatomist, that skin may be, as it were, transformed into mucous membrane, and mucous membrane assume all the characters of skin. Pathology daily shows that the influence of disease on the skin reacts on the mucous membrane, as in cases of burns ; on the contrary, that irritation of the mucous membrane reacts on the skin, as in eruptions following the use of copaiba, &c. In fevers, particularly in typhus, the co-existence of the rosy eruption, or of petechiae, together with the lesions of the mucous membrane, have not escaped notice ; and in small-pox it is now well known that the pustules may appear on the mucous mem- brane, as well as on the skin. This analogy, then, between the diseases of the skin and mucous membrane is in no case more strong- ly marked than in secondary symptoms ; they may be traced on the penis and on the prepuce, gradually passing one into the other; on the mouth we have often witnessed this transformation, and a good example is to be seen in Plate V., fig. 4. SECTION II. SECONDARY SYMPTOMS ON THE SKIN. The syphilitic affections of the skin are very varied and numerous, yet, by following the classification of our countrymen Willan and Bateman, we trust we shall give such a distinct and succinct de- scription of them, as will enable our readers readily to distinguish this large class of important diseases from those which depend upon other causes. Various as they are, they may all be reduced to one of the follow- ing forms :— Exanthematous affections. Papular affections. Vesicular affections. Pustular affections. Tubercular affections. SECONDARY SYMPTOMS ON THE SKIN. 247 By far the most common and earliest in appearance are— Exanthemata.—During the existence of the primary symptoms, or some few weeks after their disappearance, and generally in con- sequence of exposure to some of the predisposing causes mentioned above, the patient is surprised at observing a larger or smaller por- tion of the body covered with an exanthematous eruption, which sometimes assumes the form of measles ; so general is the affection of the skin, at other times, distinct patches appear, of a more or less circular form. At their commencement these eruptions are of a rosy color ; the surrounding skin is of an unhealthy appearance, of a dusky yellowish hue ; on pressure the spots disappear, but return im- mediately. The whole surface may be covered at once, or successively : this exanthematous eruption may pervade the abdomen, lower extremities, arms, face, and back. It may disappear from one part and shift to another, or reappear again on the same portions of the body in a few days. These spots, however, soon lose their rosy color, and daily become more and more dusky, until they assume a coppery hue, which is always best marked in the most dependent parts of the body ; it seems to arise from something more than simple congestion, as pres- sure does not remove it. These exanthematous eruptions may disappear without any treat- ment, or under the use of various agents, or may pass into the papu- lar form. Papula, like the exanthemata, may appear on the skin without having given rise to any general disturbance of the system: often, however,the general health maybe observed to suffer ; the face may have presented an unhealthy, pale, or earthy appearance ; the eye may have lost its vivacity, and the patient loses flesh : these premoni- tory symptoms are sooner or later followed by an eruption of papuhe, more or less general; they, however, first usually appear on the ab- domen ; at their commencement rosy, they gradually assume the coppery hue. On passing the finger over the affected parts, they will be found to present a certain elevation above the surface of the skin with a sensible hardness, and are grouped in clusters, or dis- seminated irregularly here and there; it is this condition of the papulae which has received the name of lichen. It may exist as a simple disease a long time, or it may disappear, as did the exanthemata, or the points of the papula, will become dry and whitish, the base will shrivel, and, instead of a papula a surface covered with little thin scales is seen, very distinct irom the adjacent 248 SECONDARY SYMPTOMS ON THE SKIN. sound skin ; these scaly surfaces may be quite distinct, or several may coalesce, forming a continuous surface, covered with silvery scales, which are reproduced as soon as they fall away, or are rubbed off. This appearance has given rise to the division squame, but which we believe to be no other than the drying and exfoliation of the epidermis, and reproduction of little silvery scales on the papules (See eruptions in plates VI. and VII.) Those who have specially written on skin diseases, have, as it ap- pears to us, rendered more difficult an acknowledged difficult subject; they have attempted to create distinctions between lepra and. psoria- sis, which, in our opinion, are both terminations of a papular erup- tion. The lichen above described may become dry at its summit, scales may form, fall off, and be reproduced, and this process may gain the base, and extend itself in an irregular manner, constituting what authors call psoriasis. On the other hand, the base of the papula may become scaly, the centre or apex remaining in a natural condition ; the result is, that