■■• ;,,-'' VW%i;i!-'!i- -I::,:; in,' r:' ■m is \fm masses 'iBlliiiil!! « :.,i!iili!l!!!lli!l ^llllll'll i!'. !':-! i illllillilpliili!1?'!^11,1 :*il;li|S H1|!|lll lii! I hj;;!! r |!j | j! i)H!!::S:«l« „' ;ii,!l,!;"!1'i;l|iirl,ll!'ii :■■!':■::.:.: v ...III W ;,;:;!i|.i:;iii,;i;!iii!:::;:,i:i::.i|#piiiil iiii'iiliiiMl'iiiiiiijlii'iiijii^iii:.'^ . -:li .^iiii!':!'.!!!.::;1 '■!!i'i;'-:"viv",\";':" /V ^. 0£}f fr $ J& V » Rupia Prommens Syphiulica JHBail'ardSl.ith A TREATISE GONORRHOEA AND SYPHILIS. BY SILAS DUBKEE, M.D., • •» FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY; MEMBER OF THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT, AND OF THE BOSTON SOCIETY OF NATURAL HISTORY: FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES; HONORARY MEMBER OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK. WITH EIGHT COLORED PLATES. BOSTON: JOHN P. JEWETT AND COMPANY CLEVELAND, OHIO : HENRY P. B. JEWETT. 1859. __________flirt A/g. U%1 j 1\Q .L{- Entered according to Act of Congress, in the year 1859, by JOHN P. JEWETT AND COMPANY, In the Clerk's Office of the District Court for the district of Massachusetts. LITHOTTPED BT COWLES AND COMPANT, 17 WASHINGTON ST., BOSTON. Printed by Geo. C. Rand and Avery. THOMAS C. BRINSMADE, M.D., LATE PRESIDENT OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK, WHO, BY HIS UNWEARIED, INTELLIGENT, AND SUCCESSFUL LABORS TO ADVANCE THE GREAT INTERESTS OF MEDICAL SCIENCE, --BY HIS DIGNIFIED AND COURTEOUS DEMEANOR, AND HIS TRUE MORAL EXCELLENCIES OF CHARACTER, HAS RISEN TO A HIGHLY HONORABLE AND EMI- NENT POSITION IN THE PROFESSION, %\l% 00lttttU IS CORDIALLY INSCRIBED AS AN EXPRESSION OF GRATITUDE FOR VALUABLE INSTRUCTION LONG SINCE RECEIVED, AND AS A TOKEN OF WARM REGARD AND FRIENDSHIP, BY HIS PUPIL, THE AUTHOR. PREFACE. In the year 1854, the author of the following pages pre- pared an Essay on " The Constitutional Treatment of Syph- ilis," which was honored by the award of a premium from the Boylston Prize Committee of Harvard University. That Essay constitutes a large portion of the present volume; and although it has been modified to a degree that deprives it of its original identity, it is believed that its intrinsic merits have been materially enhanced.* In the early part of my professional career I had charge, for several years, of the hospital department of a large Charitable Institution, in which venereal patients, and those affected with blennorrhagic diseases daily presented themselves; and I have now devoted more than thirty years to the therapeutics of syphilis and kindred disorders, as they may properly enough be termed. From time to time I have tested a great variety of remedies, and have pursued, by way of experiment, almost every line of treatment that has been brought to notice with any claims to favorable regard. But I have found no royal plan of accomplishing a speedy or certain removal of the maladies under consideration. They will yield to a judicious interposition of medical and surgical skill; and no man, who possesses such skill, will confine himself to a few medicinal *By a vote of 1826, the Board do not consider themselves as appioving the doctrines contained in any of the dissertations to which premiums may be ad- judged ; and in case of the publication of a successful dissertation, the author is considered bound to print this vote in connection therewith. 1* Y VI PREFACE. substances that may have acquired notoriety as specifics, while they are endowed with no such qualities. In presuming to submit this work for publication, I have not been moved by the promptings of ambition to become an author. To all such aspirations I am a stranger; and were I influenced by my own inclinations, irrespective of the solicita- tions of others, the manuscript would have slept undisturbed. The paramount design which I have endeavored to keep in view, has been, to furnish a book that shall be practically use- ful. I have studiously avoided engaging to any great extent in the discussion of all doubtful matters. These have come before me with sufficient frequency. Scarcely had I entered upon my labors, before I found myself in the thorny wilder- ness of debate, where I was unable to maintain entire silence or neutrality. The occurrence of blennorrhagia in the male, as resulting from leucorrhcea, or from the menstrual fluid, has long been a standing theme of controversy, and is still involved in ob- scurity. I flatter myself that the manner in which I have dis- posed of this subject, will receive the approbation of my readers generally. Certain I am that the views I have ad- vanced are in harmony with those maintained by men who have had the largest experience, and who have long been on the "look-out" for all the facts that are capable of reflecting any light upon this interesting question. In adducing the cases which are interspersed throughout this volume, it has been my aim to select those that appeared to be important and valuable from the peculiar symptoms appertain- ing to them, as aiding in the diagnosis of different syphilitic accidents, or illustrating the principles of a rational and suc- cessful treatment. The details of a few of these cases occupy an unusual amount of space; but it is hoped that the instruc- tion which they are calculated to convey, will justify the prom- PREFACE. VII inence given them, and repay for the time required in their perusal. It was a remark of John Hunter, in reference to distinguish- ing venereal from other affections, that a true diagnosis is the first step in the cure. In one sense, this idea may not be strictly logical or correct, that is, so far as relates to the individ- ual lesion ; and yet in a broader signification, the expression is worthy of all acceptation. A medical man may heal a chancre or other syphilitic sore without having any knowledge or sus- picion of its real character. But, in this state of ignorance, he will be incompetent to officiate in the premises to the highest advantage. He cures the local symptom or difficulty, but not the patient. The morbific cause remains unchecked, to work further mischief, and at a future day to display its effects in the appearance of some new symptoms which might never have occurred, had a true diagnosis been formed of the original trouble; for such a timely discrimination would have suggested a constitutional remedial course more appropriate, it is pre- sumed, than that which was instituted. Admonished by the words of the great medical philosopher above referred to, I have embraced every suitable opportunity to dwell in brief and unambiguous language, upon the subject of the diag- nosis of the various specific affections or consequences aris- ing from impure sexual congress. It is hoped that the labor put forth in this direction, will be found serviceable to the young and inexperienced physician, in his investiga- tions of a class of obscure and perplexing cases, that oc- casionally present themselves for his decision and man- agement. I have endeavored to delineate the characteristic features assumed by the various cutaneous affections resulting from the venereal poison, and by which the practised eye may generally distinguish them from non-specific eruptions. So far as it has been deemed advisable to classify them, and to study them in separate divisions, the nomenclature of Pro- VIII PREFACE. fessor Wilson has, with little variation, been adopted. This arrangement will aid in observing and comprehending the laws that usually regulate the development of these external mani- festations, and will greatly assist, also, in their diagnosis and treatment. The fact that some eruptions have a tendency to destroy the anatomical mechanism of the skin, — that is, to proceed to ulceration, while others evince no such disposition, has induced that excellent writer, Mr. De Meric, to divide all syphilitic eruptions into two classes; viz., the ulcerative and the non-ulcerative. By this short method of simplification, we get rid of sundry hard words employed by dermatologists; but it seems to me that such an arrangement will fail to give to the student or to the medical attendant, a clear and scientific knowledge of the respective forms which the syphilodermata exhibit, and that, in a practical or clinical point of view, it must be attended with no inconsiderable disadvantage. These diseases, at any- rate, constitute a most important group of morbid phenomena, and require to be studied most thoroughly by every member of the profession who undertakes their cure. Not a few persons on whom they exist, and who apply for medical assistance, endeavor to deceive. They have interested motives for concealing the truth, and the physician is thrown into embarrassing circumstances. If, as a general rule, the latter can rely with safety on his own ability to give a true in- terpretation of the eruptions, — that is, if he can identify them without a knowledge of their antecedents, he has no occasion to hesitate or succumb before the individual under examina- tion. His intelligence and sound judgment will soon be apparent to the other party, who will not only be driven, like the fox, from his subterfuges, but will yield respect and confi- dence to the man whom he could not deceive. The chapter devoted to the consideration of secondary syphilis, where no primary accident has preceded, contains, it is believed, a fair presentation of facts, and a truthful expres- PREFACE. IX sion of the sentiments recognized at the present day by a great majority of the most distinguished members of the profession, who have had the most ample opportunities for acquiring knowledge upon the particular points concerning which they speak. The cases and data upon which their opinions are based, will be found to be something more than mere nega- tions;— nor are they brought forward for the vain purpose of establishing or demolishing any particular pathological theory, exclusive of other and higher considerations. It would seem that a candid appreciation of what is embodied in this chapter, would lead to the conviction that there is but a very narrow margin, — or, rather, no ground at all, for controversy or doubt; and yet there are those who discredit the evidence thus adduced and fortified. If the reader finds himself still roaming in the barren realms of skepticism, let him pause at least, and in an unbiased and philosophical spirit, listen to these facts as admonitory voices to his incredulity; and let him glean therefrom a lesson of wisdom and prudence. This will be salutary both to himself and others, even if his mind be not fully emancipated from the influence of long-cherished opinions of an opposite kind; for possibly he may be required, in the course of his professional life, and in virtue of his accredited superior attainments in whatever relates to his call- ing, to give his testimony under the sanctity of an oath, on certain points at issue in the solemn halls of justice, and intimately connected with this subject, — and involving, among other things, the great question of the communicability of secondary syphilis. No one can boast that he has witnessed and treated all the accidents entailed upon the human frame, by the promiscuous intercourse of the sexes. Whatever position he may occupy, it is scarcely within the range of possibility that his individual investigations, experience and opinions, can be sufficiently X PREFACE. comprehensive to embrace every thing. The recorded observa- tions and labors of others should be consulted. Accordingly, in gathering materials from which to construct the present treatise, I have devoted no little time to the perusal of various works on venereal and other specific affections engendered by the abuse of the reproductive organs; and in the statements and views which I have offered, I have in very many instances, made other writers participate in the responsibility. Numer- ous books, essays, lectures and monographs have been pub- lished, and still have a name to live. Some of them are little else than an ingenious and gossamer fabric of conjectures, not unfrequently dressed in a most fascinating style, and displaying the workings of a lively imagination. Some of them are remarkable for sound erudition; some are enlivened with beautiful rhetorical strokes, and even glitter with the most brilliant corruscations of eloquence, that can be found in any department of literature; and some are replete with much practical good sense. On many topics appertaining to the subject of syphilis, a wide discrepancy of opinion character- izes the productions of the most gifted authors, even up to the present moment, and not a few grave problems still remain to be solved. Amid the conflict of sentiment which thus prevails, the student in pursuit of reliable information, scarcely knows how to adjust his mind, or how to sever the true from the false — the wheat from the tares. On some of these points I have ventured to offer a helping hand, and to interpose a word of reconciliation, especially in the field of therapeutics. For the most important discoveries that have been brought to light since the days of Hunter, in regard to the pathology of venereal disorders, — for various and most valuable sug- gestions and principles proposed for our guidance in their diagnosis, and for most useful rules and improvements in the remedial administrations which they require, the writings and PREFACE. XI other services of Ricord are entitled to pre-eminent considera- tion. But Ricord is not infallible; and while rendering this willing tribute to his masterly genius, I feel compelled to add a slight qualification, and to withhold my assent from a few doctrinal views, advocated by this distinguished syphilog- rapher. S. D. Boston, June 1, 1859. CHAPTER I. BLENNORRHAGIA — CAUSES — LEUCORRIKEA CONTAGIOUS — BLENNORRHAGIA NOT NECESSARILY CONNECTED WITH GUILT--LETTER FROM DR. BUCKINGHAM-- DIAGNOSIS OF BLENNORRHAGIA--SYMPTOMS —TERMINATES IN GLEET — GLEET AND MATRIMONY. For a very long period the identity of syphilis and gonor- rhoea was a fruitful theme of debate; and opinions the most contradictory were entertained by the authors and schools thus engaged in controversy. But the times have changed; and the dawn of a new and better epoch now opens upon the path of the medical practitioner. By the talents, and the pa- tient and well-directed labors of some of the most eminent writers that have come upon the stage during the last quarter of a century, the laws that govern the two diseases we are about to consider, have been brought from their long night of obscurity to the light of day, and are now comparatively well understood. And while it is a matter of congratulation that many of the theories which once flourished, and held a portion of the medical world spell-bound in error, have fallen asleep with the renowned personages who promulgated them, there is equal occasion to rejoice that the field of therapeutics has at last been explored with a large amount of success, and its various products, which were once used without method, without reason, and without mercy, are in more competent hands, and are made subservient to a more rational and satis- factory treatment of the maladies in question. At the present day, the more enlightened members of the profession agree in the opinion that gonorrhoea is not a vene- real affection; and yet as gonorrhoea is usually contracted under circumstances identical with those that give rise to syphilis, a treatise on the latter disease, however judiciously prepared, would be regarded as deficient in design, unless the former complaint received a due share of consideration. Gonorrhoea, blennorrhagia, clap, and urethritis, are used as synonymous terms, and are employed somewhat indiscrimi- l i 2 GONORRHOEA AND SYPHILIS. nately to denote inflammation of the mucous membrane of the urethra and other portions of the genito-urinary passages, at- tended with infectious, muco-purulent discharge, and a scald- ing pain in micturition, consequent upon impure sexual con- gress. The discharge is not uniform in its physical character or composition. At first, it may consist almost entirely of mucus; in a few hours the mucus will contain pus-globules, which increase in relative proportion, until the disease reaches its climax. As soon as it begins to wane, and to pass into its ultimate stage, the morbid secretion is again changed, and is once more characterized by a preponderance of mucus, until at last it becomes nearly transparent; — thus indicating that the pus-globules, upon which its contagious properties are supposed to depend, have ceased to be formed. This ab- normal discharge is the blennorrhcea luodes of Dr. Good, the gonorrhoea impura of Cullen, the venereal catarrh of Capuron, the catarrhal primary syphilis of Wallace, the chaude-pisse, as it is called in the vernacular and graphic parlance of the French populace. Still other names might be cited as applied to inflammation of the male and female organs of generation, accompanied with muco-purulent secretion, having a charac- ter totally different from the specific virus of true syphilis, although received in the same manner and by the same or- gans;— its medium of reception being cohabitation with an infected individual. No generic term, however, which has reference to the complaint, is free from objections; and until some better phraseology is introduced and acknowledged in this department of nosology, we must be content to avail our- selves of technical expressions that are sufficiently under- stood, and that have so long and so well answered all practical purposes. Causes. — Simple urethral running, or blennorrhagia sim- plex, in the male, consists in an increased secretion from the urethral glands or follicles, and proceeds from mere local irri- tation,— is destitute of any contagious element or virulence of any kind, and may be produced by a variety of causes. Of these causes, one of the most frequent in the opinion of some writers, is, sexual intercourse with a female who is laboring under leucorrhoea, or some other morbid condition BLENNORRHAGIA. 3 of the vulva, vagina or uterus, which may furnish a catarrhal discharge possessing more or less acrid properties, but spe- cifically different in its nature from the malignant gonor- rhoea impura just mentioned, and which alone can be propa- gated. Men have also been known to receive a blenorrhagia from healthy women with whom they have had sexual inter- course while the menstrual flux has been upon them. The vaginal secretions just previous to menstruation, will likewise occasion urethral irritation in men of peculiar susceptibilities. In women, blennorrhagia is a complaint rarely met with, com- pared with the frequency with which it falls to the lot of men. Ricord states with characteristic brevity, that women give twenty claps for one which they receive. Particular arti- cles of food, such as salted meats, cayenne pepper, ginger, etc., have the reputation of causing mild blennorrhagia. Some persons cannot eat asparagus without having a gonor- rhceal discharge from the urethra, a few hours afterwards. Spirituous liquors, beer and coffee, have been accused of producing the same effects; so also the use of cantharides, in- jections, bougies and pessaries, will give rise to a morbid se- cretion closely resembling ordinary gonorrhoea. The same results occasionally supervene upon violent and long continued dancing, frequent venereal indulgence, and the want of coap- tation in the genital organs of the two parties. Masturbation, rheumatism and gout will likewise occasion gonorrhoea. Druitt mentions a case of most obstinate local irritation, attended with urethral discharge, brought on by riding several miles on horseback without a saddle. The patient was a married man, and had a tendency to irritation of the mucous membranes. During treatment he suffered a severe attack of rheumatism. Dr. Blackwell relates the case of a patient seventy years old, who was subject to gout, and during one of his attacks was seized with a most copious blennorrhagic discharge from the urethra. Dr. B. is positive, that this discharge was induced by gout. Dr. Watson, of New York city, has seen two cases of the same kind. Labor and abortion are to be reckoned among the causes that give rise to blennorrhagia. Leucor- rhoeal discharges in the female are supposed to be capable of generating in the male an assemblage of phenomena almost precisely like those developed in ordinary gonorrhoea derived 4 GONORRHOEA AND SYPHILIS. from impure connection. With reference to the contagious nature of leucorrhoeal matter, Whitehead says: —" If ques- tioned on the subject, I should have no hesitation to return an answer in the affirmative, in all cases where the discharge in the female exhibits decidedly purulent properties, having my- self witnessed several incontestible instances of the kind." Hitherto no success has attended any experiments or ex- aminations that have been made with a view to detect the characteristic differences between a true gonorrhoea and some other discharges from the genital apparatus of the female, and which, it is said, occasionally excite a mild gonorrhoea in the male. The medical practitioner is sometimes called upon to give his opinion on the question of suspicion, and to adjust difficul- ties which spring up within the domestic circle in connection with this embarassing subject. As the conscientious interpre- ter of events, he can feel justified in expressing a conviction that blennorrhagia does not always have its origin in a specific virus, nor absolutely imply moral delinquency on the part of any one; for the accident may take place under the most varied circumstances, and from a multiplicity of causes, as de- tailed above. The bare fact that a man or a woman has the complaint, does not necessarily carry with it demonstrative proof of guilt. The disease may happen to the most virtuous and pure individual, male or female. If the surgeon can ob- tain access to all the antecedents in the premises, without concealment from any quarter, he will have no difficulty in arriving at a true diagnosis. A great and not infrequent ob- stacle, which the medical attendant is compelled to meet, in endeavoring to form a correct opinion, is this : he must judge in part from the general character of the patient; and yet the general character for truthfulness, in matters affecting disease of the genital organs, cannot be depended upon. Many per- sons, who are perfectly reliable on all other occasions, will not hesitate to deceive their medical advisers concerning impure connections, even when they know that deception, in any de- gree, will operate against their interests, perhaps for life. Were it possible to collect all the reputed sporadic cases of simple blennorrhagia that occur in any one of our large cities during the average professional lifetime of the physician, the BLENNORRHAGIA. 5 number of such instances, reckoned in the abstract, might seem considerable ; and the sensualist might essay to appro- priate the fact to his personal advantage, in the hope that it might shield him from the multitude of his sins, however fre- • quently he had gone astray into the path of licentiousness. But if the history of every blennorrhagia could be brought to light, I believe it would appear that for every instance not coupled with a departure from rectitude, hundreds would be found to originate under directly opposite circumstances. So that while the medical man admits that various innocent causes may induce gonorrhoeal discharges, I think he may feel war- ranted in the opinion that the combined agency of all these sources is quite insignificant, compared with the agency attrib- utable to the one chief cause, namely, cohabitation with an in- dividual affected with a specific and contagious blennorrhagia; a disease of the genito-urinary organs, arising from an animal poison generated by impure sexual intercourse, and easily confounded with various non-specific, non-contagious, inflam- matory affections, which occasionally attack the same organs, and are likewise characterized by secretions more or less puri- form. But these discharges are minus the true, infectious, gonorrhoeal element. In cases, however, where there is ground for reasonable doubt as to the cause of blennorrhagia, it is right that the suspected party should have the benefit of that doubt. The medical witness will be justified in leaning some- what to the side of mercy. I have corresponded and otherwise conferred with many medical gentlemen, with a view to obtain their opinion with regard to simple leucorrhoea as a cause of contagious gonor- rhoea. Those who have been long in practice, and who have had large experience in the treatment of both diseases, consider it a libel on the female sex to attribute the latter disorder to the former. One distinguished surgeon, who has probably seen as many cases of urethritis as any man in the country, informs me that he never saw an instance which he thought was occasioned by leucorrhoea. Were this disease capable of giving rise to a veritable gonorrhoea, few married men in the wide universe would escape being poisoned with it by their wives, for it is well known that leucorrhoeal discharges afflict, more or less, a majority of adult females. I feel bound, per l* 6 GONORRHOEA AND SYPHILIS. contra, to cite the opinion of a junior correspondent, whose scientific acquirements I greatly respect, and who occupies a favorable post of observation in the chief city of our union. He writes: " In reply to your note asking me to give you my views, derived from personal observation, as to the possibility of a woman affected with simple leucorrhoea, or during her menstrual period, communicating a gonorrhoea to the male, I would state that I have no doubt, whatever, as to the possibil- ity of such communication ; and I would go even further, and assert that a vast majority of cases of gonorrhoea in the male, arise in this manner from intercourse with women who have not the disease themselves." During a practice now of thirty years, I have had scores of patients, who have pretended that their urethritis might have been derived, or probably was derived, from the vaginal or uterine secretion now alluded to ; but I have never seen any evidence that convinced me of the fact. My faith in the power of leucorrhoeal secretion as a source of blennorrhagia in the male, is scarcely equal to a grain of mus- tard seed ; and I usually turn a deaf ear to all such specious explanations. I am unable to recognize this antecedent as the procuring cause of such an event. The subject, however, is one of which no man has the key of absolute knowledge. It must, from the very nature of things, always remain a matter of opinion. My own coincides with that of Sigmund — that gonorrhoea alone produces gonorrhoea.* I will here introduce an instance of mild urethritis, the cause of which is not difficult of explanation; but which, had it concerned parties less intelligent in medical matters, might have given occasion for dark suspicions and recriminations. A few years since, an intimate medical friend of mine, of un- impeachable character, had an attack of simple blennorrhagia, or pseudo-gonorrhoea. The facts in the case, as related by himself, were these : He had never indulged in illicit inter- course, and his wife was above suspicion. He had had no sexual communication with her for about three months, as she * In conversation a few months since, with a member of the profession, who has been President of the American Medical Association, he remarked that he had long been " on the watch " for a case of gonorrhoea produced by leucorrhoea or by the menstrual discharge, but had never met with one. No man in this country ever en- joyed a more extensive range of observation than the one here referred to. BLENNORRHAGIA. 7 was nursing a young infant. One morning, after having con- nection with her the previous night, he experienced severe irritation and smarting on passing urine, followed immediately by sharp pain, which lasted a few moments, and then subsided until the next period of micturition. During the interval, however, there was a constant sensation of uneasiness in the urethra. On the first day of the attack, the glans penis became swollen, and there was a moderate discharge of glairy mucus, of the consistence and appearance of the white of egg. On the following day, the glans and preputial surfaces were ex- coriated and decidedly sore. This state of things continued for four days, when the irritation and swelling abated, and the urethral discharge assumed a more purulent character, being thick, pasty, and of a light yellow tint. As the hypersecre- tion acquired the latter properties, it lessened in quantity, and at the same time the irritation and smarting nearly ceased. At the expiration of ten days, the blennorrhagia and its com- plications disappeared. Rest and cleanliness were the reme- dies. The above phenomena did not disturb the harmony or mutual regard and confidence of the parties, who were not only persons of high social position, but of the best intellectual and moral culture. The fact that the symptoms came on so shortly after indulgence, and also that they subsided without medi- cine, sufficiently separates them from blennorrhagia derived from a contagious virus, which usually requires an incubation of several days before its specific action is developed. The fault was not in the woman. She had no vaginal trouble. The accident was due to the peculiar susceptibility of the other party. Such results, and even worse ones, at least so far as regards the prepuce and glans, are not very uncommon in newly married men. A few years since, Dr. W. W. Mor- land, of this city, requested me to see a patient of his, who had a phagedaenic ulcer on the prepuce. The patient was twenty-five years old, and had been married one week. In a day or two after his nuptials, the prepuce became enormously swollen and cedematous. The young man bore a good char- acter, and the bride was also without reproach. He sent for a physician, who, after an examination of the parts, announced to the patient, in a coarse, rude manner, " that he had got the 8 GONORRHOEA AND SYPHILIS. pox," and prescribed accordingly. The young husband was greatly enraged, dismissed the physician instanter, and sent for Dr. Morland, who decided that the lesion was not specific. All the circumstances connected with the case and with the young couple abundantly proved the correctness of Dr. Morland's diagnosis. The phagedamic action, in this instance, set in with great suddenness, was very rapid in its progress, and did considerable mischief before it was arrested. Urethritis and ulcerations sometimes occur under circum- stances so obscure, that the medical attendant cannot arrive at any satisfactory conclusions as to the cause of the affection. In this connection, I submit the following communication relating to two cases reported by Dr. C. E. Buckingham, recently physician to the House of Industry, South Boston: — "Cases have presented themselves of mucous discharges, and of ulceration, in which I do not in the least degree doubt, that impure connection was never had. They have not been numerous. But suppose that one of your own personal * friends, who acknowledges that in former years he has had gonorrhoea, comes to you. He has not married. He con- fesses that within four or five years he has had frequent sexual intercourse ; but says that for the last eight weeks he has not touched a female, and that within forty-eight hours there has been itching and redness about the meatus urinarius. On examination, you find there is moisture, but nothing which you can decide at once to be purulent. He is cleanly in his person and dress. Now, can you with any consistency doubt the statement of such a person, who could not have the reason of shame to prevent a knowledge of what you knew before? In April last (1856), such a case was under my care, and was treated at the beginning, simply with an astringent wash to the part. In two or three days there was a profuse muco- purulent discharge from the meatus, into which no syringe or other instrument had been introduced till that time. The disease did not terminate till after the middle of September. It is true, that for days at a time — not more than three — there would be entire cessation of the discharge, and it would then re-commence. In this time there was once painful swell- ing of the testicle, which yielded easily. I have seen this BLENNORRHAGIA. 9 patient to-day (November 7, 1856), upon other business, and he informs me that since the date mentioned, he has had no return of his trouble. " My experience with syphilitic cases while in attendance upon the Hospital at South Boston, was not so great as you probably imagine. " I cannot forbear mentioning one case under my private treatment, which gave me great annoyance, and which you may be able to explain. Several years since, a friend, himself a physician, unmarried, called upon me for advice concerning what, upon any other person, I should have called an indurated chancre, situated upon one side of the prepuce and quite near the frasnum. He denied ever having had sexual intercourse at all. He had been treating it for several days with mild astringent lotions, but it constantly increased and had become as large as my forefinger nail. He was fully capable of detecting chancre in any one else, and as capable of treating it; but he called upon me because he could not make out what this was, and with the fullest belief that I should ridicule his statement. He acknowledged the wearing of a pair of riding-trowsers a week or two previous, borrowed from a friend for an afternoon's ride. He had no reason, he said, to think his friend had the disease, or if he had, that he would have loaned him the clothing unless it were known to be clean. I laughed at his account, and proposed inoculation, which he assented to; and his thigh was inoculated by myself with the discharge from the ulcer, and I believe in more than one spot. The apparent chancre was thoroughly cauterized with nitrate of silver, which did not put a stop to its spread- ing. The prepuce became very cedematous, and the inocula- tion had no effect. As the sore continued to extend, at his own request, he was put upon mercurial treatment, was etherized, and the part touched with nitric acid. After the separation of the slough formed by the acid, the oedema became so great, that it was impossible to uncover the glans; but the sore did not diminish in size. The mercurial was continued for many days without any perceptible effect upon the gums. Several weeks after the discontinuance of medi- cine, the sore began to heal, and so far as I know, he has never had any symptoms of venereal affection. I am fre- 10 GONORRHOEA AND SYPHILIS. quently in the habit of seeing this gentleman, and am quite certain that he is in perfectly good health. I know also that while he was under treatment he became a married man, and am quite as certain that his wife is a healthy woman. This is a case for speculation. " I am, very respectfully, yours, "Charles E. Buckingham." In regard to the first case furnished by Dr. Buckingham, the query arises whether the suspicious connection, which is acknowledged to have taken place eight weeks anterior to the blennorrhagia, is to be regarded as the occasion of the urethral difficulty. Instances are on record showing that more than two months may pass away before the gonorrhoeal infection manifests itself. Dr. Samuel Morrill, of this city, once had a case quite similar to the one above related by Dr. B. Dr. Morrill's patient had intercourse with a prostitute in Buenos Ayres, and the next day sailed for Boston. The ship had a long passage. In just sixty days from the time he visited this woman, and while he was yet at sea, the man was seized with a violent blennorrhagia, for which he consulted Dr. Morrill as soon as he reached port. Hunter believed that the period between exposure and the appearance of purulent urethral discharge, ranged all the way from a few hours to several weeks. His opinion was based upon statements and examples furnished by his own patients. His theory was, that the inflammatory action in some constitu- tions might exist for a long time before the suppurative period. The second case related by Dr. Buckingham is a legitimate one for " speculation." By inappropriate treatment, patients often convert a harmless pimple, or an eczematous or herpetic vesicle situated on the glans or prepuce, into an ugly, chan- crous looking sore. Nothing is easier than to manufacture such a sore. I have seen not a few created in this manner. In the case under review, Dr. B. had no opportunity to see the lesion " in a state of nature; " and the speculative idea that suggests itself to my mind in relation to it, is, that its normal features had been modified by the applications resorted to, before it came under his inspection. Its final history would seem to prove that it possessed no specific attribute. I once BLENNORRHAGIA. 11 had a case not unlike this. The patient was a pale, thin, feeble-bodied man, forty years of age,- and suffered extremely from dyspepsia. When he called upon me, he had a sore on the glans as large as a half-dime. It commenced as a mere pimple. The patient had tried his own skill at it, and nitrate of silver had frequently been applied. The sore was quite deep. It was not painful, and yielded a very scanty discharge. The man had a nice woman for a wife, and was himself of good character. He ignored all illicit intimacy with the other sex, and I did not hesitate to accept his statement. Although the ulcer bore a strong resemblance to chancre, I did not think it entitled to that epithet. The patient was put upon tonic treatment as far as his system would tolerate; and nitric acid, — two drops to the ounce of water, — aromatic wine, tannin, and weak chlorinated water, formed the local applica- tions. Four months elapsed before he was rid of the sore. He had no bubo nor secondary accidents. Contagious blennorrhagia, — that is, a blennorrhagia that can be communicated, is a specific disease. It cannot give rise to secondary syphilitic accidents. In all cases, where such phenomena have followed a gonorrhoea of the urethra, it is certain that true chancres, — such as are termed by French writers chancres larves, must have coexisted. M. Baume's, of Lyons, states that simple blennorrhagia, without the existence of chancre in the urethral canal, may be followed by constitu- tional manifestations, such as well-marked, rounded ulcers on the tonsils, mucous tubercles at the commissures of the lips, about the arms, on the scrotum,— syphilitic ecthyma, papular eruptions, etc. This opinion is not sustained by the history of the disease. There is no well-authenticated example, which proves that an individual, in whom the mucous surfaces have been examined during an attack of blennorrhagia, with- out the existence of chancre, has ever afterwards had second- ary syphilitic lesions in any form. One of the best arguments and proofs that can be offered against the identity of the syphilitic virus and the virus of gonorrhoea, is, that the con- stant tendency of the first is to produce secondary symptoms, which we denominate constitutional syphilis; while it is equally true that gonorrhoea, however severe, or however protracted in duration, is never followed by such symptoms. 12 GONORRHOEA AND SYPHILIS. In the treatment of gonorrhoea, an erythematous efflorescence of the skin, induced by the free exhibition of cubebs or balsam of copaiba, is occasionally met with; and if these reme- dies are continued after the appearance of the preternatural cutaneous redness, a well-marked, lichenoid eruption, accom- panied with much itching, is very liable to break out on the trunk of the body and upper portion of the extremities. But this eruption has no pathological relations to gonorrhoea. It subsides in six or eight days after the discontinuance of the medicines that gave rise to it. It is perfectly harmless, and does not in any wise merit a place among syphilitic papules. Certain consequences and sequelae follow blennorrhagia, but they are not venereal. Gonorrhoeal ophthalmia and gonor- rhoeal rheumatism are constantly met with; so also swelled testicle, sometimes called blennorrhagic epididymitis, occurs somewhat frequently as an accompaniment or consequence of gonorrhoeal discharge. The inguinal glands now and then become engorged and even suppurate, while a man has gonor- rhoea upon him. This condition of the glands is to be regarded in the light of a sympathetic affection, — as a bubo, an adenitis, which is no more to be considered a venereal symp- tom than an engorgement of the axillary ganglia, which may take place while a felon is forming on the finger or a vaccine pustule on the arm. Diagnosis. — Candidates for medical treatment occasionally imagine that they achieve a great exploit, if by an ingenious fabrication of stories, they succeed in deceiving the physician in regard to the origin of their blennorrhagia. The physician, on the other hand, has no positive means of distinguishing, in all cases, a simple gonorrhoea, not brought on by impure sexual intercourse, from a specific urethritis caught from an infected prostitute. Although in some rare instances of non- specific urethritis, the symptoms assume great severity, yet it may be laid down as a general rule, that they are characterized by comparative mildness. The inflammation is moderate,— producing but little pain or scalding in micturition; the ure- thral secretion occasions little or no excoriation of the parts with which it comes in contact, and the complaint yields to gentle treatment. BLENNORRHAGIA. 13 As an instance of the devices resorted to by patients for purposes of deception, let me present the following Case. — A married man who was of good standing in his neighborhood, called upon me one day for the cure of a recent blennorrhagia. His wife was a woman of irreproach- able habits and was in good health. The husband denied all improper behavior, and knew no more than "a dead man" how he could have contracted his disease. I told him that as far as treatment was concerned, it was no matter, — and pre- scribed copaiba capsules. At his second visit he stated that he had ascertained the source of his gonorrhoea. One even- ing, just previous to the commencement of his urethral run- ning, he attended a ball, at which he wore a pair of trowsers, borrowed of a friend, who had the clap. My patient got rid of his gonorrhoea in about three weeks. Scarcely had a twelvemonth elapsed, before he presented himself for the treatment of secondary syphilis. Tubercles and pustules were scattered upon the face; — the arms and legs were the seat of numerous pustular blotches and ulcers; — the buccal cavity also showed several well-marked syphilitic sores. The man now acknowledged that he had long been intimate with lewd females, — that he had suffered from primary syphilis before he consulted me, — and that the exigency of the cir- cumstances he was in, induced him to withhold the truth in regard to the symptoms, for which he first consulted me. After all that can be said, the physician must form his diag- nosis, in very many cases, from extraneous circumstantial evi- dence added to that derived from the symptoms themselves. Syphilographers tell us that if a discharge come on only a few hours after connection, and if it have continued several days without inflammatory symptoms,—if the patient have been sub- ject to some discharge, after an excess of venery or of wine,— in all such cases it is probable that he labors under some other form of urethral disease, and that although the intercourse of the sexes may have been the exciting cause, still there may be no imputation on the purity or cleanliness of the female. The hypothesis founded on all these circumstances may be safe in some cases, in others not. In November, 1856, a young man consulted me for a blennorrhagia, which appeared within forty- 2 14 GONORRHOEA AND SYPHILIS. eight hours after he had connection with a woman of the town. The discharge had existed four days, and was very copious. The other symptoms, usually attendant on urethritis, were very mild. The patient stated that he had frequently been troubled with the same complaint, but that it had never set in so soon after exposure as on this occasion. He led a seden- tary but dissolute life. The disease degenerated into a gleet, which lasted six months, and was finally cured by the applica- tion of cantharidal collodion to the penis. That this was an instance of specific gonorrhoea, arising from impure connec- tion, I do not doubt. I have occasionally met with similar instances. Where the urethra has suffered from repeated at- tacks, and where the patient is a hard drinker, as was this young man, the phenomena of the complaint do not appear with the same regularity as to time or character, as in a first blennorrhagia, and in an individual not addicted to excessive libations. The average interval between exposure and the occur- rence of the blennorrhagic secretion is from four to five days. This fact may help to form a tangible basis, on which to con- struct a differential diagnosis. All deviations from the time here specified are to be considered as exceptional cases, de- pendent on peculiar circumstances. Symptoms. — In relating the history of symptoms, patients generally state, that within twenty-four hours after suspicious coitus, they begin to notice strange sensations along the ure- thral canal, such as increased heat, irritation, itching, etc. There is scarcely any period of incubation or absolute dor- mancy. The virus commences its action almost from the mo- ment it is deposited. The disease, at first, consists of a little discharge from the lips of the meatus urinarius, which are glazed over, or perhaps become patulous, red, and slightly tumefied. On squeezing the organ, the morbid exudation slides along the canal, and runs down upon the fraenum in thick, transparent, ropy masses. These symptoms constitute the initial stage of blennorrhagia. By the second or third day from the first appearance of the mucous secretion, the inflam- mation acquires more intensity. The discharge becomes more abundant, and instead of being merely a glutinous substance, BLENNORRHAGIA. 15 it is changed to purulent matter — is more consistent — of a greenish yellow tinge, and emits a disagreeable, nauseous odor, wholly different from that of ordinary pus. The efflu- vium is sometimes so strong and impressive on the olfactories, that the practitioner recognizes the nature of the case before the patient tells what ails him. This disgusting symptom, when once noticed, will ever afterwards be remembered, and needs no further description. By the time the secretion be- comes puriform, the patient begins to complain of ardor urinae, and has frequent calls to urinate. The inflammation diminishes the normal calibre of the urethral canal, and consequently the stream of urine is small and flattened. The shaft of the penis is enlarged, and the glans assumes a dark red color, is tender to the touch, and very likely excoriated. If the inflammation be limited to the fossa navicularis, as it usually is for several days, the pain in micturition will also be confined to this spot. If the organ be pressed between the thumb and finger, the pa- tient will complain of being hurt at this part, and the physician will here also detect distinct induration and abnormal thicken- ing of the urethra. If the disease should advance, and the bulbous portion of the canal be implicated in the inflammatorv process, pain will be felt along the perinaeum, especially when the patient undertakes to walk about. If the prostate become affected, the distress will be felt farther back; there will be pain and an uncomfortable degree of heat and throbbing about the rectum, with tenesmus and incontinence or retention of urine. Another quite frequent and annoying symptom is the occurrence of involuntary and painful erections at night, which interfere with, or wholly prevent, quiet repose. At this junc- ture, still other morbid phenomena will arise, unless those al- ready mentioned are subdued. Pains in the head, in the lum- bar and inguinal regions will set in; the tongue will be thickly coated, the pulse accelerated, the mouth parched with thirst, and the skin hot and dry. Blennorrhagia presents various degrees of severity in dif- ferent subjects. The first attack is generally attended with the most acute symptoms, especially if the patient be young and plethoric, or of a scrofulous diathesis. In the latter class the constitutional disturbance is sometimes of an alarming type. Extensive abscesses form in some portion of the genital 16 GONORRHOEA AND SYPHILIS. organs or in their immediate neighborhood, accompanied with inflammatory fever and irritation of the nervous system, and the patient's life is endangered. In those who are liable to eczema and other eruptions of the skin, the blennorrhagia is prone to assume a chronic character from the beginning, and is then difficult of cure. Sometimes, notwithstanding every judicious medical attention, the complaint progresses steadily from day to day for several weeks, the discharge increasing in quantity with corresponding augmentation of the other symp- toms. In such cases, if the previous habits of the patient can be ascertained, it will generally be found that he has led an irregular life, or that he is susceptible to inflammatory affec- tions of the mucous membranes; and the system refuses to re- spond to the usual influence of anti-blennorrhagic agents. Persons who have had several fresh attacks of this malady, suffer for a longer time from each successive one, although the symptoms do not acquire so high a degree of intensity as they do in the first gonorrhoea. Blennorrhagia often subsides into a chronic form, and termi- nates in blennorrhcea or gleet. The amount of discharge is reduced to two or three drops in the twenty-four hours. In some cases it is noticed only in the morning; in others, the ori- fice of the urethra is constantly moistened with it, or its lips are sealed together a great portion of the time in consequence of the drying up of the exudation. The fluid is of a serous or mucous character. If pus globules be present, they sepa- rate into a pellicle by themselves, and leave a small, yellow stain upon the patient's linen. Sometimes the gleet is intermittent. It will disappear for several days, and then, in consequence of some imprudence, will again return. Any irregularity or indulgence on the part of the patient, or any impropriety in treatment, may result in a permanent establishment of this trifling but annoying secre- tion. Contagion. — It is impossible to say at what period the spe- cific, contagious element ceases to form a component part of a blennorrhagia. It is more persistent in the female than in the male. Hunter mentions the case of a girl, who had been two years in the Magdalen Hospital, and who infected a man with BLENNORRHAGIA. 17 whom she had connection immediately after she left that insti- tution. The only safe rule for the medical adviser to adopt in giving counsel to those who seek it, is this: while there is any morbid discharge from the genital apparatus, either in the male or female, the patient must be regarded as a source of contagion, so far as relates to sexual intercourse. This is the only pru- dent ground for all parties; and it is fit here to express a word of caution relative to this subject, inasmuch as there are Clau- dios in every community, — men of ardent and impulsive tem- perament, who have no control over their animal proclivities; and who, while a tedious gleet is upon them, propound to their medical attendant the question above alluded to, — and they will insist on a decided answer. These men sometimes turn out to be dangerous characters in more ways than one ; and the young practitioner should be on his guard how he re- plies to such inquiries. The questioner may have an ulterior purpose to accomplish, apart from mere sexual gratification ; and the moral responsibility of what he designs to do, he aims to shift, in part at least, upon the shoulders of the physician. Unless you give an unequivocal answer in the negative, he may commit the act; and if evil consequences arise, he will lay the sin at your door. He will upbraid you for sanctioning- his views, and thus virtually making yourself a party to the affair. Such stratagems have been employed to the disadvan- tage of the young physician. Another subject of greater moment than the one just spoken of, is frequently presented to the medical adviser for his de- cision. I refer to matrimony. For instance: a young man has for several months been troubled with an insignificant dis- charge, which appears at the urethral orifice as a small tran- sparent or opaque drop every morning, or perhaps only every other morning. He has made arrangements to marry within a certain time, and any proposition for, or intimation of, post- ponement, might be regarded as a strange and suspicious movement. He has sufficient respect for you and for the other party to seek your advice, which he intends to follow. Now, as an intelligent and conscientious counsellor, can you ' encourage this man's marriage before his blennorrhcea is cured? It is doubtless true that if the gleety fluid contain no pus cells, it can do no mischief; and married men, who have blennor- 2* 18 GONORRHOEA AND SYPHILIS. rhoea, have often stated that they have indulged in sexual inti- macy with their wives, without imparting disease. One reason for this immunity in females, when thus exposed, is, that the inner membrane of the vagina is protected by the presence of abundant mucous secretion during coition; and it is fortu- nate for them that this physiological condition exists in such a crisis. Although it is admitted that in most instances gleety secretions are harmless, so far as relates to contagion, yet we possess no means of determining, in all cases, when this ele- ment is present and when it is not. Blennorrhoeal matter is not uniform in its constitution in the same individual. The amount of pus globules differs at different times. Any high excitement will augment their number, and sexual intercourse is one of the chief causes of this purulent increase. Unless a sample of blennorrhoeal exudation were to exhibit the purity of distilled water when examined with a high magnifying power, no man would be justified in the conclusion that it was bereft of its noxious properties. In announcing his opinion, it is enough for the medical man to know that under certain circumstances and conditions, gleet is communicable. Cases are recorded of contagion thus communicated, and giving rise to most disastrous domestic unhappiness. M. Vidal relates two such. The disease was considered of no importance, and marriage was permitted. Separation of the parties was the result in both instances. CHAPTER II. TREATMENT OF BLENNORRHAGIA IN THE MALE — CATHARTICS — FOMENTATIONS — INJECTIONS OF NITRATE OF SILVER--DANGER OF—BALSAM OF COPAIBA-- CAPSULES--IMPORTANCE OF REST--CUBEBS — RELAPSES OF GONORRHOEA-- CASES--INJECTIONS IN GONORRHOEA--PAINFUL ERECTIONS AND CHORDEE-- LUPULIN--CAMPHOR--URETHRAL HAEMORRHAGE--CASES. In the male subject, the anterior or balanic portion of the urethra is in a majority of cases the primary seat of gonor- rhoea ; and the precise point at which the irritation commences is the fossa navicularis. From this focus the disease may extend until the canal is implicated throughout its whole length, unless an effectual check be put to the morbid action by what is termed the abortive treatment. If the patient apply to the surgeon within twenty-four hours from the first appearance of the discharge, the use of injections may in some instances be resorted to with success. In the generality of cases, it is well to order a brisk cathartic before com- mencing with other remedies. A free action upon the bowels by some saline medicine, will pave the way for beneficial results to be realized from the employment of injections and from large doses of balsam of copaiba or the powder of cubebs. In the treatment of all cases, whether by the abortive method or otherwise, it is important, in every stage of the complaint, to guard against a constipated condition of the alimentary canal. In this particular, advantage may be gained by at- tention to diet. The free use of oranges, dates, or figs, — a bowl of oatmeal gruel sometime in the after part of the day, will do much towards accomplishing all needful purposes in this direction. If repeated evacuant medicines be given, they will be liable to interfere with the digestive functions, — will render the bowels more and more torpid, — and an increase of the dose will be needed on every successive occasion. In many instances, where free purgation is resorted to, a long and tedious course of treatment is required. Patients of 19 20 GONORRHOEA AND SYPHILIS. their own accord often pursue a cathartic plan for several weeks, and then report that their urethral difficulty is as troublesome as at the beginning. At least, there seems to be no prospect of its termination, in consequence of the increased action performed by the alimentary canal. It is important, as auxiliary to more direct and specific measures, to maintain a decidedly open condition of the bowels; but not to annoy the patient by constant doses of sharp, drastic medicines. Fomentations. — As a local remedy, hot water fomentations exert a most favorable influence in allaying the severity of the symptoms attendant on acute blennorrhagia. They should be applied to the penis and its dependencies for fifteen or twenty minutes, many times in the twenty-four hours. Used in the early stage, and at as high a temperature as can be endured without actually blistering the parts, they serve to lessen the irritability of the urethra very speedily; — they allay the pain and scalding in micturition, and relieve the patient of the sen- sation of dragging weight in the testes, and about the peri- naeum and hips. On removing the fomentations, the parts should be covered with a single thickness of soft linen. I was first induced to try this method of applying heat and moisture on the recommendation of Mr. Milton.* The utility of the procedure in soothing the diseased organs and the patient, I have repeatedly witnessed. In fact, in nearly all cases where the fomentations have been faithfully tried, the anodyne effect has been immediate; and no untoward result has ever followed. If there be tumefaction and pain in the glans,— or if the patient be tormented with chordee, the employment of this cleanly and simple remedy will prove highly serviceable. It needs no addition of poppy-heads, opium, or lead. Its therapeutic action cannot be improved by any medication. The patient should be restricted to a low diet, and directed to maintain entire bodily repose. By the adoption of these ectrotic measures, he may be saved from a long and tedious gonorrhoea or gleet, and from various complications, which occasionally appear and terminate seriously. * It is recommended also by Mr. Acton and other surgeons. BLENNORRHAGIA. 21 Injections of Nitrate of Silver. — It was formerly be- lieved that a strong solution of this salt, employed as an injection, occasioned stricture; but the idea now is, among those who are partial to its use, that, instead of producing, it prevents that accident. Whether this theory be true or false, I pretend not to say; but in regard to what are called strong in- jections of silver, I can state that I never prescribe or use them. There are others, however, who do ; and a few paragraphs must here be devoted to a consideration of their employ- ment. If the injection be resorted to before the inflammatory stage has commenced, that is, before the patient complains of scalding in micturition, it will sometimes prove an efficient agent in at once cutting short the disease. Of this there is ample testimony from the highest sources; and there may be cases even in private practice, in which the measure is impe- riously demanded. Ten grains of the salt to the ounce of rose water is the usual proportion. The bladder should be emptied immediately before the solution is employed, so that the urethra may have a chance to rest for several hours after- wards. A glass syringe, in perfect working order, is the best. One drachm of the solution will be enough. As soon as the operation is completed, let the patient recline on a bed or sofa, and have warm fomentations applied to the parts for two or three hours. One injection introduced during the initial stage of the blennorrhagia, and allowed to remain in the urethra for about one minute, is sometimes sufficient to annihilate the morbid action. If the secretion still continue, and exhibit a puriform character, the injection is to be repeated in twenty- four hours, as on the preceding day. If two injections fail to accomplish the desired results, there will be little encourage- ment to make a third trial with this heroic and severe prepa- ration. An injection of three or four grains of the nitrate to the ounce of water is much safer than one of greater strength. It can be repeated three or four times in the twenty-four hours, unless evident ill consequences ensue. This compara- tively weak injection may be retained three or four minutes by pressing upon the orifice of the urethra after the syringe is withdrawn. The manner of manipulating with this instru- ment is a matter of no small importance. The surgeon should use it upon the patient once or twice before entrusting it to 22 GONORRHOEA AND SYPHILIS. his hands. The point should be inserted to the distance of an inch, and the injection allowed to traverse the whole length of the urethra. It will thus be certain to come in contact with the seat of disease, in whatever part of the canal it may be. At the moment the instrument is introduced, the penis should be turned upward in nearly a perpendicular position, and the lips of the urethral orifice be pressed with the thumb and forefinger of the left hand. The untimely escape of the injection will thus be prevented. If no good effects are realized by the third day, the injection will not succeed at all, and should be abandoned. Although the abortive treatment is productive of the most beneficial effects in certain cases that present themselves to the regular practitioner, it is manifest that the number of such must be comparatively small. If the discharge have existed more than a day and a night, before the patient applies for relief, it will be too late to make trial of the revulsive method; for the inflammation, in nearly all cases, will be too acute to justify such a procedure. The favorable moment for a fair experiment has been lost; and if now the parties have courage and confidence to engage in it, they will but prepare the way for unwelcome retrospections. The discharge, instead of being a slight adhesive mucus, has become decidedly purulent, and the patient is troubled, although perhaps not severely, with ardor urinse and other disagreeable symptoms. This state of things is a declaration that the disease has reached a considerable portion of the urethra. Patients are not slow to importune the physician to adopt, at once, the most efficient course of treatment, with the view to a speedy cure. In their impatience and ignorance, and in the hour of their desperation, perhaps, they manifest a readiness to encounter no little hazard and temporary suffering, which the employ- ment of any remedial means may involve, provided the disease, to use their own words, " can be knocked in the head." They generally have great faith in injections of some kind; and in regard to their employment in any individual case, the exer- cise of a good share of independence, as well as sound judg- ment, is requisite on the part of the young surgeon,— otherwise he may be unduly influenced by the solicitations and suggestions of the patient blennorrhagia. 23 The abortive treatment has the sanction of the most eminent surgeons. The most important element in it consists in the use of strong nitrate of silver injections. Every practitioner must see that this mode of assailing the disease in its hidden retreat, is attended with risk, especially if a solution of ten grains to the ounce be employed. It is, as it were, attacking the enemy by storm. The syringe, charged with the potent liquid, cannot, at any rate, be wielded by the patient with entire safety; nor can the danger attending its use be essentially di- minished if the instrument is handled in the most adroit and cautious manner by the surgeon ; for, from the very nature of things, even he cannot regulate the precise degree of local impression produced by the fluid. In this particular it will obey no man's wishes. The instant it is forced from its con- finement it glides like a swift torrent along the urethra; and its work, whether for good or for evil, is accomplished instan- taneously. The intense pain which always follows the application of the strong injection, is a serious drawback upon its use. Another objection is, that in many instances it not only fails to benefit the complaint, but creates an aphthous condition of the mucous membrane, or sloughing ulcerations, which prove exceedingly troublesome, and are often more difficult to cure than an or- dinary gonorrhoea. M. Vidal relates the case of a man, whose absent wife was expected home in a very short time after he discovered that he had contracted a gonorrhoea. He applied to Vidal for a sure method of at once arresting the disease ; and as that judicious surgeon could not promise this, the pa- tient consulted another man, who advised a caustic injection, which brought on a severe inflammation of the canal and of the bladder. Vidal was finally requested to take charge of the patient, who was confined to his bed for a month in conse- quence of the over action of the injection. Langston Parker mentions the case of a medical student who contracted a blen- norrhagia, to cure which he used in the incipient stage a strong solution of silver. An intense urethritis followed, with pains in the abdomen and groins. The young man had peri- tonitis and an immense inguinal abscess, of which he died in one week. From the moment the use of the syringe is commenced, an 24 GONORRHOEA AND SYPHILIS. exacerbation of the urethral inflammation is liable to ensue; the discharge also increases, and in some instances the testes suddenly enlarge to three or four times their normal size. Some patients, not of a sanguineous temperament, will tolerate stimulating, and even somewhat caustic, injections with im- punity, — perhaps with advantage; but if in any given in- stance a peculiar susceptibility should exist, the fact cannot be known until the remedy has been tried. In such a case, al- though the lesion may occupy but a mere point before the injection is introduced, it may, immediately afterwards, and as a direct consequence, extend indefinitely to the sound portions of the canal. The spontaneous tendency of the disorder is to spread along the mucous membrane, and even to penetrate the deeper tissues; and any auxiliary impulse from the hands of the patient or physician, might augment the mischief. If the surgeon can have entire control over the patient, and be certain that his directions will be carried out to the letter,— as for instance, where the case is admitted within the walls of a well regulated hospital at a seasonable time, — then the abor- tive treatment may be entitled to all the confidence, praise, and success, which its advocates claim for it; but for ordinary private practice, too many objections lie in the way of its adop- tion. Balsam of Copaiba.— No article in the Materia Medica enjoys a higher reputation for the cure of blennorrhagia than this. For many years it has been a favorite remedy both in public and private practice. The late Professor Chapman of Phila- delphia was the first physician in this country to recommend the balsam in the early stage of gonorrhoea; and on his au- thority physicians generally were induced to prescribe it. Its anti-blennorrhagic powers have been most amply tested and universally acknowledged. In very plethoric subjects, who are accustomed to high living, it is well to relieve the inflam- matory symptoms, in the early period of the urethritis, by a smart saline cathartic, before commencing its use. This class of patients occasionally suffer from the severest forms of the disease, accompanied with intense pain as one of the most prominent features. In such circumstances, the case should be conducted for a short time on a strictly antiphlogistic plan, BLENNORRHAGIA. 25 without reference to the specific cause in which it originated. As soon as the local symptoms have abated, the copaiba and other anti-blennorrhagic remedies will be appropriate. Cases, however, requiring such antecedent preparation, are very rare. In the great majority of subjects, the occurrence of painful erections, chordee, scalding in micturition, and other concomi- tants of inflammation, constitute no barrier to the immediate use of the balsam with as much freedom as the stomach and bowels will tolerate; for no other remedy can be selected, that is so well adapted to allay these phenomena, and relieve the patient of the sufferings which they inflict. It might at first view seem paradoxical that an ingredient endowed with such decided stimulating qualities, should be beneficial under such circumstances; but experience has abundantly established the fact. It has long been known by many practitioners to exert a salutary effect in some other diseases of the genito-urinary passages. In strangury from blisters, and in leucorrhoea, it may often be administered with signal relief to the patient.* Although, when given internally, it may be regarded almost as a specific in urethral blennorrhagia, its therapeutic qualities are confined to this variety of the disorder. Its nodus oper- andi is not well understood. When copaiba acts as a purgative, the urethral discharge will frequently be very much diminished, — sometimes will en- tirely cease; but it will usually immediately return as soon as the revulsive action upon the alimentary canal subsides. In order to secure its best effects upon the gonorrhoeal af- fection, it is frequently advisable to combine it with some as- tringent or sedative. There is a great disparity in the purity and curative value of different samples of the medicine in question. It is often adulterated and rendered unfit for use by being mixed with rape oil. When thus adulterated, if dropped into water, the drops do not retain their spherical form, as they invariably do in the pure state, f Professor Redwood, of London, states that the oleo-resinous properties of the balsam exist m very different proportions in different samples. The quantity of volatile oil has been found to be twice as great in some sam- * Vide Chapman's Therapeutics, Vol. i. page 416. t Journal de Pharmacie et de Chimie, Vol. xi. 3 26 GONORRHOEA AND SYPHILIS. pies as in others. In order to estimate its purity, the article must be resolved into its proximate constituents, and these be examined separately. The proportion of volatile oil in different samples met with in commerce, is, in some cases, as low as thirty per cent, and in others, as high as sixty per cent; and the pro- portion of resin, which differs but little from common resin of turpentine, varies also to about the same extent. If a drop of the balsam be allowed to fall upon sized paper, and then dried by a gentle heat, the odor of the turpentine can easily be de- tected during the evaporation, if it has been adulterated.* To some persons the taste and odor of the copaiba are ex- tremely offensive, a circumstance which may greatly interfere with its use; and it is difficult to know how to give it so that the stomach of such individuals will not reject it. It is retained best if taken about half an hour after meals. The eructations are thus rendered less offensive. It may be taken in coffee or wine ; or what is perhaps better, let about a drachm of the compound tincture of cinchona be put into half a gill of water, and then drop in the copaiba. It will rise to the surface in the form of a globule, and can be swallowed by most patients without offending the gustatory apparatus. But a still more agreeable and convenient method of administering it, is the following: — E. Copaibas,..............................................5 nJ- Spiritus iEtheris Nitrici,.................................§ ss. Tincturae Kino,........................................5 ss- Misturse Camphorse,....................................§ ij. Morphiae Sulphatis,....................................gr. v. M. Dose. One teaspoonful three times a day. Usually, an efficient check will be put to the blennorrhagia in eight or ten days by the use of this preparation. No medi- cine is more prompt or certain in its action than the balsam, although it is difficult entirely to disguise its nauseous quality by any vehicle in which it may be given. With the exception of its bad taste, it is as exempt from objections as any other remedy. If taken with ordinary prudence, it never gives rise to any serious accident. It produces no stricture, no chordee, no swelled testicle, no irritation of the bladder, no gleet. Pa- * Dublin Quarterly Journal of Medicine, Vol. v. BLENNORRHAGIA. 