a circle is formed of these little scales surrounding and surrounded by healthy skin, and as this circle is somewhat prominent, from a slight swelling of the dermis now secre- ting the scales, it has been considered sufficiently characterized to be termed lepra. On the same individual, lichen, psoriasis, and lepra, may be seen ; and we may here observe that the little white border, described by M. Biett as characteristic of the syphilitic affection, is often wanting. This scaly state of the diseased skin is very often exceedingly rebellious, remaining for a long time stationary; the progress of the circles deserves, however, particular attention. As they extend at their circumference, the centre heals ; thus the circle enlarges, until it has reached the size often of a shilling ; the regularity of the circle is often interrupted by the fusion of a second one, and thus two become united, forming a figure of 8, or 3, or 5. When they are about to heal, the scales fall off, and instead of the white scaly sur- face, the circle is only to be distinguished by the difference in the color of the skin, which, after a lapse of time, assumes all its healthy characters. A good idea of this may be derived from plates V. and VII. There is a form of lepra occurring on the palms of the hands and soles of the feet, which deserves particular attention ; portions of the epidermis, of a circular shape, become white, hard, or horny, and fall off, but are soon replaced by others, which successively fall away, causing great inconvenience to patients. This condition of parts is SECONDARY SYMPTOMS ON THE SKIN. 249 often accompanied with crevices, or a chapped state of the interstices, which become irritated by any foreign substances that may be placed in contact with them, and they pour out a secretion which forms crusts upon the surface ; in fact, the palm of the hand becomes so horny, that the patient is in part prevented from making use of it. We have observed this variety particularly in bakers, grocers, masons, i?&a"Z J4 it might be said, that in the secondary symptom, which is kept up by its presence, the virulent cause still exists ; that in the tertiary symp- tom it is completely transformed." The important consideration of this last phrase we can not too strongly impress on our readers j it forms one of the best indications for the treatment which, whatever may be said on the subject of secondary symptoms, ought not and can not be specific here. Ter- tiary symptoms must be treated on general principles; the same means should be employed as if the diseases we are called upon to treat depended upon any other than a specific cause now completely transformed. Our first care should be to remove all inflammation or irritation which can aggravate the local disorder; this point gained, we may next turn our attention to the constitution. The employment of tonics, nutritious diet, proper clothing, &c, will often have the best effects. Among other preparations, we have observed those con- taining the principles of opium to be followed by the best effects in allaying local and constitutional irritation. Mercury, in its various TERTIARY SYMPTOMS. 317 forms, is, generally speaking, as prejudicial at this stage as it was beneficial in secondary symptoms ; and although in those symptoms of transition between the secondary and tertiary, as in deep tubercles of the skin, attended with callous ulcerations, it may still be advan- tageously employed, it is nevertheless true that the further we retire from the early stage of secondary symptoms, the less efficacious it becomes, until it ends in being highly prejudicial; and when used even in the former cases, it should be combined with iodine in the form of proto-ioduret; of the dose, quantity, &c, we shall not here speak. If mercury then be, generally speaking, prejudicial, surgeons have the satisfaction of knowing that modern practitioners have the credit of discovering this, and rating the effect of the mineral at its just value, while their observations have enabled them to replace it by a preparation which daily experience in various parts of the world promises to establish as one of the most efficacious in the Pharma- copoeia—we mean iodide of potassium. Iodide of Potassium.—Those who have, like ourselves, witnessed the effects of this preparation given in all the stages of syphilis, will allow that its good effects seem pretty nearly confined to the cure of tertiary symptoms ; it has been much vaunted, but as we think in- judiciously, in the other forms, although the cases in which it has produced relief are not sufficiently detailed, and in the successful cases the disease had arrived at what we term the tertiary form. We shall, however, in the following pages, state the results that may be expected from it, and the best means of producing them, the more especially as, when employed in the cases now under consideration, it is a treatment new to English practitioners. We prefer giving M. Ricord's description: in speaking of the treatment of tertiary symptoms, he thus expresses himself:— " We may commence by a dose of ten grains taken daily in a mixture, for which I give the following formula :— Distilled water, ?iij. Iodide of Potassium, gr. x. Syrup of Poppies, f j. This mixture should