27 tients have taken two, four and eight drachms at a dose, morn- ing and night, at the very onset and in the most acute stages of gonorrhoea, with entire success and without any prepara- tory treatment. Such doses, however, are not safe. Instances are recorded where large quantities have been resorted to by the patient, on his own responsibility, and the result has been an increase of the urethral inflammation and discharge. Incontinence of urine has been induced by excessive doses. A few years ago a gentleman from the South consulted me for a recent gonorrhoea. He had taken lodgings at a large hotel in company with some friends, and for fear of being detected, he desired that a cure might be accomplished in the most summary manner. I prescribed the balsam in half drachm doses three times a day. Instead of following the directions, the patient took nearly half an ounce after a supper of oysters, and at a late hour went to bed. It was not long before he was seized with a sort of cholera morbus, — that is, he had griping pains in the stomach and bowels, — vomiting and purging, which lasted several hours. His urethral trouble vanished and did not return. The severe gastro-enteric attack doubtless served as a coup-de-main in extinguishing it. When a person applies for treatment and is particularly anx- ious to be speedily rid of his gonorrhoea, he should be advised, as already stated, to abstain from exercise. If he would be delivered from his trouble in the shortest possible time, he can receive this boon only by keeping still; and unless he conform to this condition, it will be a vain task to attempt a rapid cure by any course of treatment. The mere fact that the individ- ual is abroad, whether on business or pleasure, will effectually prevent any remedies from accomplishing a speedy removal of his blennorrhagia. And it is the province and the policy of the medical attendant to state these things in the most explicit manner. If the man be unable or unwilling to pursue the plan proposed, he should be distinctly informed that the time re- quisite for his cure admits of no sort of calculation. It may be several weeks, or it may extend to many months ; and all this, because a few important items in the management of the case have been disregarded. In adjusting preliminaries, a good understanding between the parties should exist. The physician, from the very fact that he takes charge of the case, 28 GONORRHOEA AND SYPHILIS. pledges himself, by a moral contract, to employ the best means within his knowledge for the benefit of his patient; and the latter, on his part, is under equal obligation to cooperate with the physician in carrying out the prescribed treatment. By the observance of such an arrangement, a safeguard is created against all future collision, which might otherwise spring up and seriously disturb the amicable relations of the two par- ties. Among those who seek the aid of the surgeon for the cure of disease resulting from improper commerce with the oppo- site sex, it need scarcely be said that a troublesome fellow now and then presents himself, who does not hesitate to take ad- vantage of his medical adviser, in some way or other, especi- ally if the latter be a young practitioner. Some individuals are extremely exacting, and will wittingly endeavor to extort strong assurances as to a cure ; and afterwards, if the treat- ment do not progress favorably, they will allude to some cas- ual expression that escaped the physician, and charge him with a lack of skill, while they themselves, from recklessness or something worse, have been doing little else than placing bar- riers in his way, and defeating the best and most assiduous efforts which he has employed in their behalf. In such cases —and I have certainly known such—the physician does every 0 thing within the range of medical science, while the captious patient does next to nothing in the right direction. These re- marks are not a mere irrelevant digression. They have been suggested by the fact that young surgeons somewhat fre- quently express regret that in identifying themselves profes- sionally with cases, they have, from sentiments of delicacy, or from apprehension of losing practice, omitted to enforce the claims due to them from the patient, and in consequence of their pusillanimity have experienced nothing but disappoint- ment and loss. But let us return to the consideration of the direct physical treatment. Capsules of Copaiba. — Individuals are occasionally met with who cannot use tne liquid balsam. The stomach refuses to retain it, or perhaps no little gastric distress is experienced, although the medicine may not be vomited. In such cases the remedy can be administered in capsules, and its objectionable BLENNORRHAGIA. 29 qualities will be less likely to disturb the patient. They should be taken soon after eating, and as freely as the stomach will bear. Capsules, containing a combination of copaiba and the extract or oil of cubebs, are kept by all good druggists ; and sometimes I have found them more efficient than those com- posed of copaiba alone. Where it may be deemed important to employ, with the co- paiba, remedies that exert an anodyne influence upon the organs, as well as a modifying agency upon the qualities of the urine, the subjoined formula will be found useful:__ R. Copaibae,.................................... Magnesias Calcinatae,............................. Extracti Hyoscyami,............................. Pulveris Camphorae,............................. Theriacae,............................. Micae Panis..................................... M. ft. electuarium. Dose. One drachm three times a day This is a favorite prescription of Mr. Acton. He claims for it that the magnesia neutralizes the urine, that the hyos- cyamus allays irritation of the bladder or prostate, and that the camphor checks any disposition to involuntary erections, which, without it, often become a troublesome complication. A combination of the balsam with the powder of cubebs makes a good compound, and may be employed according to the annexed prescription : — R. Copaibas,..................... Pulveris Cubebas, aa,.......... Liquoris Potassas,............. Misturas Camphoras,........... Aquas Cinnamomi,............ Morphias Sulphatis,............ Dose. Two drachms three times a day In whatever form or combination the balsam is adminis- tered, the patient should be directed to continue its use in gradually diminished quantities for ten or' twelve days after the blennorrhagia has entirely ceased. ■•" Copaiba as an Injection. — The repeated experiments of Ricord, Egan, and others, tend to show, that the balsam of 3* 3vi. 3iss. 3ss. 3i. 3 iij. §iss. 3"j- • Sir. ■S«. gr. v. M. 30 GONORRHOEA AND SYPHILIS. copaiba, when employed as an injection, has no power to arrest gonorrhoeal secretion, nor to allay the irritable and inflamed condition of the urethra. The theory is, that the remedy requires to undergo a certain modification, which can only be effected by its transit through the kidneys, before it can exert any salutary effect on the urethral disease. What this transformation or change is, has never been demonstrated. Very recently, statements have been made by M. Dallas of Odessa, and by Dr. Dick of London, to the effect that they have employed the balsam as an injection in gonorrhoea with complete success. The former surgeon reports sixteen cases treated thus, without any auxiliary measures. The latter gentleman states, that for the last two years he has employed the copaiba as an injection with excellent benefit. He has also tried the oil of copaiba, which, he says, answers extremely well. For the last mentioned substance the following is his formula: — R. Olei Copaibas,.......................................3i. Pulveris Acacias.......................................3ij. Aquae Fontanae,.......................................3 vi. M. In subacute gonorrhoea and in gleet, this injection may be used twice a day for a few days; afterwards more fre- s quently. Successful results have been reported of the balsam when used as an enema for patients who could not tolerate it on the stomach. I have never made trial of it in this manner; but Velpeau speaks favorably of it when thus administered. The following prescription can be employed : — R. Copaibas,.............................................3;; Mucilaginis Acacias,...................................? iss> Tincturas Opii,........................................3 ss. ]yj For an enema, which may be repeated two or three times in the twenty-four hours. Cubebs. — The reputation of this therapeutic agent, in exert- ing an immediate and favorable specific action upon the lining membrane of the urethra in all stages of blennorrhagia, is fully established; and by many surgeons it is more frequently pre- scribed for its cure than any other article in the materia med- BLENNORRHAGIA. 31 ica. The dried, unripe berries, are the officinal portion. Like the balsam of copaiba, they possess stimulating qualities, which are particularly exerted upon the urinary organs. They occa- sion constipation in some patients; in others, just the reverse. The berries of cubebs are sometimes adulterated with com- mon black pepper. They deteriorate by age ; and in powder, become rapidly weaker in consequence of the escape of their volatile oil. They should therefore be kept whole ; or, if pul- verized, should be preserved in a glass jar with a close stop- per. Of the powdered berries the patient may take one or two drachms three times a day in a gill of milk or water. Or, the powder may be used in what is called the enchanted wafer, a French article found in many drug stores. I have prescribed the remedy in question alone, and variously combined with other ingredients. The annexed formula I have commonly employed for the last few years : — R. Pulveris Cubebae,.....................................5 vu'- " Cinnamomi,..................................3 i- " Aluminis,....................................%i. M. Div. in chart. No. xxxii. Dose. One powder three times a day. This combination of cubebs and alum will usually diminish the urethral discharge in two or three days; and if the patient will comply with the suggestions already given in regard to absolute rest, he will find that in eight or ten days his blennor- rhagia will be nearly at an end. But let him recollect that first of all things, he should make up his mind to observe a per- fectly quiet state of body; and even to keep in a recumbent posture if he expects to experience the best effects in the shortest time. I have occasionally heard physicians speak, with self-complacent air, of making rapid cures in the majority of instances that come under their charge. Such success may have happened; but when it has, I am sure that the strictest avoidance of exercise must usually have constituted an ele- ment or condition in the treatment. The precise time requisite for a complete and permanent restoration of the parts to a nor- mal state, is as uncertain as the winds ; and in specifying the number of days, within which to cure a given case, the young practitioner had better show his wisdom by his prudence. As with the balsam copaiba, so with the cubebs; they should 32 GONORRHOEA AND SYPHILIS. not be discontinued under a fortnight after the cessation of the urethral discharge. Some excellent surgeons give two ounces of the cubebs in the twenty-four hours. This, it seems to me, is an excessive quantity, and not entirely safe. Well- authenticated instances have been reported of hernia humoralis being induced by large doses of the powder, while the blen- norrhagia was thick and puriform, with scalding in micturition, chordee, etc. In one case, the dose was two drachms, four times a day. The disease was suddenly arrested, and swelling of the testicles, with much inflammation of the cord, super- vened. The patient was confined with this complaint for two months. On the subsidence of the glandular affection, the blennorrhagia re-appeared; was again puriform and thick, but not attended with urethral pains. Subsequently the discharge yielded to small doses of the cubebs. Another instance of gonorrhoea, accompanied with severe scalding, was treated with cubebs; the discharge was suppressed; but acute inflam- mation of one of the testicles and cord succeeded. There was great effusion into the tunica vaginalis of the testes, and sup- puration was threatened. * Accidents, however, from the use of cubebs, are extremely rare. Some physicians imagine that they are not well adapted to cases in the acute stage, where the inflammation runs high. It is always the more prudent course to order the patient a cathartic, after the operation of which, he may commence with the cubebs, without regard to the degree of urethral inflammation that may be present, un- less it be of the most intense description. I have many times tried the article with plethoric subjects, and have never seen any trouble from its use, nor had occasion to regret that it had been employed. Cubebs will sometimes speedily arrest blennorrhagia under very unfavorable circumstances, as will be seen by the follow- ing case, which is an exception to the general rule. October 1, 1856.—A gentleman, thirty-six years of age, un- married, consulted me for the cure of an acute gonorrhoea, which had troubled him for eight days. He had all the ordi- nary symptoms of the complaint, — scalding, the glans swollen and of a fiery red color, oedema of the lips of the meatus, and * Med. Chir. Review, Vol. xxm. p. 550. BLENNORRHAGIA. 33 copious, puriform secretion, sense of dragging weight in the scrotum, etc. He was a stout athletic man, actively engaged in out-door business in co-partnership with another person; and he stated that it would be impracticable for him to omit work for a single day, as this would lead to inquiry and per- haps to exposure, — that if I would prescribe a proper line of treatment, he would be content. As to the time that might be required to accomplish a cure, and in regard to any ill results that might ensue in consequence of his not abstaining from business, he would take his chance, and would absolve me from all responsibility. He resided more than one hundred miles from Boston, and could not conveniently see me until several weeks. The following powders were ordered: — R. Pulveris Cubebae,..................................3 x»- " Cinnamomi,................................3 iss. " Aluminis,.................................§ iss. M. Dose. — Two drachms three times a day in water. He took the powders for five days, when his blennorrhagia and its accompaniments wholly disappeared. He discontinued the medicine as soon as the urethritis ceased. This was con- trary to the directions given him. He did not abate his ac- tivity in business for a single hour. In three months after the gonorrhoea was cured, he discovered a gleet amounting to two or three drops during the twenty-four hours, — of thin, trans- parent, glutinous fluid, that did not stain his linen. For this secretion, he resumed the above medicine, of which he had a supply. After a trial of it for nearly three weeks without re- lief, he called a second time for advice. He was directed to take from six to eight capsules of balsam of copaiba and oil of cubebs, per diem, for the gleet; and in fifteen days after com- mencing with them, was well, and had no relapse. The tincture is an elegant and convenient form of adminis- tering cubebs. It may be given in doses of one or two drachms, four or five times a day; or be combined with other agents of well known efficacy in gonorrhoeal affections, thus:— R. Tincturas Cubebae,...................................5{J- " Cantharidis,................................5 •SSi Misturas Camphoras,.................................3 iij. Morphias Sulphatis,..................................gr. iij. M. Dose. — Two drachms three times a day, in half a gill of cold water. 34 GONORRHOEA AND SYPHILIS. There is one other preparation of cubebs, which contains all the medicinal properties of the berry, and may be combined with mucilage, so as to constitute an agreeable and efficient dose. I refer to the fluid extract, which may be prescribed thus:— R. Extracti Cubebae,....................................3iv- Mucilaginis Acacias,................................. Misturae Camphoras, aa,..............................3 'J- Morphia: Sulphatis,..................................Sr-iy- M- Dose. — Two drachms three times a day, in half a gill of cold water. Some medical men are altogether skeptical as regards the curative properties of cubebs; but I am confident that those who do not acknowledge its value in cases of blennorrhagia, cannot have made a fair trial of the pure article. Specimens of the pulverized berries, that have deteriorated from having been exposed in large jars, imperfectly closed, are occasionally met with in druggists' shops. If such a medicine be pre- scribed, no wonder that it leads to disappointment and distrust. Besides the prescriptions already given for the use of bal- sam of copaiba and cubebs, other combinations maybe tried in cases that resist the more simple and ordinary formulae. The subjoined note embraces several prescriptions which may be found useful. Note. — Buchu has the reputation of being gifted with anti-gonorrhceal powers. Mr. Henry Hancock, recently attached to the British Army, states that he has treated, within a twelvemonth, more than one hundred cases of blennorrhagia by the admin- istration of the infusion of the leaves, with entire success ; rarely having recource to injections, excepting where the disease had been neglected. — London Lancet, De- cember, 1856. The copaiba may be taken with the oil of cubebs, and in some cases will be found to agree better with the stomach than the capsules, or any other combination : — R. Copaibas............................................^ ss. Olei Cubebae,........................................3 ss. Liquoris Potassae,....................................3 iij- Spiritus Myristicas,...................................^ ss. Misturae Camphoras,..................................^ i. M. Dose. — Two table-spoonfuls, three times a day. —Druitt. In chronic gonorrhoea, or gleet, the balsam and the cubebs may be advantageously given with preparations of iron : — BLENNORRHAGIA. 35 RELAPSES IN GONORRHOEA. Notwithstanding the repeated cautions given to patients not to discontinue the use of remedies until several days after the R. Pulveris Cubebae,....................................5 ss- Copaibas,...........................................3 ij- Ferri Sulphatis,......................................3 i- Terebinthinae Chiae,..................................3 iij - M. To be made into boluses of ten grains each. Dose. — From fifteen to thirty a day. Usefully employed in lax constitutions. The cubebs may also be given in powder with the carbonate of iron : — R. Pulveris Cubebae,.................................3 i ad 3 ij- Ferri Carbonatis,................................3 ss ad 3 i- M. ft. pulv. This mode of administering cubebs is much and successfully em- ployed after the acute symptoms of a blennorrhagia have subsided. One powder should be taken three times a day. — Langston Parker. R. Copaibas,...........................................5 iss- Magnesias Calcinatas,................................3 «• Pulveris Aluminis,..................................gr. xv. " Catechu,...................................3 iss. " Opii,......................................gr. xv. Spiritus Menthas Piperitae,............................ " Canellas, aa,................................gtt. xl. M. For an electuary. M. Beyran administers this electuary in subacute gonorrhoea, at the commencement of the discharge, and before the inflammation has extended throughout the urethra; also in the gleet. The dose is a teaspoonful three times a day, in a moistened wafer. When the discharge is arrested, the dose is to be gradually diminished. — Union Medicate, August, 1855. The formula now used at Bartholomew's Hospital is : — R. Copaibas,.........................................gtt. xv. Misturae Acacias,..................................fl. 3 i- Cubebas,..........................................3 i. Spiritus Aetheris Nitrici,...........................gtt. xx. Misturae Camphoras,..........................----3 x. M. The above quantity is to be taken thrice daily. It is a standard prescription at the above institution. It is also ordered for females, when it is thought necessary to administer copaiba to the latter class of patients. — Holmes Coote, on Syphilis. The foregoing preparations of copaiba and cubebs are not materially different in their specific action. Either of them is sufficient to cure all ordinary cases of un- complicated blennorrhagia, and no ill consequences will be entailed upon the patient. But let him remember that to secure the most speedy and desirable results, he must co-operate in all well-directed therapeutic and hygienic measures. In such circum- stances the skill of the surgeon will seldom be thwarted; and there will rarely be occasion to resort to an endless succession of remedies. 36 GONORRHOEA AND SYPHILIS. cessation of the blennorrhagic discharge ; and notwithstand- ing our advice to them not to respond to the calls of business or pleasure, they will, either from necessity or recklessness, disregard the warning; and as a consequence, the enemy will suddenly re-appear, and the battle, which had apparently re- sulted in triumph, must be repeated. It frequently happens that this last condition is worse than the first; for the morbid action, now re-established, will in all likelihood be more persistent, and the indiscretion of the pa- tient may have laid the foundation for an interminable gleet. In cases of recurrence, the inflammation is less intense than at first; but it occupies a larger portion of the mucous mem- brane, extending probably to the posterior part of the canal. It also penetrates into the deeper structures; and whatever method of treatment is instituted for its removal, the remedies are generally less efficacious than in the early period of the disease. The individual himself is also in a less favorable condition. He has become impatient and fretful; is less buoyant with hope, less confiding, less respectful, less inclined to carry out any measure that may be required by the new state of things which exists, and is now, more than ever, re- bellious to all restrictions. Nothing goes right. The following instances of relapse are taken from my record book. Case I. — January 3, 1856. Patient, a young, unmarried man. Gonorrhoea noticed twenty hours ago. Third attack. Discharge moderate, and scarcely purulent. No pain or scald- ing in micturition. Lips of meatus oedematous and pouting. No other symptoms. R. Pulveris Cubebae............................... " Cinnamomi......................... " Aluminis.............................. Dose. Two drachms three times a day in a gill of water Jan. 7. Stomach revolts at the medicine, which was discon- tinued, and copaiba capsules substituted—two, morning, noon and night. Jan. 19. Gonorrhoea stopped. Patient has in part refrained from his usual active habits; but states that he must now fully resume his employment, which is that of a clerk. 5viii. 3i. Si. m. BLENNORRHAGIA. 37 Would continue the capsules. Jan. 25. Discharge has re-ap- peared more copiously than ever. There is no scalding, no pain, no involuntary erection, no chordee. Cubebs and alum as at first, resumed; and as auxiliary, the following injec- tion : — R. Plumbi Acetatis,...................................... Zinci Sulphatis, aa,...................................gr. iij. Aquae Rosarum,.....................................^ v^ ^. Use with a glass syringe three times a day. February 20. Discharge has ceased, excepting a drop or two in the morning for the last five days. Injections and powders omitted ; cantharidal collodion applied to penis. This was repeated three times, when the gleet wholly disappeared. Case II.—Acute gonorrhoea — suspension of discharge — recurrence — cure — suppurating bubo in both groins. January 10, 1856. Patient aged twenty-five ; unmarried; remarkably robust. Gonorrhoea ten days. First attack. Thought it would cure itself, but as it became urgent, he took alarm and sought advice. Discharge profuse and puriform; severe scalding; prepuce inflamed and excoriated; no chor- dee ; inguinal glands somewhat enlarged, but without pain or tenderness. Patient had kept at his business as clerk " down town." Said, that come what might, he could not absent him- self from his post then. He took a dose of sulphate of mag- nesia, after the operation of which, he was put upon the use of the compound cubebs powders, — six drachms per diem,—low diet. Jan. 18. Discharge has diminished one half. Other symp- toms improved satisfactorily, except the inguinal swellings, which remained stationary. Patient got leave of absence for one week, during which he remained quiet at his boarding- house. Was advised to take the powders night and morning; and at noon, two copaiba capsules. February 5. Blennorrhagia has ceased. Inguinal enlargement on the increase, with fre- quent, sharp pains. Continue internal remedies in half quan- tities. Tincture of iodine and hot fomentations to groins. Patient is compelled to return to his place of employment. Feb. 13. Discharge has re-appeared. No scalding, no chordee, no urethral pains. Inguinal glands still enlarging, and are painful. 4 38 GONORRHOEA AND SYPHILIS. R. Capsules of copaiba and oil of cubebs,........No. viii per diem. And as an injection — R. Plumbi Acetatis,..................................... Zinci Sulphatis, aa,....................................gr. iv. Aquas Fontanas,......................................3 viii. M. The urethral discharge degenerated into a gleet. To cure this, one application of cantharidal collodion proved sufficient. After an interval of three months from the commencement of the gonorrhoea, the inguinal glands suppurated, and nearly three months more elapsed before the abscesses entirely healed. Case III.—Mild gonorrhoea — suspension of discharge — frequent relapses produced by sexual indulgence —final cure. October, 1855. A. B., a married man, aged thirty-two. Strong and healthy; an ardent devotee at the shrine of Venus for many years, and this was his third gonorrhoeal visitation. It came on three days before I was consulted. Discharge moderate and muco-purulent; slight ardor urinae ; glans in- flamed and tumefied. Patient was connected with an exten- sive trading house ; and in making arrangements for treatment, he stated that he could not absent himself from business for a single day. All he wanted was, that the best course might be adopted which the circumstances would allow, and he would find no fault, whatever might be the result. He asked for something to take that had no smell, and the capsules of copaiba and oil of cubebs were prescribed. These he took as freely as the stomach would bear, and in three weeks the ure- thral symptoms disappeared. Soon after this, he had connec- tion with a woman for several successive nights. The dis- charge returned and the capsules were renewed; the lead and zinc injections were also recommended. At the expiration of about another three weeks the blennorrhagia again stopped ; and the infatuated man renewed his libidinous habits. Thus a succession of indulgence, relapse, and cure, took place some seven or eight times in the space of about as many months. The patient was at last convinced that he must either forego the beastly indulgence of his sensual appetite, or abandon the idea of permanent exemption from his blennor- BLENNORRHAGIA. 39 rhagic trouble. Accordingly, he abstained from sexual inter- course ; and the urethral affection, which had now for some weeks been a mere gleet, received a final coup-de-grace, through the efficient agency of cantharidal collodion, which was twice applied to the offending organ. The patient assures me that since his recovery he has kept out of harm's way. Case IV. — Acute gonorrhoea — Suspension of discharge — cure — Spermatorrhoea supervening — cure. December 26, 1855. L. S. aged eighteen years. Tall, slender frame, constitution delicate. By day, doing business in the city ; at night, is ten miles in the country by railroad. Blennorrhagia eight days, profuse, yellow, puriform ; severe scalding in micturition; painful erections and chordee. Com- pound cubebs powder, six drachms a-day. Had taken a saline cathartic on the previous day. Patient remained quietly in the country for twelve days, when the blennorrhagia ceased, and he went to his place of business, where his services were urgently demanded. In five days the blennorrhagia re- turned. To arrest it, balsam of copaiba mixture was pre- scribed. In ten days the running again ceased, excepting a drop of thin, transparent mucus in the morning. For this, injec- tions were employed as in Case II., together with cantharidal collodion to the integument of the penis. In twelve days the abnormal secretion made its final disappearance. In just five weeks from the time the patient reported that the gleet had vanished, he called to be cured of sperma- torrhoea. He stated that a few days previous to the disap- pearance of the gleet, he began to be troubled with undue sexual emotions and involuntary nocturnal emissions. The latter had gradually increased in frequency, until they num- bered ten or twelve in a week, and were co-incident with erotic dreams. He was pallid, nervous, dejected,—had a poor appetite; strength reduced, and bowels constipated. He was directed to use a generous diet, to bathe in cold water daily, to take free exercise in the open air; — and as a tonic and aperient, equal parts of the wine of iron and syrup of senna to the amount of two or three drachms each day. At bedtime, a drachm of lupulin. These directions were all faithfully ob- 40 GONORRHOEA AND SYPHILIS. served. The spermatorrhoea gradually subsided, and at the end of eight weeks gave no further trouble. Abnormal sexual excitement and involuntary seminal emis- sions are frequently met with in chronic blennorrhagia. In such cases, the engorgement and irritation of the prostate gland and deeper portions of the urethra, are propagated to the vesicu- lar seminales, and hence the disturbance of their physiological function. Every physician and surgeon is naturally more deeply im- pressed with what he sees and witnesses within the range of his own field of professional service, than with what trans- pires within the limits of another man's practice. But the history of blennorrhagia, as known and treated by various practitioners, shows that it is curable through the instrumen- tality of a great diversity of remedies, no one of which is entitled to the character of an absolute and infallible specific. The disease differs greatly in the severity of its symptoms as developed in patients of different constitutions and different habits; and although its leading features are sufficiently marked to enable the practitioner to recognize it, yet he will find it a futile attempt, if he undertake to employ a uniform mode for all cases. But, although the malady yields to no specifics as such, there is a great choice of remedies, just as we find in other complaints, in the management of which our means are applied according to the daily assemblage of symp- toms. In attempting the cure of blennorrhagia, some surgeons employ the balsam of copaiba almost exclusively; some trust to cubebs as being best adapted to the greatest number of cases; some rely on a combination of copaiba and cubebs, in the be- lief that the virtues of the two remedies are best exerted when united; some resort to antiphlogistics, some to injec- tions, with no other treatment; and others, still, bring into service nearly all the above measures in the same case ; — and in addition to this, are sometimes obliged to vesicate the penis or perineal integument. All these plans of treatment succeed; all occasionally fail. Dr. Charles A. Davis, the intelligent and efficient surgeon of the United States Marine Hospital at Chelsea, near Boston, informs me, that during the last three years, he has treated about eighteen hundred cases of gonorrhoea at that Institu- BLENNORRHAGIA. 41 tion, and that he has given various modes of treatment a fair trial, including every new remedy that has come to his notice. In the abortive treatment he has employed the strong solu- tion of nitrate of silver, keeping the patient confined to his bed and restricting him to a low diet for a few days. If the period has passed for resorting to the abortive treatment, Dr. Davis orders :— R. Copaibas,.............................................. Mucilaginis Acacias, aa,..................................§ iv. Aquas Camphoras.......................................§ xv'* ^* Dose. Half an ounce three times a day. In chronic blennorrhagia and in gleet, he very generally applies the cantharidal collodion, which in almost every in- stance brings satisfactory results. In private practice it would of course be equally successful, provided it were con- venient to use it; but there are too many obstacles, too many contingencies, that will in many cases arise in the way of its employment. The objections lie chiefly with the patient him- self. He dreads the pain ; nor will he submit to the incon- venience and restraint, which its application imposes. Injections in blennorrhagia. — Although the idea of curing blennorrhagia, in its initial stage, in conformity with the old adage, ucito, tute, et jucunde," by strong injections of nitrate of silver, is scarcely tenable so far as relates to private prac- tice, yet in many cases, injections of some sort, may be advan- tageously resorted to, and without risk to the patient. As adjuncts to other agents in the latter stages of the disease, when the active inflammation has materially diminished, and the individual no longer complains of urethral pains, nor of ardor urinae, then injections of a mild, astringent, or sedative charac- ter may be employed. They are, generally speaking, most opportune when anti-blennorrhagic remedies have had a fair trial and have failed to arrest the discharge. So long as the case is doing well under the use of balsam of copaiba, cubebs, cantharides, or other constitutional treatment, we need not feel that there is any occasion to use injections. To let well enough alone is always good policy. Local remedies some- times disturb the favorable action that is being produced by the agents already at work. But if injections have been de- 4* 42 GONORRHOEA AND SYPHILIS. termined upon, the surgeon should give directions as to the best manner of employing the syringe, so that its contents may pass along the whole length of the urethral canal; for it is not certain, in any given instance, at what point or portion the disease may exist. The injection should be allowed to remain in contact with the canal for several minutes,— or until it creates a trifling degree of pain, — and its subsequent action should be carefully noted. If it increase the discharge, it should be discontinued. Ice-cold water may safely be thrown into the urethra several times a day during any stage of gonorrhoea. This can do no harm; on the contrary, it often exerts a very favorable influence. In nearly all cases I advise the use of it, many times in the twenty-four hours, provided the patient is so situated that he can employ the syringe in a proper manner. If there be much irritation in the urethra, an injection of cold water with three or four grains of aqueous extract of opium to the ounce, may be use- fully employed. It should be carefully filtered. During the last few years, Ricord has been gradually relin- quishing the employment of caustic injections in the treatment of gonorrhoea, because every now and then instances occur in which the pain is very severe ; — the artificial inflammation runs high; and then, instead of a cure being obtained, the dis- ease relapses into a chronic state, which resists all means of cure; in addition to this, the patient requires a great deal of watching, — more than a medical man in full practice is able to devote to him. Ricord now prefers the capsules of copaiba, and the following injection: — R. Zinci Sulphatis,................................... Plumbi Acetatis, aa,..............................gr. xv. Tincturas Catechu,................................ " Opii, aa...................................3 «• Aquas Rosarum,..................................§ vi. M. Injection. Acton states that his experience fully sustains that of Ri- cord ; and that it is only in old cases of gleet, in spermatorrhoea, and in chronic affections of the bladder, that he employs the nitrate of silver injections. * * Vide London Lancet, December, 1854, page 459. BLENNORRHAGIA. 43 It is often advisable to vary the character of the injections; I propose, therefore, in the subjoined note, to present a few formulae in addition to those already inserted in these pages.* I have thus submitted in brief detail, sundry methods of procedure for the cure of blennorrhagia. The multiplicity of remedies, constitutional and topical, shows plainly enough, how totally ineffectual all ordinary measures sometimes prove. Although the affection is purely local, and would seem, theo- * R. Plumbi Acetatis..................................gr. ij ad iij. Decoctionis Papaveris,............................5 UJ- ^- The above is to be used at night, and allowed to penetrate without restraint as far as the ordinary impulsion of the syringe will convey it. In four or five days it may be used more frequently. Used at the London Lock Hospital. — Henry J. Johnson. R. Vini Rubri,.......................................5 v'- Acidi Tannici,....................................gr. xviii. M. For the male urethra. For the vagina the quantity of tannin may be doubled, or still further increased. —Langston Parker. R. Solutionis Sodas Chloridi,.............................3 Ijj- Aquae,..............................................5 viii. M. This preparation is often valuable in chronic vaginal or urethral gonorrhoea or gleet; and may be employed every hour or two during the day. R. Ferri Potassio-Tartratis,..............................3 i. Aquas,.......................'......................§ viii. M. Injection. — For chronic blennorrhagia or gleet in either 6ex. May be used ad libitum. R. Ferri Iodidi,.......................................gr. xvi. Aquae Rosarum,...................................3 vi. M. In gonorrhoea or gleet, to be used several times a day. — Prof. Dunglison. R. Zinci Sulphatis,........................................ Acidi Tannici, aa,.......................................gr. ij. Aquas..................................................J ij. M. Injection. — To be used repeatedly during the day.—Acton. The tannate of zinc has been employed in the proportion of one part to one hun- dred of water, as an injection in chronic blennorrhagia with favorable results. Mr. Skey, surgeon to St. Bartholomew's Hospital, considers that the most effect- ual method of curing gonorrhoea and gleet, is by the use of mild injections, and the internal use of tincture of iron or ferro-citrate of quinine, ad libitum. The following is a convenient mode of prescribing the citrate : — R. Ferri et Quinias Citratis,................................3ss- Syrupi Aurantii,....................................... Aquas Fontanae, aa,....................................3 U- M. Dose. 3 i- three times a day in half a gill of cold water. 44 GONORRHOEA AND SYPHILIS. retically, to admit of easy cure, yet the testimony of experi- ence tells a different story; and we learn from it, that the dis- ease is now and then as obstinate as it is disgusting. PAINFUL ERECTIONS. These complications of blennorrhagia sometimes occur, to the great torment of the patient, especially during the latter part of the night; and their immediate removal, and the pre- vention of their recurrence, should engage the attention of the surgeon. The erections are involuntary. I once knew a married man — a carriage painter — who had gonorrhoea, and whose virile organ continued in a state of priapism for nearly twenty-four successive hours. He could not make known his condition to any one, without exposing himself in a way that would have raised a moral hurricane in the domestic circle, and he continued to suffer, until a brisk cathartic, which he took, brought relief. In chordee, the penis, when in a state of tension, is curved downwards or to one side. The erections are much more troublesome during the second stage of blennorrhagia, than at any other period. Now and then, in nervous men, they persist after the inflammatory symptoms have disappeared. In the generality of cases, the abnormal condition takes place when the inflammatory action extends to the reticular tissue of the urethra, and consequent infiltration of plastic lymph into its cells occurs, whereby the canal loses its uniform elasticity, and cannot expand in due proportion with the distension of the erectile apparatus. Treatment. — In some cases, antiphlogistics and sedatives are required for the removal of this phenomenon. Leeches, and afterwards, cold water to the perinaeum are useful. The latter application may be continued for several hours. It constitutes one of the most efficient local measures that can be employed. The patient should lie on a hard matress, with a light covering over him. Lupulin. — The sedative and anti-blennorrhagic influence of this remedy depends upon a resinous ethero-oily principle ; BLENNORRHAGIA. 45 while the bitter element yields a real tonic. I have employed lupulin in doses varying from one scruple to one drachm. It has an advantage over opium in not producing constipation ; nor does it create any gastric disturbance ; and on this ac- count, is preferable to camphor. A few months since, I had a young man under treatment, for whom I prescribed the lupulin, of which he could not take over a scruple in twenty- four hours without experiencing an uncomfortable, stupid feeling for several hours ; but the erethisms, for which it was given, were entirely quieted. This patient was nervous and dyspeptic. The stomach tolerated the medicine perfectly well. During the past few years, favorable reports, in regard to the remedy, have been communicated to the journals by practitioners of high standing in this country and Europe ; and I feel justified in stating that the more I prescribe it, the greater is my confidence in its ability to control painful erec- tions in gonorrhoeal patients. A late number of the Gazette des Hopitaux contains a formula for a pill consisting of bella- donna, camphor and lupulin, which is reputed to prevent at once the occurrence of painful erections, and invariably tov allay the morbid erectile tendency of the genital organs. The formula is: — R. Extracti Belladonnas,.................................. 3 i- Lupulinae Recentis,..................................... Pulveris Camphoras, aa,..................................3 vi. M. ft. pil. No. xlviii. Doss. One to four pills at night. Camphor. — In some patients camphor destroys or greatly interferes with the appetite, and for this reason it can be prescribed only for a short time in any considerable quanti- ties ; but as regards its efficacy in relieving the complica- tions under consideration, all surgeons agree; and it will probably continue to maintain a claim equal to that of any other drug employed for the relief of the same morbid condi- tions. If the gum be selected, it may be formed into pills with the extract of lettuce, according to the annexed form- ula : — R, Pulveris Camphoras,.................................. Extracti Lactucas, aa,..................................3ij. M. ft. pil. No. xx. Dose. One to six pills at night. 46 GONORRHOEA AND SYPHILIS. For chordee, common spirits of camphor, in sweetened milk, surpasses all other remedies. A teaspoonful of spirit may be taken by the patient on going to bed; and every time he wakes with the chordee, let him at once rise and repeat the dose. Sometimes the attack can be relieved instantly by making forci- ble downward pressure upon the organ. In some cases, the chor- dee becomes chronic and remains for a long period after the blen- norrhagia has disappeared, and the penis acquires the hardness of cartilage or bone. This peculiar condition, as already ob- served, is due to the presence of plastic matter in the parts, and is a source of constant discomfort and alarm to the indi- vidual. The state of things here mentioned is of rare occur- rence as a consequence of urethritis, and yet it is a result of this complaint; and the fact is worthy of remembrance in a diagnostic point of view ; for the patient is apt to fancy that the disease is a scirrhous or cancerous affection of the organ, and he lives in fear as to its ultimate and dreadful termina- tion — a frame of mind which the surgeon will have it in his power to relieve by a few explanatory words. The internal administration of the iodide of potassium in compound decoc- tion of sarsaparilla, and the local employment of the unguen- tum hydrargyri camphoratum will constitute the most suita- ble treatment for the removal of the singular accident in ques- tion. The iodide-of-lead ointment will also be worthy of a trial; likewise the application of small blisters and of the com- pound tincture of iodine. The deformity never interferes with the general health, although it does with the physiological functions of the member; and in some instances it remains incurable. urethral hemorrhage. In certain cases of acute blennorrhagia, attended with fre- quent priapism and severe spasmodic chordee, bleeding takes place from the vascular apparatus of the urethral canal. The quantity of blood thus discharged is usually small, and seldom gives occasion for the services of the surgeon to arrest it. In fact, the occurrence of slight haemorrhage is a fortunate cir- cumstance, as it is generally followed by a decrease of the in- flammatory symptoms. If the discharge be profuse, means for BLENNORRHAGIA. 47 repressing it should be adopted ; and of these, the application of ice-cold water to the perinaeum is one of the best; — cold water may likewise be injected into the urethra. Or, what is better, and more conveniently done, pressure should be made with the thumb and finger upon the urethra deep in the per- inaeum. If the haemorrhage be not arrested, draw the fingers gradually forward in the track of the urethra. The precise seat of the lesion, from whence the blood flows, will soon be detected ; and it will usually be found at the point of the ure- thra opposite the symphysis pubis. A compress should be placed upon the part, and secured by a roller around the loins and thighs. In three cases of profuse urethral haemorrhage, which I have met with, the accident occurred when the organ was in its greatest tension, attended, in two instances, with chordee also. In one case, the patient lived at some distance from me. According to his own story, he bled a quart. He applied cloths dipped in cold water to the genitals; but the bleeding, which took place in the dead of night, continued several hours. In the second individual, the laceration of the vessels occasioned a rapid flow of blood, which was arrested with ice-water and pressure upon the perinaeum. The third case occurred lately, and was on this wise. A young dandy, who had blennorrhagia " in floribus," took a fancy to have a ride in a cab on a bright summer's evening with a girl of the town. During the ride the girl got into his lap; and while the parties were busily engaged in mutual embraces, a vessel sprung aleak and bled profusely. The young man became alarmed. The cab drove up to the office of a physician. The patient alighted, and the cab went ahead with the female passenger. The phy- sician, at whose door the bleeding lover was dropped, not be- ing in, I was called. The youngster had on a pair of white trowsers. The blood was trickling down his legs. He exposed the genitals, and related the circumstances amid which the haemorrhage took place. The bleeding was staunched with cold applications and pressure, the patient lying on the floor for about an hour afterwards. CHAPTER III. GLEET. SYMPTOMS — CASE — MICROSCOPICAL APPEARANCES OF THE DISCHARGE — TREAT- MENT — BLISTERS — INJECTIONS — THE BOUGIE. This is the blennorrhcea chronica of Dr. Good; blennorrhoea luodes being, as we have seen, the name he gives to the clap or gonorrhoea. Gleet is a frequent sequel of an obstinate blen- norrhagia unsuccessfully treated or wholly neglected. The discharge is slight. Sometimes only a drop or two is noticed about the meatus urethras, in the morning. The orifice is smeared with a ropy, tenacious, serous or mucous fluid, par- tially dried perhaps, upon the lips, and slightly impeding the free exit of the stream of urine, when it first arrives at this part. Some patients have an oozing of matter, amounting to five-or six drops in the twenty-four hours. Sometimes several days will intervene and no discharge be noticed; but if the patient indulge in any imprudence in diet, severe exercise, sexual intercourse, or anything which tends to excite the or- gans, the gleet will very probably re-appear. The most com- mon seat of blennorrhoea is in the vicinity of the membranous or prostatic portion of the urethra; the lesion, however, is sometimes situated in, or near the fossa navicularis, as in acute urethritis. It is generally easy to determine when it is seated at the latter point; for if it be, moderate squeezing of the glans penis will force the matter out at the orifice of the ure- thra, whereas this cannot be so readily done if the discharge proceeds from a portion of the canal farther back. Sometimes the locality may be ascertained by pressing the integument along the urethra. The patient will complain of being hurt when the diseased spot is reached. Occasionally, a preternatural redness and turgescence of the lips of the urethra remain after the discharge has ceased. This deviation from the healthy appearance is, of itself, an affair of little moment. It is, however, indicative of a more profound 48 GLEET. 49 abnormal condition, which may still be lurking in the mucous lining of the canal, in Cowper's glands, or in the prostate, either or all of which parts may have been, at some period of the disease, concerned in the production of the morbid secre- tion, and may still be the seat of a subacute inflammation ; and so long as this continues, the patient is liable to a relapse from the most trivial excess or imprudence. He should therefore persevere in the treatment for some ten or fifteen days after the meatus has assumed its normal condition. Nor should he be allowed to indulge in the venereal act, until several weeks after the discharge has stopped. Cases are on record in which the secretion has been absent for a whole month, and then has been re-produced by sexual intercourse with a perfectly healthy woman. Such facts are entitled to remembrance. They should make the surgeon cautious what answer he gives to the inquiry which is frequently made by the patient, " When may I venture to marry?" The answer in some cases must be given under circumstances involving no small responsi- bility. Some men, with an old gleet, suffer great mental distress in consequence of its presence, although it does not interfere with their physical health. A few months since, an intelligent but nervous man, from a neighboring village, was sent to me by his physician to be treated for gleet. It had existed about one year. The discharge consisted of a drop or two of mucus in the morning. No stricture or other irregularity of the ure- thral canal was found. The catheter slipped into the bladder at once; virility was unimpaired. The patient had been read- ing an old medical book, which fell in his way, and he became greatly alarmed, apprehending that the venereal complaint, in some form, might break out upon him at any moment, unless his gleet were cured. A matter of business called him to Georgia; but he dared not undertake the journey while his genitals were in such a critical state. He was put upon the use of the following: — R. Tincturas Cantharidis,............. Olei Terebinthinas, aa,............. Mucilaginis Acacias,.............. Dose. One teaspoonful three times a day 5 5i- 5U- M. 50 GONORRHOEA AND SYPHILIS. The following injection was also prescribed : — R. Acidi Tannici,.........................................3j- Plumbi Acetatis,.....'..................................gr- viii. Aquas Fontanae,........................................5 viii. M. A syringeful to be injected three or four times in the twenty-four hours. The whole of the perineal integument was likewise made per- fectly raw with the compound tincture of iodine, and the pa- tient was confined to his room. The gleet ceased on the sixth day, but the remedies were continued for two weeks longer in diminished force. The patient was encouraged to start on his journey. On reaching Philadelphia he fancied that he de- tected a relapse of his gleet, and forthwith returned to me. Nothing would appease him but a renewal of treatment, al- though I assured him there was no call for it. Meantime, as no gleet appeared, his mind became tranquil, and he was con- vinced that he had no occasion to return as he did from Phila- delphia. He once more commenced his Southern trip, which he completed successfully. I have examined with the microscope numerous specimens of true gleety matter. In most instances it consists of large, deli- cate, well defined epithelial cells and free nuclei, which remain entire after the other portions of the morbid product are de- composed and broken up into mere shreds and amorphous granules. In other samples I have found pus-globules, although seldom in abundance. If the individual indulge in any excess, and thus augment the local inflammatory action. a corresponding increase of pus-globules can be detected. It is not easy to say, pathologically, at what precise point in the progress of urethritis, the inflammatory gonorrhoea ceases, and the gleet commences. Here we encounter a diffi- culty analogous to that which presents itself when we speak of the termination of an active inflammation in any other organ or membrane, and the commencement of a supervening subacute inflammation. We have no means of running a line of distinction that shall be mathematically correct; but for all practical purposes required in therapeutic surgery, our re- sources are sufficiently ample, and for the most part, ultimately successful; although it must be confessed that they are occa- sionally wholly inefficient. GLEET. 51 Treatment of Gleet. — Gleet has been cured by a great contrariety of treatment. There is no one plan that can claim absolute supremacy over all others in all cases. The reme- dies appropriate for one constitution, may be prejudicial to another; and what may be suitable for a patient to-day, may be injurious to him to-morrow. Whatever course of treat- ment the surgeon decides to take, let him bear in mind that he is dealing with a urethritis — a mere modification of the same malady that was treated under the name of gonorrhoea or blennorrhagia. This is true, certainly, of the great majority of cases which we call gleet. In some few instances, the discharge is kept alive by something more than a subacute inflammation of the urethra. There may be hypertrophy of the prostate ; or inflammation of the vesiculaa seminales, — or inflammation or irritation of the neck of the bladder; or stricture in some portion of the urethra. All these contin- gencies will suggest themselves to the consideration of the scientific practitioner; nor will he leave unemployed any available means of arriving at a correct opinion in regard to these possible conditions before commencing the treatment of a case. An important point to be determined, at this juncture, relates to the existence of stricture. The catheter or bougie will clear up all doubts upon this question. Patients very often apply to a surgeon to be cured of stricture when they have none. They have a gleet, — the sequence of a gonor- rhoea that has been mismanaged by some knavish quack, who has neither medical skill nor moral principle. He tells the man that his gleet is dependent on a dangerous stricture, which must be operated upon with the catheter or bougie every few days, or his urethra will close up, so that he can- not make water; and he promises to cure the poor fellow for so much—usually an enormous sum; whereas, upon proper examination of the part, no stricture can be found.* The urethral lacunae are much more developed in some persons than in others ; and when the walls of these little re- * "There is a class of scoundrels who live, not by curing strictures, but invent- ing them. Let an unhappy wretch fall into their hands, and if his urethra will admit a poker, they will still persuade him he is strictured. The duration of his case will be in the compound ratio of the extent of his credulity and the fullness of his pocket." — Henry J. Johnson. 52 GONORRHOEA AND SYPHILIS. cesses are in a state of congestion or hypertrophy, from pre- vious inflammation, they will naturally oppose the free passage of the instrument along the canal; and unless the operator be somewhat familiar with the bougie, he may mistake this oppo- sition for stricture. Long standing blennorrhagia, in which the symptoms have been very severe, may produce the change in the lacunae here alluded to; and the obstacle, which, when in this state, they must offer to the extremity of a bougie, may be misinterpreted; and if the manipulator were to persist in his efforts to urge the instrument farther in, he might easily rend the parts, — make a false passage — manufacture a pouch — or even create a stricture. Blisters in Gleet. — Of all local remedies, these stand at the head of the list for the cure of all cases not dependent on stricture or otherwise complicated. They may be applied along the whole length of the penis, except two or three lines towards the preputial orifice. As soon as vesication has taken place, the organ may be lubricated with equal parts of lime water and olive oil, or the benzoated zinc ointment, and wrapped in a linen rag. Of late I have used cantharidal collodion in preference to blistering cerate. The collodion may be applied by means of a camel-hair pencil. After the evaporation of the ether, which takes place in a few seconds, the parts may be protected with linen rag. The vesicating substance should be applied at bedtime. If the surgeon propose to blister the perineal integument, he will find the collodion much more convenient than any other substance. It is better adapted to the uneven surface than plaster, does not stain the linen like tincture of iodine, and acts more powerfully and rapidly than the latter.* I have often cured a gleet with one application of the medi- cated collodion. The discharge does not usually disappear * " If only pure gleet, sometimes mucous, sometimes purulent, be met with, it will, in almost every case, yield to a blister; very rarely does it require a second. Blis- tering is, I may now safely say, the safest, quickest, and most efficacious remedy of all that have ever been proposed. Those who have had numbers of these cases under their hands, and felt the constant disappointment, which the use of every other remedy brings with it, will soon appreciate its value. I have heard it con- demned as a violent, painful, unpleasant remedy. I deny it." — Milton in Med. Times and Gazette, 1853. GLEET. 53 until the fifth or sixth day after vesication has been produced; sometimes eight or ten days will intervene before it entirely ceases. In a few instances a second application has been re- quired, but I have rarely found occasion for a third. Patients generally prefer to submit to the operation on Saturday even- ing. During the following day they are obliged to remain at res.t; sometimes for a longer period. Injections in Gleet. — The number of these, as in gonor- rhoea, is well nigh legion. Some of them prove important allies to other remedial agencies; some are nearly inert; and some, absolutely mischievous. Injections should be weak at first, and always used cautiously. It is best to commence with two or three repetitions for three or four days, and let the pa- tient report progress. If no ill results, the repetitions may be more frequent. The urethral canal should be kept as free as possible from all gleety secretion. Hence the benefit of weak injections often repeated, rather than to use more potent ones, which must be employed less frequently, and even then may make the last state of the patient worse than the first. Fre- quent injections of ice-water are usually productive of benefi- cial effects. In refractory cases, where the deep portions of the canal are involved, advantage is sometimes realized from inserting into the urethra, to the depth of about four inches, a catheter hav- ing perforations in the sides, and pressing a drachm or two of the injection into the extremity of the catheter, by means of a small syringe. One of the best, as well as one of the cleanliest injections, is nitric acid, diluted thus : — R. Acidi Nitrici,......................................gtt. xx. Aquas Fontanas,...................................§ viii. M. Of this, a drachm may be injected every hour, or even oftener, if the patient choose. The caution, given above, need not be observed in regard to this preparation. Being quite weak, no injury would ensue were it to remain in constant contact with the lining membrane of the urethra. Its action is that of a tonic and astringent to the mucous tissue. Another injection, to which I am partial, is the French chloride of soda, where I 5* 54 GONORRHOEA AND SYPniLIS. am sure of procuring the genuine manufacture. I employ it, diluted in the proportion of one part of the solution to sixteen parts of rain water. It may be repeated ad libitum. The oxyrauriate of mercury, — one grain to eight ounces of rose water, makes a valuable injection in many cases. The nitrate of strychnia has been employed with beneficial effects as an injection in gleet, not depending upon stricture, accompanied or not, by disease of the prostate gland. Nux vomica may be given internally at the same time. R. Strychniae,.........................................gr. iv. Acidi Nitrici,.......................................gtt. viii. Aquas,.............................................§ iv. M. Inject one drachm thrice daily, after micturition. R. ExtractiNucis Vomicas,.............................gr. xii. Quinias Sulphatis,................................... Extracti Hyoscyami, aa,.............................gr. xxiv. M. In pil. No. xxiv. divid. Two pills to be taken one hour before each meal. * It is hardly worth while to continue an injection if it do not exert the desired action in the course of one week. The mu- cous membrane requires some other kind of stimulant. The Bougie. — Few cases, comparatively, present them- selves in private practice, under circumstances demanding the use of this instrument. Now that confidence in the employ- ment of blisters has recently been revived by Mr. Milton, who holds that all cases of gleet, not complicated with stricture, may be cured through the combined agency of repeated vesi- cation of the penis and injections into the urethra, it is highly probable that the bougie will hereafter be in less frequent re- quisition, than it has been hitherto. If a patient have stric- ture, the bougie will be needed. It may likewise be of service when a gleet is protracted for a very longtime in consequence of an irritable state of the neck of the bladder. There is still another class of patients, who may be benefited by the same mechanical means, when all other agencies have been ex- hausted ; for such cases, it is to be presumed, will still con- tinue to occur, to the great annoyance of the most skillful * Vide Amer. Journal Medical Sciences, April, 1850, p. 542. GLEET. 55 surgeon; and they will resist his best endeavors, until he avails himself of the bougie. Such cases, however, will with- out doubt, be extremely rare. They include those individuals, who have never had stricture; who have no abnormal vesical ir- ritability ; no chordee; and little or no tenderness along the perineal region; their condition has remained nearly the same for several months; the parts endure without complaint, com- paratively rude handling, and seem almost callous to the or- dinary influence of injections. And yet the judicious use of the simple bougie may restore the urethra to a sound condi- tion, and put an end to the morbid secretion. In regard to the use of the bougie, surgeons prescribe some- what different directions. The instrument should be suffi- ciently voluminous to distend the urethra moderately and nothing more. A bougie, unmedicated, should be introduced at first. It should extend some five or six inches into the canal, and be allowed to remain ten or fifteen minutes, accord- ing to the amount of irritation it creates. Its introduction, in some instances, may be repeated two or three times in a day; in other cases, only once in two or three days. Patients manifest every degree of susceptibility as to their power to endure the presence of the bougie; some being able to bear it nearly all the time; others cannot submit to its action, even for a few moments, a second time, so great is the suffering and inflam- mation which they experience. For persons, in whom an in- cipient stricture is detected, the bougie should be used every third or fourth day; and during the intervals, an injection of. tannic acid and sulphate of zinc — one grain of each to the ounce of rain water — should be employed. The mucous membrane becomes thickened and softened in consequence of inflammation ; the tender walls of the canal may be easily lacerated, and consequent haemorrhage . take place if the catheter or bougie be introduced in a rude or careless manner. Sir Astley Cooper mentions a case of the kind to which he was summoned by the physician, who was guilty of this malpractice. The flow of blood was checked by pressing a roller upon the perinaeum. In a short time the hae- morrhage returned. The man had been lounging before the fire with a foot on each side of the chimney piece ; and the warmth coming thus in direct contact with the perinaeum, 56 GONORRHOEA AND SYPHILIS. brought on a renewal of the bleeding. Sir Astley was again summoned, — made an incision upon the part, and divided the artery of the bulb; this operation succeeded, and the haemor- rhage was permanently subdued. In some cases of long-continued blennorrhagia, during which a variety of remedies have been applied directly to the ure- thra, it seems to lose its normal susceptibility ; and if, after a few trials with the simple bougie, no effect is perceptible, the instrument may be coated with some slightly stimulating oint- ment, thus:— R. TJnguenti Ilydrargyri,................................1 part. Extracti Belladonnas,................................2 parts. M. The bougie should be introduced cautiously ; and on with- drawing it, the surgeon should give it a slight rotatory move- ment, which will cause an equal distribution of the ointment to the whole surface of the canal. The employment of the in- strument thus medicated, gives considerable pain, and excites inflammation; and usually an increase of discharge is noticed for a few days, after which it frequently entirely ceases. But if this do not happen, a second trial with the instrument may be made in ten or twelve days from the first. An ointment of the nitrate of silver — one grain to the drachm — is sometimes efficacious when used as directed above for the mercurial un- guent. The unguentum hydrargyri nitratis, in the propor- tion of one drachm to an ounce of pure olive oil, is likewise a very suitable application under the circumstances here sup- posed. Sometimes the oil of turpentine answers a better pur- pose than any other substance for lubricating the bougie. CONSTITUTIONAL TREATMENT OF GLEET. Internal remedies alone seldom result in the cure of gleet. In nine cases out of ten the patient is doomed to meet with disappointment, after having run the gauntlet of all kinds and forms of specifics, so-called, addressed to the stomach. Tonics are generally useful; they may be given with saline aperients or alterative mercurial medicines, or in combination with remedies reputed to exert a specific influence upon the genital system. Little will ever be gained by any process of starvation. A GLEET. 57 plain but substantial diet should be allowed, of which lean meats should constitute a part. The subjoined formulae are among the best that canbe employed. If they fail to arrest the morbid secretion, it will hardly be worth while to waste time in experimenting with other preparations for internal ex- hibition. A far more hopeful procedure will be to resort to blistering as already sufficiently recommended. R. Copaibas,............................................. 3 ss- Tincturae Cantharidis,..................................3 U* " Ferri Sesquichloridi,................. .........3u ^. Dose. Thirty drops three times a day in a gill of sweetened water. R. Tincturae Cantharidis,.................................3 *• Quiniae Sulphatis,.....................................3 ss. Tincturae Ferri Sesquichloridi,..........................3 ij- Acidi Sulphurici Diluti,..............................3 ss. Aquae,...............................................3 viii. M. Dose. One ounce three times a day in an equal quantity of cold water. When there is a thickened and uneven condition of the ure- thra, the annexed formula will be found appropriate : — R. Hydrargyri Biniodidi,.................................gr. iij. Potassii Iodidi,.......................................3 iss. Spiritus Iiectificati,...................................3 ss- Syrupi Aurantii,..................................3 uss> M. Dose. Thirty drops three times a day. Good results are often realized from the use of the iodide of potassium in conjunction with iodine. Such a combination, containing both tonic and alterative qualities, is especially indi- cated in the constitutional treatment of those who betray a scrofulous diathesis : — R. Potassii Iodidi,.......................................3 iij- Iodini,...............................................gr. j. Aquae Destillatas, ....................................3 vii- M. Dose. One drachm three times a day. Ferruginous preparations are likewise valuable for patients who have become pale, emaciated, nervous and apathetic. The potassio-tartrate of iron, or the citrate of iron, should be pre- scribed in pretty liberal quantities for several weeks. Mr. 58 GONORRHOEA AND SYPHILIS. Dick states that a combination of the carbonate of iron with ergot has in his practice rendered good service. In two cases, where all other remedies had failed, the patients obtained the desired benefit from the following prescription : — R. Secalis Cornuti,......................................o iss. Ferri Carbonatis,.....................................3 ij- • Pulveris Vanillas,..................................... " Camphoras, aa,................................gr. vi. Ft. pulv. Div. in partes No. xxiv. One powder morning and evening. • The oil of turpentine, as a constitutional remedy in obstinate cases of gonorrhoea and gleet, is entitled to favorable consid- eration. Its pungent and nauseous taste constitutes a serious objection to its employment, and hence it is rarely resorted to until other less disagreeable remedies have been tried and have failed. I have never ordered it in the acute form of abnormal urethral discharges; but in chronic cases, which have resisted other remedies, have prescribed it with advantage. It should be combined with an anodyne and administered as an emul- sion. The annexed formula is as convenient as any : — R. Morphiae Sulphatis,.....................................gr. ij. Sacchari,............................................3 iij- Misturae Camphoras,.................................... Mucilaginis Acacias, aa,................................3 '■ Olei Terebinthinas,......................................3 ij- M. Dose. — Two drachms three times a day. Some patients who have had urethritis, for a long time, will complain, even after the morbid secretion has vanished, that they never know when they have done making water; that is, they will tell you that after they think the process is finished and the bladder empty, they are troubled for a moment or two with a dripping from the meatus, which makes them very uncomfortable. They can neither expel the last few drops of urine nor yet retain it. In these respects their condition is not unlike that of some very aged men. The introduction of the bougie or catheter once or twice every twenty-four hours, for a few days, will generally remove this trouble. CHAPTER IV. BALANITIS. OPINIONS RESPECTING THE PREPUCE—GLANDULE ODORIFERiE— CASE OF PSEUDO-BALANITIS--CAUSES OF BALANITIS--SYMPTOMS--TREATMENT-- PHYMOSIS — SLITTING UP THE PREPUCE — CIRCUMCISION — PARAPHYMOSIS --TREATMENT. The word balanitis, as employed by syphilographers of the present day, signifies inflammation of the surface of the glans penis, the mucous membrane of the prepuce, the glandulae odoriferae, and the follicles that surround the corona. The disease thus located, is also called balano-preputial blennor- rhagia ; bastard chaude-pisse balanite by the French; external blennorrhagia; spurious or false gonorrhoea. The inflammation is attended with more or less muco-purulent discharge, with or without superficial excoriations. If the disease be confined to the prepuce, it is called posthitis. But, as in most cases, all the tissues just named, are involved, I shall employ the term bala- nitis as being sufficiently suggestive of the seat of the com- plaint. The liability of men to this disorder, depends in some degree upon the amount of preputial integument, with which the parts are naturally endowed; and in this particular very great differences are found. It is somewhat amusing to com- pare the opinions expressed by different writers in regard to this appendage. One says, " It has been a question with some philosophers of the Monboddo school, whether the prepuce is not a piece of supererogation. It may have its uses in a state of nature, where it may defend the sensitive glans, and serve the purpose of'sheath' in animals. But we are not likely to return to fig leaves, and I think I may take it upon myself to affirm, that at the present day and with our customs, the less we have of it the better."