be taken in the course of the day, in three glasses of decoction of sarsaparilla, or some bitter infusion. The doses may then be augmented by ten grains every five days, until the dose of a hundred grains may be taken daily : this dose I have rarely exceeded. ,.,.,/. In addition to the curative effects, the iodide of potassium may 318 TERTIARY SYMPTOMS. have an action on different parts of the economy, which it may be well to mention. The digestive organs usually bear it well; but in some cases the patients complain of pain or an uncomfortable feel at the stomach ; this pain has some analogy with that met with in pleurodynia, but differs from it in being deeper seated. In certain cases the thirst is augmented, although usually the appetite alone becomes increased, and nutrition so much exaggerated that patients grow quite fat. I have seldom had occasion to observe diarrhoea or vomiting. The skin may become the seat of certain eruptions analogous to acne, or ech- thyma, with small pustules. The urinary system may be consider- ably affected, and the quantity of water voided may be considerable. The circulation has not appeared to me particularly affected, at least in the majority of cases. In respect to the nervous system, some patients have experienced what is called iodic intoxication, characterized by a slight uncertainty in the voluntary movements, some subsultus tendinum, heaviness in the head, a species of intellec- tual idleness, and sometimes slight delirium. In all cases, even at the extreme dose to which I carried this remedy, all the symptoms have been very trivial. Their appearance, however, and especially any tendency to become aggravated, has always been an indication for me to stop the dose, whatever that may have been ; in the same way that each time a symptom got better, I have continued at that dose which produced the amelioration, not wishing to increase it until a stationary condition supervened. It seldom happens that the affection we are called upon to combat does not show marks of amelioration during the second week of the administration of the iodide, or sometimes later. The tubercles become absorbed, the ulcerations grow cleaner, suppuration diminishes, the pains in the bones cease; and the osseous tumors, provided they have not reach- ed the indurative state, which resembles ivory, speedily become dis- sipated. Treatment of particular or individual forms of Tertiary Symptoms. —If the above treatment be beneficial in relieving and curino- the diathesis, or state of constitution in which we have found the patient, we must nevertheless not neglect the local treatment; for here, as elsewhere, although the local depends upon and is kept up by the gene- ral diathesis, it in its turn reacts on the general health, and maintains it in an unfavorable state for recovery. Local Treatment of Tumors seated in the Subcutaneous Tissue.— It is unnecessary here again to remind the reader that any inflam- TERTIARY SYMPTOMS. 319 matory symptoms should be combated by antiphlogistic measures adapted to the condition of the patient; when all such have ceased, the tumor, if at its commencement, or even when fluctuation is per- ceptible (provided the skin has not become discolored), should be covered with a blister, and the denuded skin may then be dressed with a solution of iodine ; this acts as a local irritant, and is far pref- erable to the solution of corrosive sublimate, as it may produce beneficial effects both locally and generally. Usually, after the first blister, the tumor will be sensibly diminished ; in such cases let a second or third be made use of, until complete resolution is effected. We have seen no cases resist this method when they have been treated sufficiently early, and when the constitution has been sup- ported by the general means spoken of above, for we repeat this form of the affection principally occurs at a late stage, and in very unfavor- able subjects. When, together with distinct fluctuation, there is dis- coloration of the skin over the tumor, it is useless to attempt this plan of resolution : the pus may be allowed to escape by puncture, and should the hard shell mentioned as surrounding the cyst be present, the cure will be often expedited by its excision. When called upon to treat those cases which assume, at a later period, a fistulous char- acter, and are surrounded with an indurated margin, their local ap- pearance may be benefited by covering the surface with the following application :— Honey . . .12 parts. Proto-ioduret of mercury . 