* The prepuce, says Ricord, " is an appendix to the genital organs, the use and object of which I could never divine; in place of being * Henry J. Johnson. 59 60 GONORRHOEA AND SY~PHILIS. of use, it leads to a great deal of inconvenience, and the Jews have done well in circumcising their children, as it renders them free from one of the ills of humanity. The prepuce is a superficial piece of skin and mucous membrane, which serves no other purpose than acting as reservoir for the col- lection of dirt, particularly when individuals are inattentive to cleanliness." In some men the prepuce is of remarkable brev- ity— hardly sufficient to conceal any portion of the glans, which, with them, always remains in nearly the same condition as if circumcision had been performed. The glandular odoriferae, with their short excretory ducts, situated behind the glans, are disseminated much more plenti- fully in some men than in others; varying, numerically, from ten to one hundred; and while they are designed by nature to perform an important emunctory function analogous to that of the sudoriferous apparatus of the skin, they are at the same time subservient to the protection and healthy condition of the parts in the immediate neighborhood, upon the surface of which they constantly pour out an oily, lubricating fluid. But, if this oily material be allowed to accumulate, and to become partially concrete, it may, and frequently does, prove a source of irritation and inflammation. It is scarcely necessary to re- mark that this accumulation is much more rapid and difficult of prevention if the glans be invested by a preter-naturally elongated prepuce, than is the case where the glans is naked, or covered by a foreskin of normal length, and easy of retrac- tion. I once knew a young medical student who had a re- dundancy of preputial membrane. After having been more or less annoyed for some weeks, by a sensation of heat, itching, smarting, and pains about the head of the penis and the inner prepuce, he one morning noticed at the orifice of the latter, an opaque, semi-fluid substance, which proceeded, as he thought, from urethral gonorrhoea. He was, at the time, trying his skill as interne du service, or dresser to another young man, who, in addition to an acute blennorrhagia, had two or three ill-conditioned sores upon the prepuce. These received frequent attentions from the student, who, not fully indoctrinated into the laws of contagion, imagined that his own trouble was derived from this patient, as he had not been otherwise exposed. Upon retracting the prepuce, a large BALANITIS. 61 quantity of thick, sebaceous matter gushed out. This filth was removed with warm water, and the glans was found to be inflamed and denuded of its epithelium in several places, and aphthous patches here and there upon it. But there was no urethral discharge. The student, at once satisfied as to the cause and source of his complaint, was not a little morti- fied. He listened to a few suggestions relative to personal cleanliness ; and with the use of weak lead-water, found him- self well at the end of a week. Instances like this occasionally present themselves; and when the patient is told that his dif- ficulty is attributable to his own carelessness, he is apt to man- ifest surprise mingled with shame, and joy, at the discovery. The existence of the prepuce is the principal predisposing cause of balanitis. Vidal, however, mentions that he once ob- served it in a man on whom he operated for phymosis by cir- cumcision. The exciting causes of the complaint are numerous. Impure sexual congress is at the head of the list. The mens- trual fluid, leucorrhoea, masturbation, and inattention to clean- liness, will occasionally produce it. If it be the result of intercourse with an infected female, the symptoms gener- ally begin to show themselves in a day or two after expos- ure. The period of incubation is shorter than in cases of urethral blennorrhagia. The first warning of the trouble is a slight tingling or smarting sensation in the prepuce or glans. Anon, the prepuce becomes very tender and oedematous; and if it be drawn back upon the glans, the latter will exhibit in- flammatory action more or less intense; and at a later period, if nothing be done to check the morbid process, a discharge of puriform fluid will take place from the glans, — near the fraenum. There is scalding in micturition. If the trouble arise entirely from uncleanliness, it is more gradual in its de- velopment ; the symptoms declaring themselves more and more manifestly as the acrid sebaceous product is allowed to accumulate. The muco-purulent matter, mingled with the natural secretion from the parts, is sometimes very abundant, and if the preputial orifice be narrow, and the escape of the fluid obstructed, will sometimes give rise to a sort of abscess; and it may be necessary to puncture the prepuce for the pur- pose of evacuating it. If phymosis complicate the balanitis, and the case be neglected, or injudiciously conducted, sloughing 6 62 GONORRHOEA AND SYPHILIS. of the prepuce may take place, and the glans be seized with severe inflammation; and this morbid action may extend to the lymphatics of the penis and of the inguinal region. Treatment of Balanitis. — Simple balanitis is quickly cured. The patient should be directed to draw back the pre- puce so as entirely to expose the glans, as well as the mucous surface of the prepuce, which should be bathed in tepid wTater, and thoroughly cleansed of all sebaceous and puriform deposit. A fair view can now be had of the parts implicated. The sur- geon will find slight abrasions and small patches of aphthae. For the cure of these, one of the best topical applications is the following: — R. Liquoris Sodas Chlorinatas,.............................3 ss- Aquas Fontanas,......................................3 vu- M. Small bits of English lint to be saturated with the solution, and laid upon the glans ; and the prepuce may then be brought forward. The penis should be covered with a light wet rag. The solution should be re-applied three or four times a day. In all ordinary cases this simple local medication will restore the parts to a healthy state in a very few days. An essential item is to keep the surfaces from coming in contact. In some cases a piece of soft, dry lint, snugly placed in the furrow behind the corona, will speedily remove all trouble; and proper attention to cleanliness will prevent its recurrence. If the erosion be considerable, and the puriform exudation copious, an astringent lotion may be appropriate, thus : — R. Zinci Sulphatis,. Acidi Tannici,.. Glycerinas,...... Aquas Fontanas, Apply with lint. Simple lime-water frequently answers all the purposes, and effects a cure rapidly. In some cases I have tried the black wash, but its action has not proved salutary. It is too stimulating and on that account will rarely suit, but will rather aggravate, the morbid condition of the parts. The introduction of a crayon of nitrate of silver between the glans gr- ij- gr. iv. 3ij- 3iv. M. BALANITIS. 63 and the prepuce in severe cases, is a practice adopted by some surgeons. If the prepuce can be retracted, it would seem that such application is uncalled for; and if, on the con- trary, there be phymosis, the proper application of such a caustic is a matter of no easy performance. Besides, it might very likely augment the inflammation. Phymosis. — If there be a close phymosis, so that no expo- sure of the glans can be effected, the whole mucous surface may be irrigated and thoroughly cleansed with tepid water many times in the course of the day, by means of a small syringe, which should be inserted as far up the preputial opening as possible. All extraneous deposit will thus very soon be expelled from its hiding place, and the inflamma- tion and irritation, occasioned by the presence of this deposit, be rapidly diminished. Sometimes a few drops of Goulard's extract of lead can advantageously be added to the water used as an injection. The patient should live abstemiously and keep quiet. After the symptoms have abated, the phymosis will some- times yield, and a normal condition of the parts be secured by introducing a sponge-tent and gradually dilating the opening. All the measures above suggested, sometimes prove merely palliative; they do not accomplish a radical cure, especially if a congenital or persistent phymosis exists. The balanitis becomes chronic; and the severity of the symptoms can be Kept in abeyance only by the steady application of remedies for a very long time, unless the patient submit to a surgical operation for the cure of his phymosis. And this is by far the wisest course. The glans and prepuce are both inflamed and in a turgid state; and while this is the case, a mutual fretting of the parts will not only be kept up, but the injury will be cumulative. The oedematous prepuce cannot slacken and expand so as to make room for the glans ; while the latter, in turn, has a tendency to swell more and more, and consequently to exert an increased pressure, against the inner surface of the former. Under such circumstances the best mode of treatment is sufficiently plain to the judgment of the surgeon. Division of the foreskin will be expedient; or, if this appen- 6* 64 GONORRHOEA AND SYPHILIS. dage be of extraordinary length, circumcision is to be pre- ferred. In all ordinary cases, Sir Astley Cooper and Mr. Johnson advise that it be divided along the mesial line. The latter surgeon says, —" Division of the foreskin is very suc- cessful; and even when it is considerably elongated, the flaps of integument that depend on either side, are ultimately so absorbed, as to occasion little unsightliness, if any. I can scarcely dwell too earnestly on the advantages of this opera- tion in cases of chronic balanitis." Sir Astley is equally in favor of this operation. The method of procedure is this: Insert a director into the preputial cavity, and let it slide along the dorsum of the glans until it has reached the point of reflection of the prepuce behind the corona. Move the point of the director about so as to be sure that it is where you want it, and that it has not entered the urethra. Then tilt up the point of the instrument. Next, run a sharp pointed bis- toury along the groove of the director, and transfix the pre- puce at the point where that instrument projects under the skin, and complete the division by cutting out and bringing the bistoury towards you. Some surgeons prefer to divide the prepuce at its lower aspect by the side of the fraenum, and assign as a reason that less deformity and unseem- liness result, than is the case if the operation be performed on the superior aspect. When the prepuce is redundant in front of the glans, it may be drawn forward and cut with a knife or pair of scissors at a stroke. The mucous membrane may still be too tight; in which case it can be slit up at two or three points, and the ends of the flaps be secured by suture to the outer integument. There is still another, and a very neat operation for the relief of phymosis, even when most complete. The instrument employed is a pair of very delicate straight scissors of which one of the blades is termi- nated by a little button, like a probe-pointed bistoury. The sur- geon glides the point of this blade between the glans and the prepuce, while the sharp pointed blade is thrust between the inner membrane and external skin beyond the stricture. The mucous membrane now separates the two blades, and by clos- ing these, this membrane is divided to the distance requisite to allow the prepuce to be drawn back, and thus relieve the phymosis. The edges of the wound spontaneously separate, BALANITIS. 65 and cicatrization follows. The operation leaves no deformity. It is called Cullerier's operation; and has been performed at the Pennsylvania Hospital for many years with success. * Either of these operations may be resorted to with a view to give facili- ' ties for carrying out other measures of treatment. If no con- genital or permanent phymosis existed before the disease, there will be less urgency for the operation; so likewise if chancres exist within the preputial cavity, it will be best not to per- form the operation hastily, because the wounds might be inoculated with the chancrous matter. Should the symptoms be urgent, and there be danger of perforation of the prepuce, or of gangrene, then the operation will be demanded even at some risk of inoculating the wound. The danger here alluded to will be essentially diminished, if a strong solution of chlo- ride of soda be applied to the chancre, or if nitric acid be employed as an escharotic. We have the authority of Mr. Cooper for dividing the prepuce, even when the worst kinds of ulcerations are present, either upon the glans or pre- puce. He was accustomed to operate in this manner under such circumstances, and he assures us that he never saw, in a single instance, any ill consequences,—never knew any unfavorable ulcerations arise in the edges of the wound. On the contrary, the sloughing chancre or phagedsenic ulceration is more likely to assume a healthy condition after the prepuce is divided; and all the parts proceed more favorably from the moment they are thus liberated, and nature is allowed to come to the rescue. Circumcision.—In permanent or congenital phymosis, this operation may be required ; and as it can, like all other surgical operations, be performed without pain, it is a procedure vastly less objectionable than it was formerly. Its results are more beneficial and complete, than mere division of the prepuce. No deformity is left —a fact of no little concernment to the owner, — and, what is still more important to him is, he is in no danger of ever again being troubled with phymosis or paraphymosis, nor yet, probably, with balanitis. Several methods, which vary slightly, are practised by surgeons in * See Miller's Surgery, edited by Sargent, p. 587. 6* 66 GONORRHOEA AND SYPHILIS. the removal of the prepuce. Mr. Milton's plan is simple and is as good as any. It gives a neat appearance to the part*. His mode of procedure is — to slit up the skin and mucous membrane as far as the reflection of the latter, and then cut away the fraenum as far as practicable. The constricted part, which is near the edge, is removed in a circle, and the bleed- ing being stopped, the skin and the mucous membrane are brought together by stiches, and covered with collodion. Paraphymosis. — When there is great constriction and nar- rowing of the prepuce from inflammation, it frequently hap- pens, that if this covering be pulled back behind the glans, it cannot again be brought forward to its normal position over this portion of the organ. It remains retracted, forming a band or ligature around the part just behind the corona, and occasioning strangulation analogous to that which takes place in intestinal hernia. This morbid condition of the penis is known in surgical language as paraphymosis. Infiltration into the integument takes place rapidly on either side of the stricture; and the glans likewise is distended with blood, and painful. There seems to be no power in the sys- tem to control the local inflammatory process that has been awakened; and which, if not checked by judicious manage- ment, will very likely result in the partial or total destruction of some of the tissues. Nature's method of relief, which the medical attendant sometimes witnesses, consists in a sloughing of the integument, including a portion of the ligature that pro- duces the constriction. The surgeon, however, if called sea- sonably, and if qualified for the duties of the occasion, will prevent this work of destruction. Let us consider the best means of doing this. A simply antiphlogistic treatment will sometimes bring immediate relief, as in the following Case. — August 13/1856. — Was called early in the morn- ing to see a stout, fat, full-blooded young man of dissipated habits. He was suffering from a paraphymosis, which had pro- gressed gradually for five days. The parts were swollen, hot, livid, and painful. The patient had kept his bed most of the time for eight-and-forty hours. On the day previous to my visit, his bowels had been twice moved by a dose of castor BALANITIS. 67 oil. Tongue coated, thirst considerable, pulse full, — ninety per minute. Ordered a large dose of sulphate of magnesia, cooling drinks, warm water to genitals, and a warm bath in the evening; patient to remain immersed until he became faint. Warm fomentations during night. Next morning preputial tumefaction and swelling of glans nearly gone; and paraphy- mosis much relieved, although the foreskin could not be brought over the glans; general condition of the patient im- proved. Continue hot fomentations, and in the evening repeat the warm bath. On the third day the prepuce advanced over the glans sufficiently, and the parts soon regained their normal state. If the patient be seen before the parts are " in extremis," the surgeon may attempt reduction of the constriction by pressing the glans steadily for fifteen or twenty minutes. If it be considerably diminished by the procedure, it may be pushed backward with the thumb and forefinger of one hand, while with the fingers of the other, an attempt is made to bring forward the prepuce. This manipulation is often suc- cessful. Should it fail, compression may be made by means of a delicate, narrow linen bandage, bound round the parts by commencing at the end of the penis and proceeding backwards, until a uniform pressure is brought to bear upon them. An old linen handkerchief furnishes a good material for the band- age. It should be torn into strips half an inch wide, and be applied so as to act equally on the parts. The degree of pres- sure should be as great as can be borne conveniently and no more. Each successive turn of bandage should overlie the previous one by about one-half its width. If the bandage ex- ert too much pressure, the patient can easily slacken it. This is a more sure and effectual plan than the taxis, and no mode of pressure can be more safe. M. Seutin of Berlin, proposes the use of forceps with spoon-like ends, which will embrace tho glans, and produce compression more uniformly than can be done otherwise. The application of, and squeezing with, such a hard substance, upon the head of the penis under such cir- cumstances, will rarely be followed by successful results. If neither the taxis nor compression with bandages will over- come the difficulty, it is not at all probable that any instru- mental force will answer any good purpose; and the surgeon 68 GONORRHOEA AND SYPHILIS. will scarcely find his account in wasting any more time in this manner. He should proceed at once to divide the stricture with a sharp-pointed bistoury. For this purpose he should seek the deepest portions of integument. If adhesions exist between the skin and the shaft of the penis, in consequence of plastic infiltration, they may require to be broken up; or free incisions may be made at different points, if necessary, in order to secure still greater relief. Sometimes the prepuce remains irreducible for a few days after the stricture is relieved. Be this as it may, no rude manipulation should be practised for the purpose of bringing things to a natural condition. As soon as the inflammation has subsided, the proper co-aptation will take place, and the patient may be told quietly to await this result. CHAPTER V. ORCHITIS. ORCHITIS NOT PRODUCED BY CUBEBS OR COPAIBA — THE EPIDIDYMIS THE USUAL SEAT OF THE DISEASE — SYMPTOMS — TREATMENT — PUNCTURING THE TESTIS AND EPIDIDYMIS — COMPRESSION OF THE TESTIS. At the present day, practitioners make no- delay in curing a gonorrhoea as soon as possible by the most efficient means; for experience has abundantly demonstrated that the morbid con- dition, erroneously termed hernia humoralis, orchitis, and swelled testicle, is not occasioned by the ordinary use of balsam of copaiba or the powder of cubebs, which are regarded almost in the light of specifics in arresting the urethral discharge. Mr. Curling, than whom no higher authority on this subject can be cited, is accustomed to prescribe these remedies separ- ately and conjointly in all stages of blennorrhagia ; and he has never found patients, thus treated, more liable to be attacked with orchitis than those who are treated differently. The same testimony may be gathered from the daily observations of medical men generally, who are constantly prescribing with impunity the remedial agents here spoken of. In regard to the agency of injections in giving rise to or- chitis it may be said, that if used with ordinary prudence, they do not produce it. If those of high strength be employed, and too frequently, they may induce this mischief. But enlarge- ment of the testicle most commonly arises in those cases of gonorrhoea, which pass into a chronic state, particularly when the prostatic portion of the urethra is affected. Cases of this sort occur generally between the fourth and fifth week from the commencement of the discharge. They may be manu- factured by the introduction and unskillful manoeuvering of the catheter, or be induced by violent exercise, excessive stimu- lation, or other imprudences, calculated to augment the exist- ing inflammation of the urethra, and excite a morbid action in the vesiculae seminales and vas deferens, until it reaches the 69 70 GONORRHOEA AND SYPHILIS. epididymis ; or it may be generated in virtue of what physi- ologists call the common law of sympathy, the intervening parts not being involved in disease. The action of a similar law is seen in cases of hernia humoralis, occasionally developed in connection with mumps. While the urethra is the seat of a blennorrhagic discharge, the other portions of the genito- urinary apparatus are easily brought into a diseased state also ; and among the accidents which attend this condition of the canal, orchitis is perhaps the most frequent. The testicles are connected by continuity of tissue with the mucous lining of the urethra through the medium of the vasa deferentia; and when inflammation has reached that part of the urethra in which these minute, intermediate canals ter- minate, it readily enough finds its way into them, and rapidly pursues its march, until it arrives at the convolutions of the epididymis, where its further progress is usually arrested. This appendix of the testis receives and retains the principal force of the morbid action, and thus serves as a wall of pro- tection to the parenchyma of the gland itself. Sometimes the enemy overleaps this barrier and attacks the testis proper. In all cases there is a general and sudden swelling, — a swelling of the testicle as we term it,— but this enlargement is produced by the presence of lymph and serum within the tunica vagi- nalis. The epididymis is, after all, the chief seat of the dis- ease in most instances. The old theory of metastasis, or the sudden translation of the inflammation from the urethra to the testicle, is not entitled to much favor. It is extremely ques- tionable whether any thing of the kind ever takes place in gonorrhoeal orchitis. The inflammation, in a majority of sub- jects, may be traced advancing along the vas deferens to the epididymis; or the morbid action may seize upon the latter without involving the vas deferens. This is what Ricord de- nominates sympathetic or vicarious inflammation. In nearly all cases of orchitis, the pain and urethral discharge diminish very considerably, especially during the early stage of the testicular affection. When orchitis attacks young men, who are troubled with blennorrhagia, the morbid action is more apt to reach the body or glandular structure of the testis, than it is in older men. These cases Vidal designates as parenchymatous orchitis. The ORCHITIS. 71 swelling is comparatively moderate; there is no serous effu- sion into the cavity of the tunica vaginalis, and the gland is drawn upward toward the abdomen. This variety is attended with great pain; and the symptoms are all much more severe and dangerous, than those which accompany other forms of orchitis. The variety of orchitis, in which the vaginal tunic becomes rapidly distended with the exudation is also very pain- ful ; where the inflammation preponderates in the epididymis the suffering is much less. In thirteen hundred and forty-two cases reported by Pro- fessor Sigmund, the seat of the disease is thus distinguished: the epididymis alone, sixty-one; the epididymis and cord, one hundred and eight; epididymis and tunica vaginalis, eight hun- dred and fifty-six; all the three parts, three hundred and sev- enteen. The testis itself, in more than half of these cases, was but a little enlarged. Of the number here cited, the left side alone was affected in two-thirds, — the right in one-third of the whole.* Vidal coincides with Sigmund that the left side is more frequently affected than the right; it is on the left side also, he says, that the accident first appears when both testicles are attacked. The observations of Curling, Johnson, and others, indicate that the right testicle is the one most fre- quently involved. From the above evidence it is manifest that no great difference obtains as to the direction which na- ture takes, — the right or left. Symptoms of Orchitis. — The attack commences with a sense of increased weight in the testis, with dull pain along the course of the spermatic cord, in the perinaeum, in the groin, and in the lumbar region- In a few hours the epididymis be- comes swollen at the lower portion or tail, as it is called, — is hard, knotty, and tender to the touch; the patient can scarcely tolerate any covering upon that side of the scrotum ; or bear to have it come in contact with the thigh. He feels most com- fortable when he holds it in his hand. In two or three days, if not arrested, the inflammation reaches the tunica vaginalis; and the general tumefaction, which preserves the natural, oval contour of the testicle, increases to the size of a hen's egg. * British and Foreign Med. Chir. Review, October, 1856. 72 GONORRHOEA AND SYPHILIS. The pain, which in the beginning, was of a dull, aching de- scription, soon becomes more absolute, especially when the patient attempts to assume the erect posture. There is great irritation in the bladder, and a constant desire to urinate. The distress about the loins, hips, and scrotum is sometimes excru- ciating. As the disease advances to its culmination, the sur- face of the scrotum, which invests the gland, participates in the inflammation, becomes red, hot, thickened, and oedematous. Generally, the constitutional disturbance is not severe; occa- sionally, it assumes a very serious character. Sometimes the patient suffers from extreme nausea, and perhaps vomits freely; the tongue is coated; there is great thirst; quick pulse; and all the symptoms maintain their activity for eight or ten days, by which time they are usually inclined to yield. The blen- norrhagia diminishes or wholly subsides for the time being; and when the order of events is reversed in regard to the orchitis, — that is, when the symptoms begin to be less severe, and con- valescence from the scrotal trouble is fairly commenced, the gonorrhoea generally re-appears. Now and then the urethral flux is not affected in any way by the swollen condition of the testicle, even where no remedies have been used, and where the swelling has gone on increasing to the size of the fist; and what is still more singular, instances have been known where the testicles have swollen and yet the discharge has become more profuse than before. In some feeble constitutions, the symptoms are moderate in degree, slow of development, and long in duration. Such cases are less easy of management than those in which an in- tensity of symptoms prevails. A trivial circumstance, such as carelessness on the part of the patient, or deviation from the prescribed line of treatment, will be sufficient to interrupt his progress towards a cure, and, perhaps, will provoke an un- fortunate relapse. In some such way the malady may be trans- formed into a chronic orchitis or epididymitis, which may harass the patient more or less for many months or even years. I once had a case of this kind in a married man living in the country. He was of a scrofulous diathesis, and every few months, on slight exposure, was tormented with swollen testi- cle for more than a dozen years after his recovery from an old, neglected gonorrhoea. ORCHITIS. 73 Treatment of Orchitis. — The modern treatment of blen- norrhagia has doubtless caused a diminution in the frequency of inflammation of the testicle, in this country at least, al- though, judging from the accounts that come to us in the med- ical journals from the other side of the Atlantic, such would not seem to be the fact in relation to the European popula- tion. * Any apparent immunity from this accident among our people, compared with its frequency among trans-atlantic sub- jects, must be ascribed, if real, not to superiority of treatment, for that we do not claim; but rather to the more provident and careful habits which characterize the ordinary classes of our citizens. These remarks involve no contradiction ; nor, I fancy, do they really traduce " our distant neighbors." The history of the symptoms, progress, and termination of Orchitis, as it has been studied within the last few years, and as its real character now stands unfolded in the writings of such men as Astley Cooper, Curling, Velpeau, Brodie, and others, shows it to possess the attributes of a truly sthenic disease, and to be rapidly aggressive in its tendency. The clinical experience of every practical physician and surgeon, at all familiar with the complaint, will bear witness to this truth. If the patient has the discretion to consult his medical ad- viser as soon as the symptoms, that foreshadow the approach of orchitis, begin to declare themselves, the testicle and its immediate dependencies, can frequently be rescued from the impending danger. But in many instances, the man pays but little regard to the first sensations of uneasiness along the perinaeum, the iliac fossa, and across the inferior portion of the spinal column. These symptoms continue for a day and a night, perhaps, when to his surprise, and while engaged in his usual pursuits, a sudden increase in their severity is ex- perienced ; his gonorrhoea ceases ; a sharp pain, with swelling in the posterior part of the scrotum, and other abnormal phe- nomena, already specified, arouse his fears. He takes to his room and the physician is summoned. The individual being in the condition here supposed, should be directed to go to * " Whatever may be the success attendant upon the treatment of gonorrhoea in recent times, the number of cases of epididymitis does not seem to diminish." — British and Foreign Med. Chir. Review. 74 GONORRHOEA AND SYPHILIS. bed and lie on his back. A cushion of cotton and an old soft napkin should be so arranged between the thighs as to support the scrotum, and be gently tucked up against it, so that no dragging force can be exerted upon the cord. The proper position of the parts being well secured, they are to be kept wet with cloths, dipped in cold wTater. In two or three hours* ice may be added to the water. The patient will tolerate this degree of cold now, much better than he would at first. It is not exactly prudent to commence with ice-water. It is safer, as well as more comfortable to the person, to reduce the tem- perature gradually. The application may be continued without intermission, so long as it gives relief. A brisk cathartic should be prescribed; low diet, as orangeade, rice water, bread-and- toast-water or tea, and the like, for nourishment. It is hardly necessary to say that all stimulants should be forbidden. These measures, adopted early, will be likely to check the further progress of inflammatory action. They constitute, at any rate, the most judicious antiphlogistic treatment that can be insti- tuted. They are to be persevered in with greater or less energy, according to the severity of the case and the constitu- tion of the patient. If the symptoms continue to increase ten or fifteen leeches should be applied to the perinaeum, over the course of the inguinal canal or upon the dartos, and the flow of blood should be promoted by the application of warm water. It is seldom necessary to resort to venesection, not even by opening any of the scrotal veins. The latter oper- ation would not be free from danger. It might expose to phlebitis. Instances of the kind are on record. After a suf- ficient quantity of blood has been abstracted, ice-water should again be applied to the scrotum. If half an ounce of lead water and an ounce of alcohol be added to each pint of the ice water, the efficacy of the lotion will be still more conspicu- ous. As the inflammation subsides, the use of lukewarm water will be found to agree better than a refrigerant. Mercurial Ointment; Iodide of Potash Ointment.—In some cases, one or the other of these may be advantageously used after the inflammation has abated. If the mercurial be selected, let it be spread on flannel and the whole scrotum laid in it. Its effect in reducing the swelling is sometimes remarkable; but orchitis. 75 it is liable to irritate the skin so severely that some men can- not bear it. If it be allowed to remain for any length of time, it will occasionally bring out a vesicular eruption (eczema mercuriale) which will be a source of no little discomfort, if the patient be endowed with a particularly sensitive skin. The iodide of potassium, in the proportion of a scruple to the ounce of benzoated ointment, may be used instead of the first named ointment, with similar results in diminishing the enlarge- ment, and in preventing the morbid action from extending to the tunica vaginalis. The potash will likewise occasion an eruption upon the integument; so that its use is not without objections. There is this also to be thought of, — the continual application of an unguent to these parts for several days, will get matters into an uncomfortable dirty condition, which is not easily got rid of. Lotions and fomentations, all things con- sidered, are to be preferred, and in chronic enlargement of the testicle or of the epididymis, the following application is the best that can be selected:— R. Iodini,.............................................gr. ij. Potassii Iodidi,......................................." vi. Aquae Ferventis,......................................3 xv'- M. This solution should be used, warm, as a fomentation to the affected parts, by means of a large sponge, three or four times during the twenty-four hours. In cases where the tincture of iodine, or either of the above-named ointments seems to be indicated, it will be found particularly agreeable as well as beneficial to the patient. The sponge should be kept in con- tact with the scrotum for thirty or forty minutes at each ap- plication. The progress of absorption will thus, in many cases, be hastened in the most effectual manner. This local treatment is both mild and cleanly — two not unimportant particulars, in which it has the advantage over the tincture and the unguents, while its discutient power is not inferior to theirs. The watery extract of belladonna, dissolved in the propor- tion of one drachm to a quart of boiling water, and applied by means of flannel cloths to the scrotum, and renewed repeat- edly, will sometimes promptly relieve the pain, and render ef- ficient service in promoting a speedy cure. 76 GONORRHOEA AND SYPHILIS. The employment of cathartics should be so' timed, if possi- ble, that the patient may not be disturbed by their operation during the hours of night, — the season which he most needs for repose, and of which if he be robbed, the succeeding day will find him irritable, disheartened, and in all respects worse than he would have been after a night of rest. Purgatives, therefore, in the early part of the day, and opiates by night, should be the order of arrangements. Attention to such small details will aid not a little in promoting the comfort and actual convalescence of many persons, whose genitals are the seat of inflammatory disease, whether acute or chronic. A few practitioners still cling to the old method of giving mercury to the point of salivation, or even beyond it, in nearly all cases of epididymitis or true orchitis. They find great diffi- culty in laying aside preconceived opinions and practices, emanating from the high authority of some favorite teacher; and they rely on the internal employment of the above men- tioned article as well nigh omnipotent in controlling every form of phlegmasia; and are slow to believe that mild lax- atives, quiet repose, anodynes, opiates, narcotics, and dia- phoretics can accomplish any great amount of good, unless " mercury is thrown in " as an accompaniment. It should be borne in mind, when mercury is thought of, that the dyspeptic, the scrofulous, the nervous, those who have naturally a feeble constitution, or who have become debilitated by their wild habits, rarely do well under the use of mercu- rials, while suffering from any active disease. In acute orchitis, there is excessive irritability of the sem- inal apparatus, — an irritative inflammation. The condition of the testis is not of the precise nature of inflammation in the strict sense of the term, as when we speak of swelled testi- cle from a kick or severe blow. The complaint, in its recent stage, even where the symptoms are severe, will sometimes yield readily to low diet, a moderate purgative, and the subse- quent free use of the tincture of hyoscyamus. The latter may be given in drachm doses every three hours, in rice water or barley water, until a decided narcotic effect is produced. As soon as the patient experiences the specific influence of the henbane, the local symptoms will almost certainly abate ; and it may afterwards be employed in diminished quantities. ORCHITIS. 77 The following combination of antimony, sulphate of magne- sia and colchicum, may likewise be used in many cases with good results. It will be sure to maintain a slightly nauseat- ing and depressing effect on the stomach, while at the same time it will keep the bowels free, and help to subdue the in- flammatory diathesis. R. Antimonii Potassio-Tartratis,...........................gr. ij. Vini Colchici,........................................3 iij- Magnesia; Sulphatis,..................................3 •• Aquas,...............................................3 vm- M. Give half an ounce of this mixture every two or three hours during the day. The frequency of the dose must be varied, of course, according to the effect. At bedtime morphine may be required to insure quiet rest. R. Morphias Sulphatis,...................................gr. vi. Aquas Camphoras,....................................3 'ss- M. Dose. One drachm, to be repeated in three hours if necessary to procure sleep. Opiates may be given at any time to allay pain. PUNCTURING THE TUNICA VAGINALIS TESTIS AND EPIDIDYMIS. If the disease has extended to the tunica vaginalis, and effu- sion has taken place within that membrane at any stage of the inflammation, the operation of puncturing the tunica should be resorted to and the fluid evacuated. The operation is entirely practicable and gives immediate relief. The puncture is to be made with a grooved needle. In true orchitis, where the body of the testicle is involved, and the pain severe in consequence of constriction occasioned by the tunica albuginea, punctures may be made with a lancet into the testicle itself. This prac- tice was first proposed by M. Petit, and is adopted by Ricord, Velpeau, and other surgeons. The epididymis may be punc- tured in the same manner and with equal safety. The opera- tion does not interfere with the physiological functions of the parts in question. It removes the most distressing symptoms and hastens the recovery more rapidly than any other method. Cases requiring these measures, however, are comparatively infrequent. A timely and continuous application of refriger- ant lotions, and other antiphlogistic treatment, will usually be productive of amendment and complete cure in a short time. 78 GONORRHOEA AND SYPHILIS. Compression of the Testis. —In 1836, Dr. Fricke, surgeon to the General Hospital of Hamburg, recommended the application of compression to the testis, by means of strips of adhesive plaster, as a substitute for every other form of remedial appliances, in the treatment of orchitis. Following the recommendation and practice of Fricke, many other sur- geons have adopted his method of pressure, and up to this day have borne testimony to the simplicity of its application, to the slight trouble it gives the patient, and to the trifling care and attention required on the part of the medical attend- ant ; they also speak in the most decided manner of its efficacy in relieving pain, and promoting a rapid cure of the disease itself. At St. Bartholomew's Hospital, strapping the testicle in cases of epididymitis, is regarded as the best plan of treat- ment. When, in consequence of pain, it cannot be carried out, the use of leeches to the parts, and the administration of emetics, are resorted to; and these are very efficient means for reducing the inflammation of the organ.* To some surgeons, the employment of emetics, for the relief of orchitis, may seem a strange mode of procedure. The late Professor Nathan Smith of New Haven, recommended this treatment. In some instances of orchitis, I have pre- scribed emetics and beneficial results have followed their use. The relief is sometimes immediate, and is to be explained on the principle of what is called revulsive action. Hunter tells us that he had known an emetic to remove the swelling almost instantaneously. The effects of the remedy, he thinks, most probably arise from the sympathy between the stomach and the testicles. In acute and severe attacks of swelled tes- ticle, or of epididymitis, free vomiting will speedily relieve the local symptoms in many cases ; and if, after the use of emetics, the surgeon decides upon the employment of adhesive straps to the testicle, the application will, in all likelihood, be less painful. The emplastrum ammoniaci cum hydrargyro may be used, or one composed of soap, belladonna and adhe- sive plasters in equal proportions, and carefully spread on thin, firm leather. The strips of plaster are to be cut about two- thirds of an inch wide ; and the manner of employing them is * Holmes Coote.on Gonorrhoea, 1857. ORCHITIS. 79 as follows : The patient is placed in a recumbent position, and the surgeon having gently drawn down the testicle to the lower part of the scrotum, the skin of which is stretched over the surface of the gland, proceeds to apply the strap in a circular manner, commencing from above the insertion of the cord, which must be closely embraced in order to pre- vent the testicle from slipping through the loose rings of the plaster, when the inferior portion is compressed. In this way the operator encircles the gland by a succession of straps, each lying over its predecessor by one third of its width, until the whole organ is covered. A second series of straps is then passed from above downwards, and thus the entire tes- ticle is completely enveloped and compressed. When the local symptoms have begun to wane, and the dis- eased gland will bear considerable squeezing with the hand, compression with straps to a moderate degree may be advan- tageously applied, for the purpose of promoting a more rapid subsidence of the swelling, the removal of plastic exudation, and of the thickening of the epididymis. At this juncture, the internal use of the iodide of potassium will be service- able. Should the inflammation be very severe, or be on the increase, or if there be great effusion into the vaginal sac, compression will do harm. But when the tunic has been punctured with the grooved needle or the lancet, and the fluid drawn away, pressure can then be beneficially resorted to. This plan has often been adopted, and it works well. But the most favorable time for the employment of pressure, if applied at all, is after the chronic stage has fairly set in. After the straps have been adjusted, the patient should be confined to the recumbent position and to a low diet. These precautions will ward off any tendency to increased inflammatory action, and will render the cure more effectual and speedy. The views of Ricord on this subject are thus communicated by Mr. Acton : — " Swelled Testicle. — Compression of the testicle by means of strapping has now been mostly given up by M. Ricord in his hospital; it is, he still admits, an excellent remedy when well applied, but the patient should be seen in the early stages, twice a day, and the strapping re-applied, if 80 GONORRHOEA AND SYPHILIS. necessary. Without watching, this treatment is sometimes accompanied with disagreeable consequences, which aggra- vate the complaint; at least the French professors think so; but in London, in private practice, I have every reason to be satisfied with the treatment, which shortens the duration of the disease very much, and dispenses with the usual incon- veniences attending these cases. M. Ricord places his princi- ple dependence on leeches, mercurial ointment and plaster, and, above all, a purgative taken every morning, consisting of aperient salts. In this last recommendation, I can bear testi- mony most fully."* Mr. Johnson is extremely severe in his condemnation of the practice of strapping the testicle. He compares it to the pro- cess of the Buccaneers of the Spanish Main, who slung their prisoners to the yard-arm by the testicles, until they confessed where their dollars were laid. " If," says he, " the inflammation is acute, it is a piece of ridiculous cruelty; if mild, it is dis- proportionately painful, troublesome to manage, apt to lacerate or excoriate the skin, and not a little treacherous. I would not wish to be understood that I would never recommend it nor have recourse to it. Where concealment is a great object, where the patient is not of a nervous habit, and either is not sensible to pain, or has the will to bear it, and where the in- flammatory action is moderate, pressure may be fairly tried. Yet, even here, with all things in its favor, I warn the young surgeon not to expect too much from it. I believe that in most cases it is better left alone, and I am mistaken if it is not declining in favor, and likely to decline still more. At all events, the conclusions I have arrived at and expressed, are founded on my own experience and pretty numerous trials of it." In chronic cases of epididymitis, where there is a lingering induration, and a low degree of inflammatory action, extending perhaps, to the glandular portion of the testis, with but little constitutional disturbance, the antiphlogistic treatment is not required; it is in fact, injurious. The patient generally looks pale and feeble, and is in just that condition that calls for a generous diet and the careful use of bitter tonics. He is liable * Lancet, December, 1854. ORCHITIS. 81 to have uncomfortable nights. He is unfit for much physical activity by day, and the sleep of the laboring man is not his. He therefore requires some artificial aid to insure the necessary repose; and opiates, sparingly as may be, must be allowed at the hour of rest. During the day, free libations of sarsaparilla decoction will be found useful. This drink is something more than a mere beverage to fill the stomach and employ the kid- neys and bladder. Its mild and agreeable tonic qualities endow it with more than negative claims to favorable consideration as a constitutional remedy. In this class of cases, some mercurial preparation may be found serviceable; but it should hold a sub- ordinate place in the general treatment. Whatever form is selected, the course should be a very mild one, and should stop entirely short of salivation, or even before any but the slightest affection of the gums is perceptible. Two formulae are here submitted, either of which will scarcely fail to suit, unless some peculiar idiosyncrasy is inherent in the patient. R. Pulveris Opii,.........................................gr. vi. Pilulae Hydrargyri,.................................... Extracti Hyoscyami, aa,................................3 iss. M. ft. pil. No. xxx. The other mercurial preparation is the bichloride: — R. Hydrargyri Chloridi Corrosivi,......................... Ammonias Muriatis, aa,...............................gr. v. M. ft. pil. No. Ix. Of the above pills one may be taken morning and night. The condition of the mucous membrane should be carefully watched during their use. Together with the sarsaparilla and the pills, small doses of iodide of potassium may be given, thus : — R. Potassii Iodidi........................................3>j- Tincturas Cinchonas Compositae,........................3 iss- Aquae Fontanas,.....................................3 nJ- M. Dose. One drachm thrice a day in compound decoction of sarsaparilla. The scrotum should be well supported in a suspensory bag. The patient should be encouraged to be abroad in the open air as much as possible, and to bathe daily in warm or cold water, as he may choose. Dashing a few tumblers of cold water 82 GONORRHOEA AND SYPHILIS. against the pubes three or four times in the day, will likewise tend to restore the parts to their normal condition. The ap- plication of the compound tincture of iodine to the scrotum. will contribute to the removal of any induration or swelling of the epididymis or testicle, and to the perfect restoration of the parts to health. CHAPTER VI. HERPES PR^PUTIALIS. SYMPTOMS--TREATMENT. This vesicular affection is of frequent occurrence. Men who have a long, superabundant preputial membrane are more liable to be troubled with the eruption than others. Those who are familiar with its appearance in the different stages of its existence, and who have much practical experience in its treatment, may consider that it is so insignificant, and so unlike any syphilitic sore, that it is hardly entitled to con- sideration in this place. But a correct diagnosis of the eruption is a matter of no little consequence; for an error or confusion here, will lead to improper treatment, to say nothing of the moral bearings immediately connected with the subject. Patients who have contracted herpes upon the penis in consequence of sexual intercourse, or who have suffered from it as a concomitant or sequel of blennorrhagia, have occasion to apply to the physician for the purpose of obtaining his opinion in the premises. And in some instances herpetic eruptions, located upon the foreskin, have been treated as chancrous products. Such cases have presented themselves to my notice, and although not frequent, they justify the appropriation of a few pages to the exanthem in question. Symptoms. — The most common seat of the eruption is along the border of the prepuce, where the external and inter- nal surfaces meet. At first a sensation of heat and smarting, accompanied with considerable itching, draws the attention of the patient to the part upon which the eruption is about to be evolved. Upon inspection, he notices that it is slightly thickened and suffused with a preternatural redness ; and if he merely touch it with his fingers he induces a higher degree of itching and rubs it with the expectation of appeasing the 83 84 GONORRHOEA AND SYPHILIS. sensation. In a few hours, he perceives, if he looks, an aggregation of some dozen or twenty points closely crowded together; and on careful examination discovers that these pimples are filled with a transparent, watery fluid. They are the vesicles of herpes praeputialis. They are about the size of a common pin's head, and have been compared to so many transparent glass beads reposing on a red base. Instead of one group or cluster, two or three may appear simultaneously. They are not inclined to enlarge the area they occupy, but have nearly the same dimensions in the latter stages which they had at first. Instead of appearing on the confines of the preputial ori- fice, as mentioned above, the eruption may arise at a little distance from it, either on the mucous or cuticular surface of this membrane. In two or three days, the contents of these globular vesicles lose their transparency and are slightly tur- bid ; and in four or five days the matter becomes puriform. The walls of the individual vesicles break away and the eruption is then confluent. Next, desiccation ensues, forming a thin, delicate incrustation, which in two or three days is cast off and brings to view a smooth, raw, florid spot, amount- ing to little more than an abrasion ; or, if it be an ulcerated surface, it is of the most superficial kind, and has no hardened base as in syphilitic ulcers. When the complaint is situated on the inner surface of the prepuce, the inflammation is gener- ally quite severe. The vesicles are usually a little larger than when developed on the external surface. The serous exudation of herpes passes rapidly into a lactescent state, the membrane or sac containing it is easily ruptured and excori- ations are produced, which may be mistaken for venereal ulcerations. But the speedy development and progress of the eruption, the level of the exposed surface after the incrustations have fallen off, with the adjacent healthy tissue, and the ordinarily transient duration of the affection, are entirely in contrast with the true venereal sore. I must here append the qualifying remark—that if the herpetic action take place on the inner surface of the prepuce, no incrustation or scab is formed, in consequence of the constant moisture of the parts and their protection from the air. If the eruption be not seen by the physician until five or six HERPES PRAEPUTIALIS. 85 days after its first appearance, by which time incrustations may have formed on the skin, or the secretion have passed into a sero-purulent state ; and if its antecedents indicate that the patient has been exposed, then it will not be an easy matter to say whether the affection be follicular chancres or simply herpetic. Under such circumstances, the practitioner can very properly claim a postponement for a day or two, before he expresses a decided diagnosis ; meantime keeping matters in statu quo by some mild appliances. This is a justifiable and wise arrangement; for upon a true recognition of the malady, will hang the proper line of treatment. The eruption of herpes, when situated upon the foreskin, is quite evanescent, if not injudiciously tampered with. It runs its course in eight or ten days, and then, in most cases, all is over. Occasionally it becomes chronic, and whatever be the treatment, is extremely difficult to cure. Some men of pecu- liar cutaneous susceptibility, are troubled with frequent attacks. The eruption will readily disappear under the appli- cation of chloride of soda or lead-water, in weak solution, and will be reproduced by a variety of trivial causes, such as the ordinary friction of the trowsers, neglect of cleanliness, constipation, errors in diet. I have known sea-bathing to occasion this eruption. Sometimes numerous minute vesicles are seen clustered on the mucous surface of the prepuce, along the fossa just behind the corona glandis, and forming a cincture around the organ. The accompanying inflammation is moderate, and when the vesicles burst, there is seldom any disposition to assume an ul- cerative process, and there is a total want of depth to the sore. The foregoing description corresponds in the main, with the characteristic features presented by herpes praeputialis, whether situated on the external or internal surface. The complaint derives its chief importance from two facts : one is, that it is too apt to be regarded by the patient, and sometimes by the medical adviser, as syphilitic ; and the other, that a man having it, or being predisposed to it, is more liable, coz- teris paribus, to contract a venereal affection, than one who has no such herpetic tendency. The following case occurred in my practice a few years 8 86 GONORRHOEA AND SYPHILIS. since. I introduce it here, as illustrating a method of pro- cedure which may be applicable to other patients in like cir- cumstances : — A clergyman from a neighboring state, consulted me for a preputial eruption, which had troubled him, at intervals, for several years. Leading as he did, a sedentary and studious life, he had become rather thin and dyspeptic, and not a little nervous. Like many others, he had a ready faith in the stories that are so often concocted among the ignorant and the cred- ulous, concerning the divers ills that befall the sexual system. He was a married man and his wife an invalid; but she was free from all known uterine or vaginal derangement. My clerical patient had, however, imbibed the notion that his wife was the cause of his genital trouble, especially as it was ag- gravated by sexual intercourse. Another circumstance, still more singular, was, — he believed his complaint to be syphilis ; and as he proceeded in the narration of his case, he remarked, " I suppose I have got what they call the ladies' disease." I asked him if he considered his wife a virtuous woman. " As pure as the virgin Mary," was his reply. I requested to ex- amine him, and upon inspecting the virile organ, the prepuce was found to be much elongated and narrow; its whole border thickened, slightly everted and covered with herpetic disease. A little extra force brought the prepuce fairly back, so as to expose the glans, which was covered with a dense sebaceous deposit. The gentleman was quickly told that the fons et origo mali was within himself; and that his trouble, instead of being syphilitic, was the offspring of malformation and neg- lect of cleanliness. The treatment proposed was: to keep the bowels regular, exercise freely in the open air in all good weather, practice daily ablution of the whole body and limbs in cold water, and away with all thoughts of the " ladies' dis- ease." As a topical application, the following lotion was pre- scribed:— R. Liquoris Sodae Chlorinatas,..............................3 iij. Aquae Fontanas,.......................................? Xt ]yi. To be applied constantly by means of a soft rag; also to be HERPES PR.EPUTIALIS. 87 injected between the glans and prepuce repeatedly during the day. Some months after prescribing for the patient, I ad- dressed to him a note, and received the following reply: — " With respect to the subject concerning which you wrote me, I would say, I followed your directions for nearly six months, — received relief from smarting and soreness in about six weeks. The disease seemed to be removed almost en- tirely in six weeks. Occasionally I feel a little smarting and experience a little inflammation about the once diseased place. At such times, I resort to your prescriptions, and after one or two applications of the wash, etc., the difficulty is removed. I think yours is the remedy for such a complaint as mine was. Allow me to thank you most cordially for the benefit I have received from your directions. I. B." Case II. — Herpes prceputialis twice in the same man in connection with acute gonorrhoea. June 15,1856.—Patient, A. K.,aged twenty-six years. Thin, tall, spare frame. . Twelve days ago fell into bad company, and as a consequence, contracted gonorrhoea, which appeared in five days after exposure. To-day the discharge is copious, thick, and puriform. Ardor urinae for last two days, and pain- ful erections and chordee the last two nights. Prepuce very long, contracted, and inflamed; about the orifice, numerous herpetic vesicles have formed. Complete retraction of pre- puce difficult. No balanitis; no swelling of inguinal glands. For the blennorrhagia, cubebs were prescribed, and in a few days the discharge ceased. The herpetic eruption, produced by the irritation of the urethral secretion, continued undimin- ished for four weeks before the prepuce was restored to its normal condition, notwithstanding the free use of opiate lo- tions, lead-water, chloride of soda, etc. November 29, 1856.—A. K. has signalized his folly by plunging into danger anew. The exposure happened on the night of the 14th ; and on the morning of the 20th, the present attack of urethritis declared itself. A sense of shame pre- vented him from calling earlier for treatment. The gonorrhoea on this occasion degenerated into a gleet, which lasted for three months. The reason for this was, the patient became reckless of all directions and restrictions. The prepuce was 88 GONORRHOEA AND SYPHILIS. again the seat of herpetic disease, more severe than during the previous attack. The inguinal glands of the left side were enlarged, and the condition of things for a short time was similar to that seen in genuine follicular chancres or syphilitic ulceration of the prepuce. Had the case been seen by a surgeon for the first time while at its acme*, he would have found the real character of the disease a question not easily settled, unless a detailed history of it from the commencement had been furnished. But as the complaint originated in a ves- icular eruption, and as follicular chancres and syphilitic prepu- tial ulcerations never have such an origin, the differential diagnosis could be readily made out. The herpetic affection did not quit its hold of the prepuce until more than eight months had elapsed. Treatment. — If herpetic vesicles appear on any portion of the inner surface of the prepuce, the application of dry lint will frequently cause them to vanish ; the liquor plumbi, in the proportion of a drachm to four ounces of water, will do the same; and thus prove the non-venereal character of the erup- tion. Sometimes the solid nitrate of silver, lightly drawn over the part every three or four days, will prove an effectual rem- edy. The hydrocyanic acid is likewise a valuable article to be employed as a lotion in obstinate cases of herpes, not only when situated on the prepuce of the male, but also when it at- tacks the genitals of females. The following preparation will be found useful: — R. Acidi Hydrocyanici,.....................................3'j- Spiritus Rectificati,....................................3 ij- Aquae Destillatas, ......................................3 iv. M. To be applied by means of lint. The arseniate of iron, in common with other preparations of arsenic, possesses properties which render it worthy of a trial. The advantage of this substance is, that it may be ad- ministered in sufficient quantities, without giving rise to any of the unpleasant consequences which sometimes follow the use of other arsenical remedies. It should be given in gradu- ated doses, commencing with one-fifteenth of a grain once a day for the first eight days; then one-fifteenth twice a day for HERPES PRiEPUTIALIS. 89 eight days more; after which, the fifteenth of a grain three times a day, making the maximum daily amount to be one-fifth of a grain. The formula I employ is: — R. Ferri Arseniatis,......................................gr. iv. Extracti Gentianas,....................................3ij- Pulveris Glycyrrhizas,.................................3iv. M. ft. pil. No. lx. The pills should be taken on a full stomach. They are com- patible with the use of almost any other medicine which the surgeon may wish to employ, and may be continued uninter- ruptedly for three or four months, if necessary. They are not only useful in herpes, but also in squamous affections. The arseniate of quinine is likewise a valuable medicine for the same cutaneous maladies. The dose is one-third of a grain blended with the extract of gentian and taken directly after the morning and evening meal. The tincture of the muriate of iron, twenty drops three times a day, in a gill of water, is also useful in obstinate cases of herpes praeputialis. Whatever course of treatment is pursued, it should be a principle of cardinal importance to rectify any constitutional derangement that may be present. Simple and insignificant as the foregoing eruption is repre- sented to be by some authors, it occasionally shows itself more than a match for the skill of the medical attendant, and re- mains upon the patient as a source of sore vexation. CHAPTER VII. ECZEMA prjeputialis. APPEARS IN CONNECTION WITH CHRONIC BLENNORRHAGIA — FRATERNIZES WITH IMPETIGO — MISTAKEN FOR A SYPHILITIC AFFECTION—TREATMENT. In bilious and sanguineous subjects, who have a dry, un- perspirable skin, and indulge in strong proclivities for eating and drinking whatever comes before them at table, the prae- putial integument, especially if there be a redundancy of it, sometimes proves to be a favorable locality for the develop- ment of this complaint. Its occurrence, however, is less fre- quent than the preceding affection; but of the two, it is usually the more serious and persistent. Although both present a common elementary type,— that is, a vesicle, — yet the course pursued by the two is widely different. The solitary vesicles of eczema are smaller and more acuminated than those of herpes. They are accompanied by a sensation of heat and pruritus of higher intensity than the herpetic affection, and no application seems adequate to appease these annoyances for the time being. After the vesicles have occupied the prepuce for a day or two, they are inclined to become confluent; and in consequence of the effusion of serum beneath the epiderma, they form small, oblong, flattened bullae, half the size of a pea at the base. The cuticle of these multilocular vesicles is easily broken, and a glutinous exudation, having the peculiar sickly odor well known in eczema when situated elsewhere, is dis- tilled in sufficient quantity to stand in drops on the inflamed and denuded derma. The malady, at first, covers but a small patch of ground, but is rarely content to keep within its origi- nal limits. It has a diffusive tendency, and in this respect differs from herpes, which has no disposition to spread when situated on the same part. Unlike the eruption of herpes also, it seldom implicates the mucous lining of the prepuce, but in most instances extends over the entire external surface, seizes upon the dartos, is now severe, now better, fitful in its beha- 90 ECZEMA PRiEPUTIALIS. 91 vior, for a few days highly inflamed and yielding a copious exudation, then occasioning scarcely any moisture, itching, or redness ; but a flimsy, laminated incrustation is formed, blended with newly formed cuticle. This latter condition sug- gests to the inexperienced eye, a proximity of cure; but in lieu of this, a few rough, involuntary scratches with the finger nails, which the affected parts are pretty sure to receive, re- produce the eruption in two-fold severity, and dissipate all hope of immediate deliverance from this local trouble. For the most part, the eruption appears in connection with chronic blennorrhagia. The secretion, which it yields, spreads over the sound skin, and by the irritation it excites, causes an extension of the trouble in every direction. It is very apt to assume a chronic form, and when it does it sometimes simu- lates psoriasis. It is, however, but a resemblance. I do not believe it ever loses its identity, or that it undergoes a trans- formation into another disease. We might as well say that one animal or one plant degenerates into another. The two mal- adies in question are different in appearance, and require dif- ferent treatment. Even where the vesicles have ceased to form in successive crops, and when the prepuce and even the scrotum remain covered with scales,—these, as the result of eczematous action, are less friable, less furfuraceous, and more laminated, broader and flatter, than the scales of psoriasis. Furthermore, in long-continued eczema of the prepuce and dartos, the in- tegument, after the scales are removed, does not present that smooth, red, polished, elevated surface which is observed in psoriasis; but is rough, chapped, and marked by fissures, from which, as well as from the sudatory apparatus and the hair- follicles, a frequent and copious oozing of the irritating fluid of eczema will take place. Eczema, of however great duration it may be, rarely ever loses its natural tendency to form vesicles on some portions of the integument, which is the seat of the complaint. They appear here and there, as solitary specimens, just outside or inside the borders of the affected district, re- main for a few days, a new source of trouble to the patient, and then disappear. These facts or circumstances do not happen in psoriasis. Sometimes the eczematous eruption, es- pecially if it spread over the dartos, or along the upper part of the thighs, or over the pubic region, fraternizes with im- 92 GONORRHOEA AND SYPHILIS. petigo; that is, the exudation beneath the cuticle consists, from almost the very beginning, of a small number of pus globules suspended in a large quantity of serum, and giving it an opal- escent appearance; and the inflammation, the heat, the scald- ing, and burning sensations, that accompany the evolution of the eruption, attain a higher degree of activity than in simple eczema. The scabs and incrustations become thick, firm, and rugged. The affection, having these impetiginous characters, is partial to the upper part of the thighs in both sexes, and is occasionally met with as the joint production of chronic blen- norrhagia and want of cleanliness, and has been mistaken for a true syphilitic pustular disease. Treatment. — The means best adapted for treatment, must necessarily vary according to the degree of severity which the disorder assumes. Ordinarily, but a limited portion of integument is involved at any one time, and local applica- tions of a soothing, unstimulating kind may be relied upon. During the day the following lotion may be used : — R. Liquoris Plumbi,......................................3'j- Glycerinae,............................................3 iij- Aquas Fontanas........................................3 v'u< ^- At bedtime, the parts may be covered with the benzoated oxide of zinc ointment, prepared as follows : — R. Gummi Benzoini pulveris,...............................3iij" Adipis prasparatas,......................................3 nJ- Liquefac, cum leni calore, per horas viginti quatuor, in vaso clauso ; dein cola per linteum, ct adde, Oxydi Zinci purificati,..................................3 ss- Misce bene, et per linteum exprime.* The benzoin prevents decomposition in the above ointment; so that it does not become rancid as is the case with ointments generally; and as a soothing, local application, it is all that can be desired. I have prescribed it almost daily during the last year. If there be much discharge from the eczematous surface, it should be wiped off with a soft rag, but not washed; * " The benzoated oxyde of zinc ointment, properly prepared, is the most per- fect local application for all chronic inflammations of the skin that is known." — Erasmus Wilson, on the Skin, fourth edition, p. 73. ECZEMA PR^EPUTIALIS. 