1 part. The same effects will be obtained if the margin of the ulcer be touched with the solution of iodine, which is thus composed :— Tincture of iodine, 3ii. Distilled water, ^viii. The latter preparation is particularly useful in cases where no indura- tion exists ; these chronic ulcerations will slowly cicatrize, and their edges rise to the level of the surrounding skin. This may be often hastened by applications of strips of plaster composed of vigo cum mercuric An alternate treatment with sedatives and stimulants may, likewise, often be employed with advantage. These observations equally apply to those cases of submucous cellular tumors, which admit of this treatment from their position, when placed beneath the mucous membrane of the mouth and pharynx. On the first symptoms of the appearance of suppuration, the cysts should be at once opened, and treated by emollient gargles ; the parts may then be touched with the watery solution of iodine, or a gargle 320 TERTIARY SYMPTOMS. may be employed, which, containing 3i. of iodine to eight ounces of water, and gradually augmented in strength, will speedily bring a healthy action of the affected parts ; but this local treatment alone will not suffice. The general one of the iodide of potassium com- bined with mercury, in proper proportions, when any induration exists around the edges of the ulcerations, must likewise be put in practice, and its success will surpass the most sanguine expectations. Local Treatment of Affections of the Osseous System.—Pains in the Bones should be treated, at first, by repeated applications of a few leeches, followed by poultices; or the parts may be covered with lint dipped in a warm decoction of poppies, or water and laudanum; this treatment, together with a general one compatible with the state of the patient's constitution, will usually suffice, when the pain does not depend upon deep inflammation of the bones. How- ever, there are forms of this affection which resist, and, although we are unable to detect either periostitis or ostitis, yet only cease on employing the treatment adapted to them. The Treatment of Periostitis should consist, at first, in attempting to allay all irritation by leeches and poultices; when the first and third varieties exist, such a practice will often suffice ; in other cases we must have recourse to a treatment which acts like a charm on the disease. Let a blister be applied on the painful portion of the bone ; when it has risen, the serum may be allowed to escape, but the epidermis need not be removed, as the pain will be less ; lint spread with the ceratum opii may be laid over it, and the whole covered with warm poultices, which should be constantly renewed. The severity of the disease, or its return, may require a repetition of the blisters, which should be treated on the same plan. When the tissues have not undergone much organic change, the relief felt is immediate and lasting ; we have frequently seen patients fall into a calm sleep even during the drawing of the blister, and this in the case of persons who have been kept awake by violent pain for weeks ; if swelling be present, it may be often removed by the employment of blue oint- ment, applications of tincture of iodine and water, as by the formula given above, or the suppuration may be kept up by means of the solution of corrosive sublimate. The pain attending this last sub- stance will, however, generally preclude its employment. In the second variety of periostitis, this treatment is less efficacious ; it may be necessary in such cases to make incisions and let out the pus, as by such means we may prevent a further separation of the periosteum from the bone, an object always to be desired. SYPHILIS IN CHILDREN. 321 Local Treatment of Ostitis.—The treatment recommended in the two former affections, viz., pain in the bones and periostitis, is equally applicable and judicious in the early stages of ostitis, accompanied with a deposition of callus forming the epigenic exostosis; but it may be necessary to employ the treatment more actively, and for a longer time, particularly in the parenchymatous exostosis. When called upon to treat a patient for diseased bone which has been converted into a species of ivory, all treatment will be unavailing, and it will become a question whether or no we might be justified in removing, by a surgical operation, this form of exostose. In cases of caries or necrosis, particularly of the bones of the face, no time should be lost; they must be removed as soon as that is possible. M. Ricord observes, that the surgeon should be fully aware that caries produces caries ; that a bone, the organic matter of'which has been destroyed by suppuration, or which is dead, can never be regenerated by any treatment, general or local; and that it should never be left to be eliminated by Nature's efforts, except in those cases where the surgeon is unable to reach it. Bone of this descrip- tion is truly a foreign body, keeping up and maintaining the disease, which, by means of the suppuration it gives rise to, may gain still deeper parts, and thus occasion death. The means adopted to re- move these portions of necrosed bones need not be mentioned here. CHAPTER IV. SYPHILIS IN CHILDREN. This subject has been already treated of in various parts of this work, but it has been suggested to me that, in a " Complete Practi- cal Treatise on Venereal Diseases," a chapter ought to be devoted to syphilis as it occurs in infancy. I therefore shall, in the following pages, speak of such peculiarities as may be met with in early life. Primary Symptoms.