93 and the ointment may be used two or three times during the day, if the surgeon choose, instead of a lotion. The old prejudices against " greasy applications" need not be raised against the ointment here recommended. The sulphuret of potash is prescribed by some writers. This article has an extremely unpleasant odor, soils whatever it touches, and my experience with it as a topical application, leads me to regard it as inferior to the remedies above suggested. Acetic acid, six drops to the ounce of water, and used repeatedly during the day, when the pruritus is troublesome, will be found bene- ficial; so also, equal parts of lemon-juice and water, dabbed upon the spot with a bit of rag, will, in many cases, wholly quiet the itching. When the eruption attacks the scrotum and thighs, it is nearly useless to rely on mere topical applications. The patient requires constitutional treatment. The first of such remedies, in importance, are, moderate saline cathartics, pro- vided the patient is of a full habit. If of an opposite consti- tution, aperients will be sufficient. In all stages of the eruption, a free state of the bowels should be maintained. The alimentary canal can be made to perform excellent service to the skin, and should never be allowed to remain idle a sin- gle day. The uropoietic apparatus may also be employed in the work of relieving the cutaneous vessels. I have derived advantage from the use of bitter-sweet and common yellow dock-root combined as follows: — R. Solani Dulcamaras,.....................................? i, Pulveris Radicis Rumicis Obtusifolias,....................3 ss M. Let these ingredients be put into a quart of water and sim- mer over a slow fire, until the water is reduced to a pint and a half. Strain the decoction, and direct the patient to take an ounce of it three times a day. The quantity may be gradu- ally increased, unless some unpleasant effects, such as vertigo, nausea, or palpitation, are induced. After the decoction has been taken for two or three days, its influence is usually mani- fested in a decided manner by the increased action of the kidneys and bowels, — a'nd amendment of the cutaneous affec- tion follows very soon afterwards. The liquor potassae and the aqua acetatis ammoniae are like- 94 GONORRHOEA AND SYPHILIS. wise remedies which ought not to be omitted. Either of them may be taken in liberal doses, unless some known cir- cumstance should exist to contraindicate their use. In regard to the employment of arsenical preparations, the course recommended in herpes praeputialis, can be prescribed with equal advantage in eczema of the same or neighboring parts. CHAPTER VIII. IRRITABILITY OF THE BLADDER. IN IRRITABLE BLADDER THE SYSTEM IS RARELT DISTURBED — IN INFLAMMA- TION OF THE BLADDER IT IS --DIFFERENCE OF SYMPTOMS IN IRRITABLE BLADDER AND CALCULUS — TREATMENT OF IRRITABLE BLADDER. In some cases of blennorrhagia, which become chronic, a certain amount of irritability of the bladder is induced, which often requires medical treatment. Persons of a nervous tem- perament are particularly liable to suffer from this affection, while those of a robust, sanguineous constitution, are more disposed to cystitis or inflammation of the bladder. In irrita- bility of this viscus, the mucous membrane becomes morbidly sensitive; and the presence of the urine is quite insupporta- ble. The patient complains of a sense of uneasiness in the lumbar region, about the verge of the anus, at the extremity of the penis, and above the pubes; he is continually haunted with a desire to pass urine, and unable to endure the smallest accumulation of this fluid. It is seldom that he suffers much pain anywhere, but his nervous system is wrought up to a state of constant excitement. He loses all relish for food, and sleep departs from him; and if these abnormal conditions are not removed, the general complexion of the symptoms will simulate those of cystitis, or what is still worse, the latter dis- order will actually set in. In mere irritability of the bladder, the system is rarely affected; whereas, in inflammation it is always involved. This is the rule, and should be borne in mind in forming the diagnosis. Simple irritation may also be known by the absence of that profuse secretion of mucus, which is a prominent characteristic of catarrhus vesicae. In the latter affection, immense quantities of thick, semi-transpa- rent, tenacious mucus, and coagulable lymph, accumulate in the bladder, and frequently block up the urethral canal, so as to impede, or wholly prevent, the flow of urine. Sometimes 95 96 GONORRHOEA AND SYPHILIS. the complaint extends to the ureters and kidneys, which con- tribute a share of the secretion that is produced in such extra- ordinary quantities. In irritation, the urine is free from any admixture of blood; in inflammation, it is* more or less deeply tinged. In inflamma- tion, there is constant and severe distress in the rectum, with a sensation of heat and throbbing in the part as well as along the course of the perinaeum; and if the surgeon make gentle pressure upon the supra-pubic region, the patient will complain of lancinating pain, which is not the case when the viscus is merely in an irritable state. In inflammation of the vesical mucous membrane, the symptoms, both local and constitutional, are all of a much more grave and intense character than those which prevail in uncomplicated irritation. An acute attack of irritation occasionally passes into a chronic state,and may lead to suspicion that a calculus exists in the bladder; and this idea may suggest to the surgeon the impor- tance of introducing the sound; whereas, if this instrument be used, the chances are that it will excite inflammation in the organ, which has been thus needlessly explored. The patient's condition goes on from bad to worse. No stone is found; and a little reflection upon what has passed, and a more abid- ing and deliberate attention to what is present, will now ena- ble the surgeon to form a correct diagnosis of the case. To such a course of procedure with such results as are here men- tioned, the annals of surgery abundantly testify. The most salient points of difference between irritability of the bladder and a calculus within its cavity, may be summed up in a few words. In the latter disease, the moment of the pa- tient's greatest suffering is after the last jet of urine has es- caped from the meatus urinarius; whereas, if he have only an irritable bladder, the time of his greatest distress is before the urine is evacuated; and the amount of pain experienced will be in proportion to the quantity of urine contained in the bladder. If the medical attendant have a knowledge of these simple facts, he will have no occasion to introduce an instru- ment for the purpose of resolving doubts and arriving at a true diagnosis. When irritability of the bladder assumes a chronic character, it is one of the most formidable and dreadful maladies that can IRRITABILITY OF THE BLADDER. 97 befall the patient. He is compelled to keep aloof from society, and his life of seclusion is also a life of almost unremitting tor- ment. If irritation and inflammation co-exist, as they some- times do, the latter, being the more important of the two, should occupy our chief attention. TREATMENT OF IRRITABLE BLADDER. In the acute stage of this disease, the free use of opium is re- quired. The administration of an enema containing a drachm of the tincture of opium, is one of the first things to be done when the physician is called to relieve a sudden attack of the com- plaint. Should the case be very urgent, the enema may be repeated in one hour. No remedy is more certain or speedy in its action than this. The laudanum may be put into about three ounces of warm water. The patient should keep the re- cumbent posture. Fomentations, as hot as can be borne, should be applied to the perinaeum, the pubes, and hips ; a warm-water bath, twice a day, will also materially aid in allay- ing the irritable condition of the bladder, and will quiet the general nervous excitement of the sufferer. Aperients should be administered in sufficient quantities to keep the alimentary canal in a soluble condition; and for this purpose, small doses of castor-oil will be found better than any thing else of the kind. It should be given in the early part of the day. Its ac- tion may be promoted by an enema of warm water. The individual should occupy, if possible, a large, well-ven- tilated apartment, and not be subjected to the annoyance of company — not even that of intimate associates. His welfare will be essentially enhanced by having quietude reign around him at all times. He should abstain from drinks as much as possible, especially those that contain a large amount of sac- charine matter in solution. Even tea, coffee, and milk will be injurious. They tend to increase renal action and thus add to his sufferings. If he complains of thirst, cold water will be the best antidote. Liquor potassae, ten drops to a wine glass of cold water, or in as much weak hop-tea, every two or three hours, will be found beneficial. A blister should be applied over the sacrum or over the pubes. The counter-irritation thus created, will be very useful, and no apprehension of strangury need be entertained. 9 98 GONORRHOEA AND SYPHILIS. To keep the bladder in a state of repose, a short gum-elastic catheter should be introduced as far as the distal end of the urethra, but must not be allowed to enter the bladder. The length of the instrument should be nine inches, which will correspond with the length of the urethra, almost invariably.* It should be carefully secured to a bandage carried between the thighs and around the loins. The instrument need not be withdrawn from the urethra oftener than once in twenty-four hours. An infusion of diosma crenata, taken freely, either alone or with decoction of pareira brava, has long enjoyed the reputa- tion of tranquilizing the local irritability when the disease has passed into a chronic state. Warm water injections into the bladder are serviceable when much mucus is present in the urine. They may be employed twice in the twenty-four hours. If the contents of the bladder are offensive, ten or twelve drops of chloride of soda may be added to each ounce of the injection. Nitric acid, in the proportion of two drops to the ounce of water, is recommended by Sir Benjamin C. Brodie and by Mr. Henry Thompson, as an injection, f Nitrate of silver has been employed for the same purpose, in the propor- tion of half a drachm to the ounce of water, in cases where the milder forms of injection fail to check the albuminous secretion into the bladder. The operation is a painful one, and it is frequently necessary to repeat it in four or five days. Its effects are said to be, generally, highly beneficial. It is best adapted to cases requiring a strong, stimulating application to the affected organ, as when the mucous membrane is in an atonic and relaxed condition, and when there is no evidence of any inflammatory action. Injections would be inadmissible during the acute stage of the complaint; but in all chronic cases, they are serviceable not only in relieving irritability of the bladder, but also in removing any collection of mucus, that may be retained within its cavity. The best and most ap- proved method of administering injections is the one employed by Mr. Fergusson, which is, to introduce the water in a con- tinuous stream by means of a double syringe like -that of a stomach pump. J * Astley Cooper. t Lancet, 1854, p. 594. J Miller's Surgery, p. 490. IRRITABILITY OF THE BLADDER. 99 If the complaint terminates in inflammation of the bladder, then, in addition to the liberal use of opiate enemata, hot baths, and blisters, as recommended in irritable bladder, it will also be expedient to resort to antiphlogistic measures. Twenty leeches may be applied to the perinaeum, and the bleeding promoted by warm water fomentations. If the use of an opiate by the mouth be required, the sulphate of morphia may be selected :— R. Morphias Sulphatis,....................................gr. iij. Misturae Camphoras,...................................3 nJ- M Dose. One drachm, pro re nata. In a non-inflammatory condition of the bladder, or when the inflammatory action has become chronic, the balsam of copaiba should be prescribed with a view to arrest the formation of the thick albuminous deposit. No remedy more promptly checks this morbid secretion than the balsam. It can be given in cap- sules, from six to eight per diem, or in mixture with other in- gredients, as mentioned under the treatment of blennorrhagia. If the urine should become acid, which can be known by its turning blue litmus paper red, alkalies will be indicated. R. Potassas Carbonatis,..................................3j Syrupi Aurantii,......................................3 ij Aquas,...............................................3 iss- M To this add the powder of citric acid,....................gr. xxiv. Let the patient drink the mixture while it is effervescing. The draught is to be repeated several times in the day. Lemon- juice makes a good substitute for the citric acid. If the urine should contain an excess of alkaline properties — turning red litmus paper blue — the dilute nitric acid, to the amount of a drachm each day, in three gills of water, should be taken in divided portions. The wine of colchicum, under these circumstances, may also be prescribed with marked benefit. CHAPTER IX. EXCORIATIONS. MOST FREQUENT LOCALITY — GENERALLY BUT ONE EXCORIATED PATCH—COM- PLAINT APT TO RECUR--TREATMENT. Simple abrasion of some portions of the glans penis, or of the mucous or cutaneous surface of the prepuce, is not an infrequent accident resulting from sexual congress. The injury takes place where there is a want of co-aptation in the relative size of the organs, or where the parties engage in their amative embraces in an impetuous manner. The most frequent locality of the disease is near the fraenum, or just behind the corona, among the glandulae odoriferae. Although it is one of the non-specific affections incidental to the venereal act, it is very apt to be viewed by the patient with alarm, as being syphilitic. The excoriation is sometimes situated on the free edge of the prepuce, especially when the latter is long and narrow, and does not readily retract behind the glans. Such a prepuce is liable to receive the brunt of the effort; and the seat of injury is along the line of union between the two surfaces, oftener than elsewhere ; and least in frequency the lesion is met with upon the dorsum of the glans and on the external surface of the prepuce, a few lines from the orifice. When situated within the preputial cavity, the abrasions, if neglected, sometimes assume an appearance closely allied to chancres. They ulcerate, occasion little or no pain or smarting, and are attended with only a moderate inflammation. If early treated, they can be easily cured by simple applications ; but if allowed to take their own course for a week or two, uninfluenced by remedial means, the sores or ulcerations, which form upon the abraded spots, are ex- tremely reluctant to heal, — not on account of any peculiar, bad quality inherent in them, but partly because of the struc- tures in which they are situated, and partly from the fact that the secretions to which the diseased surface is exposed, keep 100 EXCORIATIONS. 101 up a morbid irritation. Generally, there is but one irritated patch. The patient states that it attracted his attention imme- diately after the exposure in which it originated; and this fact is important in aiding the physician to distinguish it from chancre, at whatever period he may be consulted in the case; for the latter affection is always more tardy in manifesting itself after the application of the cause. If, when the medi- cal attendant sees the individual for the first time, the part is in a state of ulceration, the interval between the exposure and the development of the disease, is a point that should always be ascertained. If he computes the time between the cause and the effect by hours instead of days, it is almost certain that the excoriations or ulcerations are not venereal. It is worthy of recollection that the item of time furnishes one of the surest "rational signs," which the case admits of; and whatever the anatomical appearances may be, as sug- gestive of the nature of the affection, they never, in my esti- mation, transcend in value the chronological evidence derived from the patient. So far as physical characters go, we are unable to distinguish these sores from chancres, to which they have a strong resemblance in situation, size, etc. Ulcerations resulting from abrasions of the cutaneous sur- face of the prepuce, bear less resemblance to chancres than those situated within the orifice. They are on a plane with the adjacent healthy integument, and of course do not present the elevated, sharp, perpendicular edges which characterize chancres; nor have they any indurated base, which many chancres have. They are irregular in form and size. After the excoriation has healed, the integument remains quite ten- der for sometime; and a slight cause, such as friction of the part against the clothing, is sufficient to awaken the injury anew. Such relapses are not uncommon, and they are gen- erally worse than the original attack. The surface of the excoriation is larger, and the morbid action now re-estab- lished, is more difficult to subdue. It may assume a chronic type, and give rise to a sympathetic bubo in the groin, so that the recurrence of the accident may turn out to be a most un- fortunate event both to surgeon and patient. By it, the latter becomes disheartened and alarmed, distrusts the diagnosis that may have been given in the early period of his illness, 102 GONORRHOEA AND SYPHILIS. impugns the treatment adopted, and expresses a desire, per- haps a determination, to be treated for the venereal disease, — a complaint which he has not got. Thus the surgeon has a troublesome affair to manage. In illustration, I submit the following Case. — Excoriation of prepuce—relapse—eruption on the glans penis—and on the body, etc.—disagreement in diag- nosis. January 7, 1857. — A. B., aged 19, Salesman. Had inter- course with a girl of the town on the night of December 31, 1856. Was conscious, before he had completed the act, that he had wounded the prepuce. Next morning the part was swollen, and he discovered an abrasion as large as the thumb nail on the dorsal aspect of the external surface, near the orifice. By the use of a weak solution of chloride of soda, the injury was healed in four or five days. On the 16th of January, the young man again called for treatment. He had been actively employed at his labors in a wholesale establishment, and his troubles had re-appeared with increased severity. The exco- riation now occupied more or less of both preputial surfaces, and yielded a free exudation, which irritated the adjacent parts not a little. The glans was uncovered and inflamed, but there was no abrasion upon it, nor was there any urethral discharge. The patient was advised to suspend business and remain quiet at his boarding-house for a few days. This he said he could not do without the hazard of exciting suspicion or per- haps forfeiting his clerkship. He was told that simple as his local difficulty appeared to be and really was, it would prob- ably resist all sorts of treatment, unless he refrained from exercise. Under these circumstances different lotions were ordered, and small doses of the iodide of potassium prescribed for internal use. After the potassium had been taken for about two weeks, a slight eruption appeared on the face and chest. This salt was discontinued, and the arseniate of iron, in the dose of one-seventh of a grain each day, was substituted. The bowels were kept free by salines. For six weeks this treat- ment was assiduously pursued to no good purpose. The in- guinal glands became enlarged and tender. On the glans, EXCORIATIONS. 103 minute vesiculo-pustules appeared from time to time in suc- cessive crops. Trivial fluctuations of amendment and relapse took place. Such is the history of the case up to the morning of February \Qth. — At this date, numerous well-defined, scar- let-colored, erythematous blotches were seen upon the trunk, hips and thighs,shoulders and arms. They were totally different in appearance from the eruption spoken of above in connection with the use of the iodide of potassium. Nothing like a papule could be felt, as in lichen, or in recent examples of psoriasis guttata. They were on a level with the adjacent skin. What gave rise to this blotchy condition of the integument, I am unable to say. It remained about three weeks and then dis- appeared. Three or four sores broke out just behind the glans penis, and two small ones were perched exactly on the corona, and the whole glans was inflamed. All these phenomena, to- gether with the disease of the prepuce, the tumefaction of the inguinal glands, and a soreness within the buccal cavity, of which the patient complained, presented an ensemble of symp- toms allied to real syphilis. A crisis happened to-day. The patient informed me that although I had assured him that his complaint was not venereal, a certain respectable physician, whom he named, had casually heard of his condition, and had said that such a case must be syphilis and nothing else ; and he (the patient) desired that I would treat him for that. I de- clined ; and the patient was dissatisfied. I proposed that he should call at mid-day, when I would exhibit him to some of my medical friends. Three came, examined the case, and sure enough, decided that it was syphilis. Thus, seemingl}'-, the tables were fairly turned against me. In the evening the young man called again. I informed him of this decision, and told him my own views were not changed. To put an end to the question, it was now agreed that it be referred to Dr. S. D. Townsend, Senior Surgeon of the Massachusetts General Hos- pital, who pronounced it to be non-venereal. The patient's mind was at rest. He agreed to keep house according to pre- vious advice; and was directed to dress the penis with a weak, black wash; that is, 3ss. of the submuriate to 3iv. of lime 104 GONORRHOEA AND SYPHILIS. water. This he did, and in six days was well. The foregoing case is not devoid of instruction. If the surgeon is consulted before the excoriations have ad- vanced to a state of ulceration, local applications will be suffi- cient to cure the patient at once in all ordinary cases. The chloride of soda, Goulard's extract, or dry lint, as recommended for preputial herpes and eczema, will accomplish all needful purposes. Should other local measures be required, the fol- lowing lotion will be found useful: — R. Liquoris Potassas,...............................3 i. Glycerinas,..................................... Acidi Hydrocyanici, aa,.........................3 ij- Aquae Fontanae,................................3 iv- M. Lotion. This will allay the itching and smarting; and may be kept on the part as a dressing. Oiled silk or gutta percha tissue should be used as an envelope. R. Liquoris Plumbi,......................................3i- Vini Opii,.............................................3ij- Spiritus Rectificati,....................................3 i- Aquae,................................................31Y- ^. This last lotion is a good remedy in cases characterized by a high degree of inflammation. The black wash, of the strength mentioned above, is likewise a valuable topical appli- cation where the affection has become chronic and the inflam- mation feeble. The black wash of maximum strength is apt to produce a minute eruption on the glans and prepuce when applied to these parts. At night, the benzoated zinc ointment will be appropriate. The parts should be soaked in water as warm as can be borne, three or four times during the day. If the ulcerations pertinaciously maintain their ground, the dilute nitric acid or the tincture of muriate of iron will constitute a suitable internal treatment. All stimulants, externally or in- ternally, will only exasperate the morbid condition. CHAPTER X. URETHRAL PAINS. USUAL SEAT OF THESE PAINS — THE TESTICLES SOMETIMES PARTICIPATE—ALSO THE BLADDER — TREATMENT. Now and then, a man who has been cured of blennorrhagia reports that he is troubled with pains in some portion of the urethra, usually in that part which is anterior to the scrotum. Sometimes the pains are seated farther back, as if near the neck of the bladder, from which they seemingly radiate in every direction. These sensations are pretty constant, although marked at irregular intervals by exacerbations of great se- verity, and amounting, in the estimation of the patient, to a bond fide disease engrafted upon the pre-existing malady, or at least in some way connected with it. Occasionally, the tes- ticles participate in the affection; and if the man happen to cross his legs or bring his thighs together carelessly, he ex- periences in these glands a sharp pain, and at the same moment a sensation of faintness, with nausea and other distressing symptoms of a nervous character. In most instances, these neuralgic affections are to be regarded as a consequence of a previous gonorrhoea, in which the bladder sympathized, and in which the treatment was necessarily protracted, before being crowned with success. In other cases, these sensations haunt the individual for a long period, when there has been no want of success and no impropriety in the treatment, where the patient has been prudent in his habits, and is not of a particu- larly nervous constitution. In examining a person who has the symptoms in question, no abnormal condition of the urethra or bladder can be detected : the stream of urine is natural; the catheter or sound traverses the canal with ease throughout its whole extent, and enters the bladder without obstruction; the meatus urethrae looks healthy, and no tender point is observed when the penis is squeezed between the thumb and finger. In fact, it is said that the latter 105 106 GONORRHOEA AND SYPHILIS. manipulation actually affords relief. The patient is frequently teased with a disposition to urinate every few minutes, which shows that the bladder still sympathizes with the urethra. If an examination be made per anum, the prostate gland is found to be healthy, and whatever means are employed to ascertain the condition of the entire genito-urinary system, no structural lesion can be discovered. If the patient be of a nervous temper- ament, the unexpected circumstances in which he finds himself, exert a most depressing influence upon his mind. He is sure to magnify the severity of his sufferings in the part, and to re- gard them as the harbinger of something worse to come. For the time being he is well nigh a monomaniac, and for an ex- planation and cure of his case he consults the physician or surgeon. Treatment. — Several methods of relief are at our command. Constant compression of the penis by means of diachylon plaster, cut into narrow bands, is often a successful mode of treatment. The bands should be about one-third of an inch wide, and long enough to allow the ends to lap over each other. The compression should commence at the glans, and be as decided as may be compatible with the flow of urine. The plasters must be renewed as often as they become deranged. If the pains are seated behind the scrotum, compression of the penis will do no good. Blisters to the perinaeum are, in many cases, perfectly efficacious in removing urethral pains; or what is more convenient, cantharidal collodion, which can be applied either to the penis or perineal region. In some in- stances, vesication over the sacrum will answer, and if the circumstances of the patient require him to be engaged in active business, and will not allow of his being blistered on the perinaeum, the integument of the sacrum may be selected. The blister will require to be repeated, perhaps, every ten days for several weeks. Meantime, other remedies are to be tried. Lallemand's method of superficial cauterization of the urethra has been adopted with success, but it is a severe measure, and should be appealed to only as a last resort. The daily use of a bougie of moderate size, sometimes proves sufficient to re- move the complaint. Sea bathing is usually attended with ex- cellent results, and the dashing of iced water upon the parts is URETHRAL PAINS. 107 also beneficial. At night, camphor and opium will be service- able. Most men who are afflicted with urethral pains are of a highly nervous temperament, and require to have the mind occupied in some agreeable pursuit, which will tend in no small degree to promote a cure of the local difficulty. CHAPTER XI. SPERMATORRHOEA. CAUSES — PATHOLOGY — TREATMENT — MENTAL DISCIPLINE — LUPULIN — NOTE FROM DR. JAMES JACKSON--PORTE - CAUSTIQUE--ANODYNE INJECTIONS-- BROMIDE OF POTASIUM--MARRIAGE--CASTRATION. The term spermatorrhoea, as employed by most medical writers, and as understood by medical scholars, has been brought to signify involuntary emissions of seminal fluid, recurring at sufficiently frequent intervals to derange the general health. According to Lallemand, however, all excessive generative secretions are to be regarded as spermatorrhoea, in whatever manner they may take place, and whether they have infringed upon the integrity of the system or not. This signification and use of the word is convenient, and is applic- able to all cases that present themselves for treatment. Some individuals listen to the note of alarm at an early period, and the first morbid phenomena of the kind now under consideration are viewed by them with a just apprehen- sion ; and in anticipation of a train of mental and physical evils of direful import, they have the discretion to make known their condition to some medical adviser, and to receive from him words of salutary admonition and counsel, and thus escape impending ruin. Involuntary discharges of the spermatic substance happen to a majority of the male sex from the time of puberty to old age, when it ceases to be elaborated. The most continent and pure minded men occasionally find themselves subject to erotic dreams during which the event here alluded to, takes place. Sometimes emissions occur without the coinci- dence of lascivious dreams; at least the individual is not con- scious of them when he awakes ; and he is surprised to find that the spermatic product has escaped while his faculties have been wrapped in profound sleep. These remarks are applicable to those that are in a state of wedlock as well as 108 SPERMATORRHOEA. 109 to those who are not, although to the latter they are particu- larly pertinent. They are introduced here, not because such infrequent seminal evacuations really amount to disease, requiring medical prescriptions or surgical attentions, but because we occasionally meet with men of good intellect and high moral worth and refinement, who, in consequence of this accident, suffer much mental distress, amounting to profound melancholy. These cases demand both moral and medical treatment, and should enlist our best efforts. Some men affect great indifference and even aversion to individuals who are in a suffering condition from the disease under consideration. Such patients, although they may be reaping the rewards of their own folly, are, nevertheless the very ones who have special need of correct counsel, and are for the most part in just the frame of mind to appreciate a word fitly spoken by a kind-hearted, judicious medical man. They require skillful management also; and if driven from the consulting office of the regular physician, will unwittingly place themselves in dangerous hands, rather than suffer on alone. " It has always appeared strange to me," writes Mr. Milton, " that this affec- tion should remain abandoned by the profession to a few sol- itary specialists, and for the benefit of the vile harpies, who prey on this class of victims. Surgery, which has wrested so much from the hands of empiricism and ignorance, seems disposed to yield up this, as if it were debatable land, to chance, philosophy, utter neglect, or quackery." Mr. Curling holds similar views, as in the following sentence: " Medical men are too apt to treat the complaints of such patients lightly, making no efforts to allay their anxiety, — a course which often leads them to apply for aid in illegitimate quar- ters, and to become the victims of unprincipled men." I shall never forget the case of an estimable young gentle- man who consulted me a few years ago for what he called seminal weakness. He had completed his collegiate education and was engaged in a professional course of study at a higher institution remote from the city. His head was so filled with a wild delusion in regard to his procreative system, that his ability for intellectual employment was seriously impaired; and he was every way miserable. He told a doleful story, — 10 110 GONORRHOEA AND SYPHILIS. the sum of which was, that his present state was the result of " chiromania," or solitary vice, of which in former years he had been guilty. He was familiar with various trashy books on the evils arising from the practice, and was fearful that he had so far enfeebled his intellectual and physical energies, that he should not be fit for any thing in future life unless he could obtain speedy help. He was of a slender figure, dark com- plexion, pale and dejected, and his countenance was the model of despair. He complained of sundry anomalous feelings in the urino-genital apparatus, thought the testicular organs and their corporeal forces were gradually diminishing, and believed that they would soon entirely waste away. His appetite was poor, bowels sluggish, sleep irregular and unrefreshing; he had headache and involuntary seminal emissions about once in the week. He had come to Boston as his city of refuge. It was apparent that the trouble in this case, was chiefly mental, and that to dispel the hallucination which haunted his mind was the principal work to be done. He was assured that all was right and safe within the scrotum, and that the nocturnal accidents were not sufficiently frequent to require any special medical treatment. The plan proposed was this: A gener- ous diet, bathing in cold water, and drink a bottle of Congress Spring water every morning, exercise in the open air in all good weather, read no more pseudo-physiological books; early to bed and early to rise. He was advised, in short, to pursue a course that should combine the advantages of recre- ation and the appliances of health. The patient gained in appetite and flesh; the material functions of the system be- came natural; despondency soon gave place to hope; and after a sojourn in the city of a few weeks, he returned into the country with unembarrassed capacity for study. In a few months he was called to fill a position in a literary seminary where he still remains distinguished as a man of letters and influence. Causes. — One of the most prolific sources of this derange- ment of the sexual system is to be found in masturbation. This habit is usually formed at an early age, and while the boy is attending school. He is generally induced by older boys to resort to titillation simply as an affair of sensual gratifica- SPERMATORRHOEA. Ill tion, without having the slightest idea of the terrible conse- quences which it may entail upon his physical and mental constitution. The precocious and fascinating excitement once experienced, and its repetition invited by the contagion of bad a example, the lad soon surrenders himself to a frequent indul- gence of the all-absorbing and fatal propensity, until morbid symptoms of various kinds and degrees of severity, are in- duced. The idea of self-abuse haunts him wherever he goes and in whatever he is engaged. He loses his ability to resist the promptings of the baneful passion, and seeks every oppor- tunity to reproduce the pleasurable sensations. The constant draughts made upon the nervous energies, bring exhaustion and irritability upon the whole corporeal organization ; and it is not long before the ensnared victim exhibits mournful evi- dence of declining health, as a matter of course. The brain is usually the first organ to give indications of disturbance orig- inating in the debasing habit. Among the injurious effects exhibited from day to day, may be mentioned lassitude, dejec- tion, failure of appetite, and of muscular vigor. Sometimes the boy becomes petulant and exceedingly irascible; and the im- pulse of temper is occasionally so intense that he is exhausted from its indulgence, and the administration of stimulants is required to relieve the serious depression into which he has fallen. In other instances, more frequent than the above, the mind sinks into an absolutely stupid condition, which gets a firm hold, and he has neither the disposition nor ability to engage in the customary sports and other innocent employments of his age; his sleep is broken, he becomes pallid and wastes away into a state of marasmus. In some instances, violent palpitations of the heart come on suddenly, threatening almost instant death; or epileptic convulsions and idiocy ensue, un- less the toils which hold the infatuated victim in their embrace, are effectually destroyed. Derangements of the system, analogous to those which are seen in the male sex as a consequence of masturbation, are also observable in females who are the subjects of nympho- mania ; and these morbid conditions, as physiologists have long ago announced, and as daily observation confirms, are in- duced by over-taxing and exhausting the energies of the entire nervous fabric; and not because of any waste of spermatic 112 GONORRHOEA AND SYPHILIS. fluid, for this is impossible. " The high degree of nervous ex- citement," says Carpenter, " which the act of coition involves, produces a subsequent depression of corresponding amount, and the too frequent repetition of it is productive of conse- quences very injurious to the general health. This is still * more the case with the solitary indulgence which (it is feared) is practised by too many youths." In adult life many causes are sufficient to excite spermator- rhoea, especially in individuals endowed with a peculiarly deli- cate constitution or an excitable temperament. In these persons, the vesiculae seminales acquire the habit of contract- ing themselves under the influence of excitement less energetic than usual, and quite abnormally so. A distended bladder, a bed too warm or too soft, lying on the back, warm or stimu- lating drinks, etc., provoke involuntary emissions more readily than they ought. The intimate and reciprocal relations be- tween the vesiculae seminales and the brain, induce lascivious dreams, les plus desordonnes, under the slightest direct or indirect excitement of the genital organs, and inevitable pol- lutions from the reproduction of all the ideas which are con- nected with those of generation. * Faecal accumulations in the rectum, and the presence of ascarides are to be reckoned among the mechanical causes that occasionally give origin to this disease. A varicose state of the haemorrhoidal veins, by exciting disturbance of the adjacent parts, will sometimes create undue activity in the seminal apparatus and preternat- ural secretion of the spermatic fluid takes place. Pruritus ani is another abnormal circumstance, which, in some individuals, exerts an influence in stimulating the function of the genera- tive organs to an inordinate degree. Other morbid conditions about the anal region may exist, and operate as excitants of frequent erections and nocturnal emissions. An inflammatory state of the urethra, whether arising from gonorrhoea or other- wise, is one of the most frequent causes of the malady under consideration. The inflammatory action, commencing in the mucous membrane of the canal, extends to the contiguous structures, as the prostate gland, vesiculae seminales, and per- haps even to the epididymis and testes. Inflammation or irri- * Vide Lallemand, Vol. n. page 337. SPERMATORRHOEA. 