—On the subject of contagion in children, I may mention that the same laws exist as in the adult, with this dif- ference alone, that the tissues being very delicate, inoculation would be more liable to occur, provided children were as frequently exposed to the effects of the virus. This, however, is not the case ; and I have met with no instances of primary symptoms, nor can I find in 21 322 SYPHILIS IN CHILDREN. authors any cases where distinct chancres have existed. In early life, however, ulcerations of the genitals are not unfrequently met with. I have lately seen in St. Bartholomew's Hospital two instances of children (both females) with some ten or twelve ulcers on the thighs and labia, attended with discharges from the vagina, and a considerable excoriation of the surrounding parts. Such appearances I could attribute alone to dirt and want of cleanliness on the part of the parents, together with pustular itch which had ulcerated; but as inoculation was not employed, it was impossible to speak more pre- cisely of their nature. Cleanliness alone speedily produced a per- fect cure. In the children's hospital at Paris, I have not unfrequently met with ulcerations about the anus, mouth, and throat, depending upon a disease called Muguet or Thrush. A very able article on the subject has been lately written by my friend M. Roget, which may be seen in the French Medical Dictionary, in twenty-five volumes. Such appearances have been often attributed to syphilis, but, I believe, on insufficient grounds. Without, then, in any manner denying the occurrence of primary symptoms in children, I think they must, be very rare. Should they occur, the treatment would be necessarily simple, and guided by the same indications spoken of in the chapter on Chancres in the Adult. Secondary Symptoms in children are, as far as my own experi- ence goes, much less common than is generally supposed ; such, however, is not the opinion of those who have written upon the sub- ject ; but when the difficulty which surrounds the whole question is considered, when the little attention that has been paid to the diseases of infants (until within the last few years) is considered, this sup- posed frequency of syphilis is not so surprising. The opportunities I have possessed of studying infantile disease in special hospitals, and of seeing the children of prostitutes, lead me to urge the correct- ness of my opinion. The result of my own observations I shall, therefore, now describe. Infection of the foetus in utero is stated to occur, and is now sup- ported by so many facts, that it would be superfluous for me to insist upon it. Authors, however, are not agreed upon the manner in which this takes place. The physiological school would attribute it to sympathy ; my own opinion is, that as the foetus partakes of the existence, and lives on the mother, so does it participate in many of her diseases, although, as we are in ignorance of the exact connexion between the foetal and maternal placenta, how this is affected must SYPHILIS IN CHILDREN. 323 still be unknown, and I could but amuse my readers with a more or less probable conjecture. We must, therefore, be content with the knowledge of the possibility of infection, in the present state of physiology. Some modern authors believe that syphilis is communicated to the child by means of the milk of the nurse, the parents being perfectly free from disease, as well as the child previous to suckling a nurse who labors under secondary symptoms. This opinion, as far as I can collect from the cases which I have read, seems to require further corroboration ; without denying the possibility, I should believe it very improbable. I have, never met with a case, and those recorded in books are liable to so many objections, that on this score I would give no opinion of my own. It is a very prevalent opinion that the father who labors under secondary symptoms will beget offspring who show visible marks of constitutional syphilis, and such cases are scattered up and down medical writings and books on midwifery. This opinion, like the last, however, seems very problematical; the chances of error are so great that I can hardly credit them ; and the fact, if true, is so contrary to direct experiments, that I am inclined to be skeptical. My incredulity is based on the following reasons : The father may have chancre in the urethra, and the semen, acting as the vehicle to the virus, will thus infect the mother, and secondarily the child. (See case in note to page 202.) The father or mother may have gone astray and contracted chancres, of the existence of which they are ignorant, or wish to conceal. The mother may have contracted chancres in other parts of the body, by the virus coming in contact with a sore or abraded surface. There are, in fact, a thousand chances of contagion, as modern investigations have proved, and *vhich have been alluded to in various parts of this work. Mr. Colles and Mr. Carmichael, if I mistake not,, believe that secondary syphilis may be communicated to the child by the dry- nurse ; how this could occur I am unable to understand; and I must believe that parties have conspired to deceive these eminent surgeons, who have such claims to public confidence, as correct observers and faithful ctelineators of symptoms. In the commencement of my studies I *as taught to believe that the death of the foetus, and abortion about the seventh month, was due to constitutional syphilis in the female, and to its effects on the fetus as characterized by a discoloration and peeling of the skin of the expelled embryo. Modern treatises on midwifery and diseases 324 SYPHILIS IN CHILDREN. of children still repeat these opinions, and support them with what is supposed to be corroborative evidence, namely, that if mercury be given, these abortions cease, and living children are born at the full period When I was attached to the Venereal hospital in Paris, a great many pregnant prostitutes passed under my notice, who were labor- ing under secondary symptoms, but I did not remark that abortions were more frequent at the seventh month than at any other period. If the reader will refer to the valuable work of Parent Duchatelet, he will find that abortions frequently take place, but syphilis is not the cause : unnatural means, excesses of all kinds, abuse of the sexual organs, are there stated as the exciting causes, and the period at which it occurs varies from the fifth week to the ninth month, and no mention is made of the peeling off of the skin, or other marks of secondary symptoms. I am inclined, then, to believe that these statements, once started by eminent accoucheurs, have been admitted and believed on too slight grounds, and that they have not yet passed through the crucible of modern analysts of facts. The children that I have seen laboring under secondary syphilis, have usually at birth presented no morbid appearance, although the mothers were severely affected with well-marked constitutional symptoms. Such children may have a healthy appearance, or be puny and weak ; a few weeks pass over, and spots are seen about the anus or scrotum. A child was lately brought to Mr. Wormald, the assistant-surgeon at St. Bartholomew's hospital, with very dis- tinct condylomata encircling the anus, which, the mother stated, ap- peared three weeks after birth. Frequently these spots resemble those seen in plate VIII., are raised, of a livid color, and have a very unpleasant *dor. They may disappear, and a papular eruption cover the little patient, the stains having that coppery-colored hue which is so very characteristic, and lasting long after the papules have disappeared. The general healthy color of the skin is lost, the eye is dull, and the corners of the mouth and tongue present those white pearly patches so characteristic, and which have been alluded to elsewhere. Mr. Carmichael, in No. lxxvi., of the Dublin Medical Press, says, that the eruption in children is always found to be scaly ; such an opinion does not accord with my investigations. Prognosis.—As far as my own observations go, the prognosis is favorable, provided the mothers can and will take proper care of the children ; in a few weeks the disease can be cured, and the child will rapidly gain its strength. I can not help here calling attention SYPHILIS IN CHILDREN. 325 to a statement of Mr. Tait, in his book lately published, entitled Magdalenism. According to his account, the mortality among chil- dren born of mothers laboring under secondary symptoms is dreadful. In the Lock hospital of Edinburgh, he states, out of twelve children seen during a period of three years, only one lived to the age of twelve months. Now I would appeal to any surgeon if this has ever been equalled in any other city in Europe. I answer no ; and I am al- most afraid that professional readers must admit, either that the treat- ment in the Lock hospital does not keep pace with the progress of knowledge elsewhere, or that Mr. Tait has been led away in draw- ing a too unfavorable picture of the severity of syphilis, not only in this case, but in others where he has deigned to enlighten us with the few medical passages which can interest the surgeon. Treatment.—Had I not dwelt, elsewhere, at considerable length on the treatment of secondary syphilis, I might devote several pages to it; but, as far as my experience goes, I should say that the same indications must be followed in the treatment of infants as in adults, the doses being diminished, and the mildest preparations being em- ployed. For this purpose we refer the hydrargyrus cum creld, in doses of two or three grains twice a day, and continued until the entire disappearance of the eruption. Other means have been recom- mended, but we have not found them so successful. It may here be mentioned that salivation is not liable to occur in the child, and that under the use of a mild preparation the recovery of the infant may be expected: it then rapidly gains flesh and recovers, but is liable to relapses, although, as Drs. Evanson and Murphy state, each will be slighter than the last. The mother at the same time should undergo a course of mercury for the cure of her complaints; and the child should not be allowed to take her breast, but may be fed on spoon food. Provided, however, it has no affection of the mouth, we can see no reason why it may not be suckled by a healthy nurse ; we have not seen any disease produced on the nipple of its wet-nurse, or the occurrence of secondary symp- toms follow, although instances are stated to have occurred in pre- viously healthy young women who have nursed syphilitic children. We have, however, met with a few instances where a child with aphtha? on its mouth has produced sores on the nipples of its nurse, who affirmed that she had never had syphilis. We believe that such cases may be classed under two categories. In the one, the sores have no specific character ; they are the result of irritation and the contact of the diseased secretion of the child's mouth on an irritable 326 SYPHILIS IN CHILDREN. nipple. Such instances are not followed by secondary symptoms. The second category includes those cases where the nurse has suf- fered under syphilis, although she may have reasons for denying it, or motives for concealing it, wishing to attribute it to a sickly child she has taken in to nurse ; such cases are very frequently followed by secondary symptoms, and may give rise to the supposition that the child was the cause. An interesting example will be found at page 508 of M. Ricord's valuable treatise : notwithstanding all his endeavors, the sores on the nipples (stated by the female to have resulted from suckling a diseased child), tested by inoculation, failed to produce the characteristic pustule ; only slight irritation of the inoculated point followed, and passed away in a few days. EXPLANATION OF THE PLATES. PLATE I. FIG. 1.—EXCORIATION. The subject of this drawing had suffered many months from a greenish purulent discharge. She was a married woman, and attrib- uted it to a disease which her husband had contracted about the same period. The introduction of the instrument was not attended with much pain. The characters of the excoriated condition of the epithelium, and the color of the secretion, show the analogy which it bears to balanitis in the male. FIG. 2.—GRANULAR CONDITION. This granular appearance of the os uteri and vagina is a very marked instance of what is often to be met with in the hospitals of Paris and London ; though generally in a less degree. The subject of it was a short stout female servant; she stated that a discharge from the vagina had appeared eight months previously, and had con- tinued to increase. The introduction of the instrument was very painful. The secretion was purulent, of a green color, of the con- sistence of cream, and so abundant that it ran out of the speculum. The analogy between this disease, and the granular condition of the conjunctiva in chronic affections of that membrane, can not escape the notice of the surgeon. 328 EXPLANATION OF THE PLATES. PLATE II. FIG. 1.—ULCERATIONS. This view was taken from a female, the wife of a shoe- maker at Tours; she came to Paris in consequence of a discharge which had existed twenty months. This patient attributed it to abortion which occurred about that period ; her husband, she stated, had suffered from several successive venereal complaints. Inocula- tion was tried on several and separate occasions, by M. Vidal de Cassis and myself, but the inoculated point healed in twenty-four hours, and as we always failed in producing the characteristic pustule, we concluded that these ulcers were not specific. FIG. 2.—CATARRH. This affection occurred in a young girl, a Belgian by birth, seven- teen years of age, who presented a lymphatic temperament. She had been placed as servant to wait upon an old lady in Paris, and entered the hospital for a discharge. She stated, that previous to her arrival in Paris she had used much exercise in the open air, but during the last few months had hardly ever left the house, and lived in a very crowded and damp situation. The condition of the os tincae in young females is well shown, but the mucous membrane is paler than usual. The artist has very correctly represented the glairy white of egg like discharge proceeding out of the os uteri, in which we occasionally meet with globules of pus, a secretion very different from those witnessed in the other forms of blennorrhagia. EXPLANATION OF THE PLATES. 329 PLATE III FIG. 1.—BALANITIS. The character of balanitis may, with advantage, be studied in this plate. It was impossible to say if sexual intercourse or a want of cleanliness was the cause. The general erysipelatous redness of the glans is well seen, and the excoriated appearance so often to be met with in this affection. FIG. 2.—VEGETATIONS. The subject of this complaint was a young man twenty-four years of age. States he never has had either gonorrhoea or chancres. The characters of the complaint are well seen ; the clusters of the granules are very florid, each granule presenting a conical appear- ance, though collected into masses. FIG. 3.—ECZEMA. The appearances as seen in this plate are very characteristic of the affection ; namely, the exudation of a serous fluid forming little scales, and the crevices are distinctly seen running between these little lamellae, resulting from the drying of the exuded fluid. The history of the case was obscure ; the patient advanced in life. FIG, 4.—HERPES PRAEPUTIALIS. Herpes in its various stages is delineated in this plate; commencing as a vesicular disease, its vesicles may ulcerate, and assume all the physical characters of chancre. The five or six vesicles will be seen on distinct patches of inflamed skin, differing in this respect from all other vesicular eruptions. 330 EXPLANATION OF THE PLATES. PLATE IV. FIG. 1.—INOCULATION—SIMPLE UNCOMPLICATED CHANCRE. The original drawing was taken at the Venereal hospital, Paris. from a patient forty years of age. Connexion had taken place six weeks previously. The patient had continued his usual occupation of a blacksmith until two days prior to entering the hospital. The characters of simple chancre are well seen, more or less circular in shape, with loss of substance ; the edges of the sore neither elevated nor indurated, only slightly oedematous, with a red areola. The bottom as well as the sides of the sore are covered with tenacious yellow lymph. The letters a, b, c, d, e,f g, point to the progress of the artificial chancre produced by inoculation on the thigh with the secretion of fig. 1 ; a represents the inoculated point six hours after the operation, the other letters at intervals of twenty-four hours. Letter h is the chancre on the thigh about the tenth day. FIG. 2.—FOLLICULAR CHANCRES. Represents a case similar to that of Mr. H., detailed at page 188. The drawing was taken two days after the appearance of the af- fection, and ten days after connexion. We observe the co-existence of gonorrhoea; the pus is seen issuing from the urethra. The principal object, however, is the development of the virus in the follicles on the glans, resembling the appearance" seen in figure, marked a, b. EXPLANATION OF THE PLATES. 331 PLATE V. FIG. 1.—DIPHTHERITIC PHAGEDENIC CHANCRE. This drawing was taken from a patient under the care of M. Ricord. A mason by trade ; twenty-nine years of age. On entering the hos- pital this patient's constitution appeared broken down by the combined effect of dissolute habits and poverty. A thin ichorous discharge flows from under the prepuce, from which a piece of lint, soaked in opium, is seen projecting. A distinct chord was felt, extending up- ward, in the direction of the ganglionic bubo, which commenced as a pimple. It was impossible to collect dates from this person. On un- covering the glans it presented the appearance figured in fig. 1, the phagedena is seen extending rather in breadth than in depth; no in- duration accompanies it; but we observe some oedema around the ulceration. I should wish to call attention to the analogy of ulcera- tions in the same individual. FIG. 2.—INDURATED PHAGEDENIC CHANCRE. This patient, a tailor by trade, twenty-three years of age, of a beautiful transparent complexion, stated that six weeks previously he had contracted chancres ; they healed under simple treatment, and the cicatrix became indurated, and then red; and lastly a sore began in the centre, which has since been extending; a similar sore exist- ed on the other side of the glands. The molecular gangrene is very marked, and the transparent indurated circle around it, elevated and distinct from the surrounding skin, is well seen. FIG. 3.—GANGRENOUS CHANCRE. This affection occurred in a young man twenty years of age, a bargeman on the Seine ; who drank freely. He stated that eighteen days previous to his admission, he had had connexion with a prosti- tute at Rouen; fourteen days after a black spot showed itself on the upper part of the prepuce, which had become swollen and red, and had increased to the extent seen in the drawing. The whole of the prepuce was destroyed in the succeeding thirty-six hours. Fig. 4, shows the mouth of a person affected with mucous tubercles in different parts of the body and the white bleached mucous mem- brane is well shown. 332 EXPLANATION OF THE PLATER PLATE VI. SYPHILITIC AFFECTIONS OF THE MOUTH AND THROAT. FIG. 1.—SECONDARY This patient entered St. Bartholomew's hospital, in February last, under the care of Mr. Stanley. He stated that in the previous Sep- tember he contracted chancres, which he cured with some aperient medicine. About Christmas he first perceived eruptions on the scalp, and his throat soon after became sore. I would direct atten- tion to the analogy between the affections on the skin and the mucous membrane ; they are seen to pass insensibly one into the other. In fact, the white and bleached superficial excoriation of the throat answers to the syphilitic lepra seen on the body. The speculum oris allowed us to gain a good view of the back part of the throat. FIG. 2.—TERTIARY. The subject of this complaint was a young girl who had led a very dissipated life. About fifteen months previous to the time the draw- ing was made, she had had primary symptoms, and had been in various hospitals, but I could not learn that she had ever taken mer- cury. The principal features of the disease are well seen. The absence of papilla on the tongue, where ulceration had previously existed, excavated ulcers covered with a pulpy secretion, and sur- rounded with a red areola, bespeak at once the tertiary symptoms ; this is made more evident by the occurrence of rupia, which was present on various parts of her body. EXPLANATION OF THE PLATES. 333 PLATE VII. (see frontispiece.) This plate (the frontispiece) represents different phases in the ev- olution of tubercles. In the middle of the cheek are maculae ; on the upper lip and the external and lower palpebral region, are several small and separate tubercles ; on the left side of the nose are con- fluent tubercles, which are thicker at the back part of the ala, and there form a large tubercle. On the cheek also are two pustules of ecthyma with tubercular base and surrounded by a dark red areola. On the lower pustule the crust appears. 334 EXPLANATION OF THE PLATES. PLATE VIII. This plate represents those abnormal vegetations which some- times occur in syphilitic patients and are seen around the anus, and sometimes even on the penis.