113 tat ion of the bladder may also be mentioned as now and then giving rise to spermatorrhoea. Dalliance with women, and inordinate indulgence in the venereal act, are fruitful causes of the complaint. In illustration of this last sentence I must here introduce a remarkable Case. —I once knew a married man, who was obliged to maintain an unceasing warfare against his voluptuous propen- sities, or rather, I should say, his sensuous desires were con- stantly goading him to commit the venereal act. He had a tall, slender, gaunt frame, was well fenced in with bones, but was far from being robust. The conformation of his head was thought, by some, to afford an illustration of the theory of Spurzheim, that the cerebellum is the organ of sexual impulses • and I well remember that the disciples of this German philoso' pher were wont to cite the singular cranial development and the well-known corresponding mental peculiarities of the man who is the subject of this narration, as lending support to the principles of phrenology. He was looked upon as the incar- nation of lust, and, like the moth of the silk-worm, he died a martyr to his ruling passion. He held a fair standing among certain classes of the community, although as to his faithful adherence to the marital pledge, the birds of the air sometimes carried news. So far as related to his wife, it is certain that he had but little control over his venereal desires, or over the excessive indulgence thereof. So insane was he at one period that he could not so much as take her hand, or sit on the same sofa with her, without being overtaken by the surges of pas- sion, and experiencing all the phenomena that attend the com- plete congress of the sexes. These facts were communicated by the patient to several medical gentlemen, whom he con- sulted occasionally in reference to the exuberance of his animal feelings, the gratification of which he foresaw would ultimately sap the vital organs, and bring him to an ignoble grave. His forebodings were verified in the meridian of life. His insati- able appetite was destroyed only by the hand of death. A great difference obtains in different constitutions in re- gard to the consequences exerted upon the system by inordi- nate indulgence in venereal pleasures. Lallemand says: « I 114 GONORRHOEA AND SYPHILIS. have met with men who have given themselves up early in life to the greatest abuses of masturbation, and who have subse- quently had many mistresses at the same time, and who, in spite of such a mode of life, have been capable of continuing it at sixty years of age, without their health suffering. I have seen others the victims of most obstinate nocturnal pollutions, fol- lowing the slightest errors of their youth. These differences do not, by any means, co-exist in a constant manner with those outward characters, which announce the predominance of one of the elements entering into the composition of all organs,— still less with the development of the frame or muscular system. Thus in the sanguine, lymphatic, or nervous temperament, with a robust or delicate constitution, the usual organs may present all the varieties of volume, power, and ability." The virile power in the male is not usually established until the age of fourteen or sixteen years. Under the influence of excitement, the seminal glands may at an earlier period secrete a viscous fluid not containing spermatozoa. In some cases, however, the specific changes which betoken, unequivocally, the advent of puberty, are well pronounced in boys of a few years old. An instance of sexual precocity in a boy of six years of age came under my observation a few years since. The organs of generation began to exhibit unusual develop- ment as early as the eighteenth month. At the age of four years, the voice was on the base key; at five, the hair began to grow on the pubes, and at six the physical organs had attained the usual adult size, and the child frequently gave evidence of strong sexual instincts. He was the son of a respectable physician, and was in all particulars well tutored. The generative power may continue, if not abused, during a very long period. Undoubted instances of virility at the age of one hundred years are on record ; but in these cases the general bodily vigor was preserved in a remarkable manner. The ordinary rule seems to be, that sexual power is not re- tained by the male to any considerable extent beyond the age of sixty or sixty-five years. Individuals who are suffering, either in reality or in im- agination, from an abnormal condition of any portion of the generative circle, not infrequently propound to the physician questions more or less related to the foregoing facts, which, SPERMATORRHOEA. 115 although more strictly belonging to the province of physiology, are not out of place, it is believed, in the position assigned them in connection with the main subject of this chapter. Other facts, akin to those here introduced, might be presented, but their multiplication would scarcely increase the practical value of these pages. Lallemand made a post mortem examination in two se- vere and complicated cases of spermatorrhoea, in which the patients labored under symptoms of cerebral congestion before death. Curling states that he has in one instance had an opportunity to dissect the parts affected by the com- plaint, in which the patient was comatose for several hours previous to dissolution. In all three of the cases which are here alluded to, the morbid appearances were of the same char- acter. The mucous membrane of the prostatic part of the urethra was swollen and injected. The prostate was nearly de- stroyed and converted into a multilocular abscess, or a number of alveoli or cells communicating with each other, and the diseased mucous membrane covering it, was riddled with holes formed by an enlargement of the original orifices of the gland, through which pus or altered secretions escaped on pressing the prostate. One or both vesiculae seminales were infiltrated with pus, and their wajls thickened by inflammation. The orifices of the ejaculatory canals were enlarged and abraded. When the prostate is affected, slight pain is occasioned by pressing upon it through the rectum, and there is usually a discharge from the urethra when the patient is at stool.* In protracted cases, there is irritation and chronic inflammation of the posterior portion of the urethra. The introduction of the catheter gives pain, the patient retains the urine with diffi- culty, and it is sometimes tinged with blood. This morbid condition of the canal tends to excite seminal discharges, to keep alive a train of lascivious desires, and to cause the patient's mind to be occupied with imaginary scenes of sensual gratification, to the exclusion of almost every other subject. Treatment of Spermatorrhoea. — If we could rely with * Curling on the Testis, p. 329. 116 GONORRHOEA AND SYPHILIS. confidence on the representations made by the patient rela- tive to the facts in his case, we should, as medical advisers, experience less difficulty than we now do, in directing the pro- per course of treatment. But, unfortunately for the parties concerned, it often requires the ingenuity of the most expert tactician to winnow the truth from error. The patient does not intentionally aim to misrepresent or deceive; nevertheless, if allowed to tell his own story without interruption, he is prone to bring forward all manner of vagaries ; and we feel compelled to regard his statements with many grains of cau- tion and doubt. Few men who are, or who fancy they are, suffering from spermatorrhoea, are really competent to give a correct account of their symptoms. They generally view things through a false medium. They are full of fears and an- ticipations of various kinds which impair their normal mental vision. A young man, who had for many years indulged in masturbation, called on me one warm summer's morning, and reported that his health had been for some time declining in consequence of the habit. His ability both for physical and mental exertion was much enfeebled; he was nervous and hy- pochondriacal, and disinclined to go into company. He com- plained of a multitude of troubles, such as pains and soreness in the urethra, bladder, kidneys, scrotum, perinaeum, etc., and stated that for several weeks the semen had passed from him almost constantly, especially during the day. While he was asleep at night, seminal emissions occurred about twice in the week. During his call at my office he occupied a sofa, and while relating his case, he assured me that he could per- ceive the spermatic fluid escaping and moistening his trowsers and making him feel very uncomfortable. I examined the parts; they were bedewed with the natural product of the sudoriferous and sebaceous apparatus of the integument,and nothing else. This moisture the patient took to be the seminal fluid escaping from the testicles through the scrotal tunics and spreading upon the external surface; and this was what he meant by his seminal weakness. An exploration of the ure- thra with a catheter showed that this canal was in a healthy state, so far as one could judge from such an examination. Pressure along the perinaeum gave no evidence of disease. The young man was convinced that his difficulties were imag- SPERMATORRHOEA. 117 inary. I counseled him to correct his habits; and he took his leave. I am inclined to the belief that many cases of supposed spermatorrhoea exist for every true case. I have seen not a few spurious instances, and but seldom those that were real and requiring medical treatment. I must here cite from Ri- cord, than whom, no man has a better claim to be heard on this subject. " I have had an opportunity to examine a very large number of patients or hypochondriacs, and most of them, I find, have only discharges of mucus entirely free from ani- malcules and other characteristics of the semen. I know that the contrary may have been observed in many cases; but has there not been a little exaggeration?" Let us now suppose a simple case of spermatorrhoea. The accident constituting the disease, happens at irregular inter- vals; sometimes, once every night; in other instances, oftener. This state of things usually continues for a few months before the patient begins to realize that his health is declining. For a time, a sense of modesty or shame prevents him from mak- ing known his complaint, but as its debilitating effects continue, and perhaps accumulate, the system sustains itself with less ability, the symptoms gradually augment in violence, and an increasing apprehension of danger at length drives the victim to the physician. The first thing to be done, with reference to treatment is, to ascertain as far as practicable, the actual condition of the urino-genital system. In ordinary cases, a careful examination will convince the practitioner that no organic change has taken place. The urethra, prostate, blad- der, and vesiculae seminales, give no evidence of anatomical lesion. In some of these organs there exists a morbid irrita- bility and nothing more. It is encouraging and gratifying to the medical attendant, and should be to the patient, that no structural disease has occurred. The excessive irritability of the parts is, however, in some instances, no trifling circum- stance to deal with. Although not the origin of the sperma- torrhoea, it now acts as the exciting agency of the accident; and the hope of preventing this must rest on the removal of the local irritability. Moral hygienic regimen must be asso- ciated with physical means. Both classes of remedies, psy- chological and pharmaceutical, are equally and properly within 118 GONORRHOEA AND SYPHILIS. the limits of our domain; and the one as well as the other, should be summoned to our assistance. No two patients are precisely alike. Every case must therefore be managed ac- cording to its own peculiarities and merits; and in the treat- ment of the causes, as well as in the treatment of the symptoms of the disorder, the medical attendant will do well to gain an insight into the mental constitution, the peculiar habits of thought, the personality of the patient. To carry out a defi- nite and judicious plan of remedial dietetics and prophylactics for the mind, is as essential as it is to recruit the strength and energy of the physical system through the combined agency of salubrious air, cold ablutions, bodily exercise, and other restorative and hygienic measures. If the patient still indulge in his indiscretion, this must be abandoned. Self-control in this particular is a sine qud non, as a means of cure, and will constitute the true moral aegis of health in the future. Hav- ing gained his confidence, the physician may safely presume that the right moment has come to aim an effectual blow against the all-absorbing thought that preys upon the patient's mind; and he may express his rebuke in a kind but decided manner, of the practice of self-abuse. Let him be told that this bane- ful habit, if not relinquished, will surely plunge him into the abyss of destruction, and that no efforts put forth by the med- ical man can save him. It is sometimes difficult to detect the practice of this solitary vice. The physician may be morally certain of the fact, from the character of the symptoms ; and yet the young man may stoutly deny it. Dr. Kriner, who published some extraordinary cases a few years since, has given certain diagnostic marks, which are not unworthy of note. The eye is " lack-lustre," hollow, watery, without ex- pression, red at the edges, with a surrounding circle of blue. The look is unsettled, timid; and the individual cannot bear the steadfast gaze of another person, a circumstance that is very characteristic. The sight is troubled or diminished. There is great lassitude, without pain, in the limbs, and espe- cially about the loins and sacrum; inaptitude for mental or corporeal exertion; great depression of spirits, and a variety of other symptoms of functional disturbance of the central or- gan of circulation; the stomach and other digestive organs; nervous cerebral disturbance, etc. " The disgusting nature SPERMATORRHOEA. 119 of the subject," says the Medico Chirurgical Review, " has prevented English writers from any description or investi- gation of the phenomena; but we are well convinced from many cases, which have presented themselves to our observa- tion, and where the cause has been voluntarily confessed, or unexpectedly drawn forth, that a great number of cardiac af- fections, as well as anomalous symptoms of disorder in other parts of the system, are owing to this destructive vice. We have, therefore, though reluctantly, been induced to draw the attention of our brethren to this melancholy item in the list of human failings, because it is, assuredly, a prolific source of misery, nay, of death." * If any symptoms of dyspepsia exist, care in the use of suit- able diet, and in regulating any abnormal condition of the ali- mentary canal, should be a prominent feature in the treatment. Very many persons who are severely troubled with sperma- torrhoea, complain that their food does not set well on their stomach; they have gastric or intestinal pains, flatulence and other discomforts of the digestive organs, which should be rectified by careful attention to hygienic measures. In this way not a little can be accomplished in improving their physi- cal condition. A judicious plan of diet and exercise is scarcely subordinate in importance to the use of pharmaceu- tical remedies. Tobacco, in all its forms, should be inter- dicted. Wine and porter may be permittted in moderation. They will serve as good tonics, and will prevent the system from being completely exhausted. The patient should avoid books of a frivolous and imaginative description; also thea- tres, operas, and all places of idle and fashionable resort; but if possible, means should be devised, by which his mind can be actively engaged in some useful occupation. Intellectual culture, where it can be pursued, is one of the surest methods of placing the invalid upon advantageous ground. Were circumstances convenient, and were I called upon to select a branch of study for a young man of suitable capacity, I would recommend some department of the natural sciences. They are easy of comprehension, seldom fail to entertain and cap- tivate the individual, create no unhealthy excitement, are full * New Series, No. 17. 120 GONORRHOEA AND SYPHILIS. of instruction, and well calculated to absorb the powers of the mind, and thus abstract it from any morbid, lascivious train of thought. A young man once enlisted in these pursuits, will find in them a fountain of knowledge, which he cannot ex- haust. Mr. Curling mentions that he once had a patient—a man of great intelligence, but without employment, whose recovery was essentially promoted by his engaging in the study of chemistry, to which he applied himself with great zeal. It is well known that the sexual secretions are strongly influenced by the condition of the mind. Hence the great advantage of having the mental powers actively engrossed in some enno- bling pursuit, in combination with vigorous corporeal exercise. The effect of such a course is to render less active or even to check altogether, the processes by which the spermatic se- cretion is elaborated. This is a physiological fact of high moral importance with those who are of a studious turn of mind, although it must be confessed that the number of such is very limited, when compared with the large proportion of directly opposite character. This latter class, however, may be brought under the beneficial influence arising from some agreeable business or task, which they can execute without exhausting or greatly fatiguing the physical or mental powers, such as gardening, hunting, fishing, a journey or a short voyage upon the sea. While I have been preparing the con- tents of this page, a young gentleman—a student — who has been under my treatment for seminal weakness, has called upon me to report his condition. He has spent the last six weeks in the country, and has been pleasantly and actively engaged every day in various recreations, mowing, raking and pitching hay, hoeing corn, gardening, fishing, swimming, hunting squir- rels, and the like. At night he occupied a large, well venti- lated room, lay upon a straw bed, and retired and rose at an early hour without variation. He states that he is now in fine health, has had no seminal emissions for four weeks, has sained in flesh, his spirits are buoyant; he is now, in fact, perfectly happy. To-morrow he will resume his studies, and to use his own words, uttered in a most animated and joyous style, " he is ready for them." If the patient cannot avail himself of any of the foregoing pursuits, let him devote a like amount of time to gymnastic exercise, verging even on fatigue. If he can be SPERMATORRHOEA. 121 induced to resort to these regularly, and be encouraged to perform athletic feats to as great an extent as may be prudent, it will be but a short time before a decided amendment will follow. Indeed, in all ordinary cases, a cure will be accom- plished. But if, after a fair trial of a few weeks, the plans above suggested fail to remove the difficulty, it will then be advis- able to vesicate the perineal integument, or that of the sacrum, by means of the cantharidal collodion, as for the cure of gleet. The vesicatory ought to be repeated as soon as the skin recovers from the effects of the previous application. I have made repeated trials with the collodion. I have never known it to occasion the least strangury, and instead of fearing a frightful exaggeration of the spermatorrhoea, as Lallemand seems to have done, the surgeon may look forward with the expectation of the most gratifying results from its use. No local remedy acts so quickly or so surely in checking the com- plaint. When these measures fail to effect a cure, a still more severe local treatment may be employed in chronic, asthenic cases, and that is, the insertion of a seton in the perinaeum. Mr. Marris Wilson regards this as one of the most effectual means, on account of the extensive and permanent counter- irritation which is excited.* As the mischief we seek to prevent takes place during the hours allotted to repose, an important point to be gained is, to bring the system into a quiescent state,— into a " deep sleep," and thus, as almost a matter of course, allay the morbid ir- ritability of the sexual organs ; and for this purpose the exhi- bition of sedatives will be required. The use of opium at bedtime will, in many individuals, control nervous excitement in a satisfactory manner, and will also serve to invigorate the exhausted powers of mind and body. Its tendency to render the bowels costive and impair the appetite, somewhat invali- dates its claims in certain cases complicated with dyspepsia. These objections may be partially obviated by combining with it hyoscyamus or conium. The use of lupulin, as an anaphrodisiac, has lately become a popular idea with many experienced men in the profession. It may be remarked of it, that it is sometimes decidedly efficacious. * On Diseases of the Vesiculas Seminales, p. 89. 11 122 GONORRHOEA AND SYPHILIS. Given in doses ranging from thirty to sixty grains, in sweetened water, when the patient retires for the night, it frequently in- duces sound sleep, prevents erections, and lessens the chances of seminal emissions. Another point of importance may be predicated in regard to its properties, it does not appear to interfere with the healthy functions of the stomach or other digestive organs. The only inconvenience mentioned by those who have taken it, is a sense of drowsiness and moderate cerebral plethora for a few hours on the day following its use. It certainly acts as a harmless and quite efficient sedative or narcotic. Another thing in its favor, — its employment is com- patible with that of tonics or almost any other medicinal agent which it may be deemed advisible to prescribe. The following note from Dr. James Jackson of this city re- specting the use of lupulin will be read with interest. "Hamilton Place, Nov. 13, 1856. "Dear Sir, — I have received your note inquiring what my experience has been as to the effects of lupulin in cases of spermatorrhoea. In reply I will remind you of the saying of the father of medicine that experience is encompassed with difficulties. The disease in question is one, in which this is peculiarly true. It consists in involuntary discharges of semen, mostly in the night. They may occur every night, and even twice and thrice in a night. But many nights may be passed without this occurrence. Hence, when a remedy is adminis- tered, and they do not take place, you cannot at once decide whether the exemption is due to the remedy. I have used this article for the disease in question only within two or three years. The result of my experience with it is, — first, that I have not found any inconvenience to arise from it; second, that it has appeared in two cases, both violent as respects the constancy of the discharges at the time when the medicine was prescribed, to have prevented in a good degree the repetition of the discharges. In these two cases I felt assured that the reports to me were accurate. In one or two other cases I had reason to believe that benefit was derived from the medicine, but was not perfectly sure of the accuracy of the reports. In more than one case no benefit was derived from the lupulin. I do not think that reliance can be placed on less than one SPERMATORRHOEA. 123 drachm for a dose. It should be administered every night for two or three weeks, and afterwards according to circumstances. I think that my experience justifies me in recommending a trial of the remedy, since it is not injurious in any way. But at best it is only to be regarded as producing a respite from the disease, allowing a chance for the beneficial use of other remedies. Allow me to add that I think no permanent relief can be obtained in bad cases, except from matrimony. Illicit intercourse is not the same thing. These are points on which I do not wish to enlarge. Yours truly, Dr. S. Durkee. James Jackson." The secale cornutum exerts a powerful influence over the generative system; and its use as an anaphrodisiac, in old atonic cases, has been attended with signal benefit. In recent cases, associated with a sthenic condition of the parts, it does not act favorably. The forms in which it can be prescribed, are a spirituous extract made into pills, and an infusion of the powdered kernels with camphor mixture. The latter is the most effective. R. Secalis Cornuti,............................................3 iss. Aquas Ferventis,...........................................3iy- Infunde. Dose. One half, to which may be added two drachms of camphor mixture, to be taken at bedtime. The ergot should not be continued for any great length of time- Its protracted use is well known to impair the general health. In cases of long standing, in which irritation of the pros- tatic portion of the urethra has become a well marked feature, the application of the nitrate of silver sometimes answers a valuable purpose in removing the irritable and sensitive con- dition, or other lesion that may exist in the urethra, at the orifice of the seminal ducts, or in the follicles of the prostate gland. To overcome this preternatural sensitiveness and ir- ritability of the parts, and thus break the chain of morbid phe- nomena, is an important achievement, and it is claimed by the advocates of Lallemand's plan, that the nitrate will accomplish this work; and it is admitted that in some cases its action is perfectly effectual. But the operation with the porte caustique 124 GONORRHOEA AND SYPHILIS. is extremely painful and also hazardous; it has not the merit of uniform success, and it does not supersede the necessity of other measures. It sometimes gives occasion for their most energetic use, for it is exceedingly apt to provoke a high de- gree of inflammation, and there is no calculating where it may stop, or what final mischief it may do. The application of caustic, gently employed, and not allowed to remain in con- tact with the parts for more than a second or two, may be a safe and justifiable procedure. It has been thus used many times without any unfortunate results. On the contrary, se- vere retention of urine, haemorrhage, and the most excruciat- ing agony, and even stricture, have been produced by the porte caustique. All these terrible effects may follow without one iota of benefit to the malady for the cure of which the caustic is brought into the field of action. It is no more than truth to say that Lallemand's instrument is now regarded with instinctive horror and as a barbarous weapon; and its intro- duction into the urethra of any man should not be attempted until all other resources of surgery have been appealed to in vain. Injections of mucilage containing one grain of opium and two grains of the acetate of lead to the ounce, are often at- tended with good effects, and are worthy of a trial. They are free from danger, they give no pain, and may be repeated every three or four hours during the day. Water em- ployed as an injection, has a soothing effect, and is appli- cable to nearly all cases. It may be used as warm as can be borne, and may be repeated many times in the day. Let it reach the whole length of the urethra. As valuable adjuncts, small doses of cubebs should be administered internally. The inunction of veratrine and belladonna upon the perinaeum will sometimes be of service in relieving pain and allaying the irritable condition of the organs : — R. Unguenti Belladonnas, Veratrias,........... In some instances the patient suffers from an irritable state of the kidneys and bladder, accompanied with constant drag- ging pain. Under such circumstances, a combination of the 3ss. 3ss. M. SPERMATORRHOEA. 125 tincture of hyoscyamus and camphor will form a good seda- tive, which may be administered at bedtime : — R. Mucilaginis Acacias,.....................................3SS- Tincturas Hyoscyami,...................................3 '• Misturas Camphorae,....................................3 ij. MP Dose. — Three drachms in toast-water or rice-water. This maybe repeated in two hours if the desired relief be not realized from the first dose. The bromide of potassium exerts a powerful sedative effect upon the genital organs ; and it has been successfully adminis- tered in severe cases of spermatorrhoea, in doses of fifteen to thirty grains, in mucilage. Quinine, dilute nitric acid, the tincture of muriate of iron, the carbonate of ammonia and the carbonate of potash, are all medicinal agents of well-known properties and utility, and can be variously employed as the condition of the individual may suggest. If the general health should improve under any course of treatment, let that treatment be continued. While in all forms of spermatorrhoea the most important remedial indication has reference to the amelioration and cure of the constitutional effects of the complaint as displayed both in the physical and the mental fabric, the medical attendant will take good care, first of all, to discover, if possible, and remove, the primary cause. There is great liability to a return of the malady even after the organs and the constitution generally have been restored to a sound state; and great watchfulness will be requisite to keep the patient from falling into a relapse. If there be reason to suppose that he is capable of successfully engaging in sexual intercourse, if he be of suitable age to marry and if other cir- cumstances converge to this point, then he may with great propriety be advised to assume such relations, for here he will find the most efficient remedy, and will be secure, if he can be anywhere, from those diabolical influences and temptations, which gave rise to his disease. It so happens, however, that a majority of young men, who are subject to frequent involuntary spermatic discharges, are not of suitable age nor in proper cir- cumstances to take upon themselves the responsibilities of matrimonial life. 11* 126 GONORRHOEA AND SYPHILIS. Castration. — Spermatorrhoea may be kept up by a diseased condition of the kidneys, the bladder, the prostate gland or urethra. In such instances the testicles are not the offending organs; and if the individual were to be deprived of these glands, as a curative measure, success would not attend the operation. Mr. Wilson relates an extraordinary instance in which Sir Astley Cooper was induced to remove one testicle. The operation brought no relief. Repeated cauterization of the urethra was then tried, but in vain. Next, the remaining testicle was removed, but with no alleviation of symptoms. Erections and emissions both nocturnal and diurnal, returned as soon as the patient recovered from the inflammation that fol- lowed the operations. The fluid ejected was less in quantity and altered in quality from what it was before castration. A cure was finally accomplished by establishing issues with potassa fusa introduced beneath the integument midway between the anus and commencement of the scrotum. In this case, it was at last supposed that the disease was located in the vesiculae seminales. The patient was a medical man. For several years he had been the victim of self-abuse, brought on by bad ex- ample at school; and to this practice he attributed his in- firmity. CHAPTER XII. GONORRHOEAL OPHTHALMIA. DISEASE NOT MENTIONED BY HUNTER—INOCULATION THE MOST FREQUENT CAUSE — OPINIONS OF COOPER AND OTHERS — LETTER FROM DR. H. W. WIL- LIAMS, WITH CASES—DIAGNOSIS — TREATMENT. This affection is of rare occurrence. Some surgeons who have seen much of gonorrhoea and its consequences, have had no instances of the frightful forms of the malady mentioned in standard works, and they regard as almost fabulous the vivid descriptions of cases reported from time to time in the medical periodicals of the day. It seems a little singular that no edition of Hunter contains any allusion to the malady until we come to that by Ricord, who has inserted a brief chapter on the sub- ject from his own pen. Mr. Johnson in his work on Gonor- rhoea, gives us to understand that the popular idea relating to the affection is in most instances a humbug; such calamitous results as are detailed in some surgical treatises having never been seen in his practice. Dr. Vetch also, a distinguished ophthalmic surgeon, is skeptical on the same subject. He recognizes contagion as a source of the disease; but denies that the matter taken from the urethra of the infected patient, can produce any effect in the same individual. The incorrect- ness of this theory, however, is amply demonstrated by the experience of other surgeons. Some years ago, and almost simultaneously, two cases, wThich are in point, occurred in the practice of Mr. Travers at St. Thomas' Hospital in London. In one of these, purulent ophthalmia commenced seven days after a gonorrhoeal discharge from the urethra. The inocu- lation happened thus: While the man was employed in breaking stones and shortly after micturition, a particle of stone struck his left eye, which led him immediately to rub it with his fingers. Pain and swelling of the eyelids took place immediately, and the inflammation attained to such a degree as to destroy all vision in that eye in the course of an hour. 127 128 GONORRHOEA AND SYPHILIS. He experienced very severe pain in the eyeball, the temples and occipital region, and also that sensation of animate, ex- traneous particles on the conjunctiva, so frequently observed in inflammation of that membrane. The cornea sloughed away in a few days, and the lens and a portion of the vitreous humor escaped. In the second case, virulent gonorrhoeal ophthalmia was distinctly traced to the local application of matter from the urethra. Both eyes were implicated, and in a brief period total blindness followed. Mr. Travers states that in all cases of gonorrhoeal ophthalmia that ever came under his notice, the disease had its origin in the contact of matter transferred from the urethra to the eye. Surgeons almost universally regard inoculation of gonorrhoeal pus as the most frequent cause of the ophthalmia. Cases have been known in which the com- plaint has been caused by the patient washing his eyes in his urine as a collyrium, whilst suffering from blennorrhagia. It is, on the other hand, certain, that in thousands of instances, persons who are careless in their habits, put the gonorrhoeal matter in direct contact with the mucous membrane of the eyes with impunity. They rub and scratch the lids without any regard to the fact that the fingers may be coated with the virus, but no harm ensues; and direct experiments of inocu- lating the conjunctiva with the morbific urethral discharge, have failed to induce ill effects. Patients are also constantly running their fingers within the nasal passages, and picking the mucous surface, while from the very nature of things, the ends of their fingers are smeared with the gonorrhoeal dis- charge. And yet not more than one or two cases of nasal blennorrhagia have come to my knowledge. On the contrary, students, who have officiated as dressers in gonorrhoeal cases, and washerwomen, who have had charge of the linen of such individuals, have frequently been attacked, in a sudden manner, with the most violent and malignant form of the complaint. In the generality of cases, it is developed only in one eye at a time; if it invades the second eye, it is after a short interval. In nine instances out of fourteen, recorded by Mr. Lawrence, only one eye was diseased. In the most violent cases, the complaint bursts forth with extraordinary fury, advances with rapid strides, and entirely destroys the sight at an early period. Inflammation, tumefaction, and chemosis of the conjunctiva GONORRHOEAL OPTHALMIA. 129 take place, and the lids are soon involved in acute inflammation. The chemosis becomes phlegmonous, forms a close band around the cornea, which is concealed and constricted, and is soon af- fected with deep ulcerations and sloughing; the lens drops out, the vitreous humor follows, the iris protrudes, and the remain- ing portions of the eye collapse within the socket, where they are deeply buried by the closing up of the lids. All this is the work of a few days. The true etiology of gonorrhoeal ophthalmia is still the theme of discordant speculations and opinions. Some of these views are better calculated to bewilder than to instruct. The means of propagation of the virus remain, to some extent at least, a sealed problem, and as such they must continue, until pathological science shall have made greater advances than it has yet done. I shall not attempt the fruitless task of examining all the various theories that have been maintained by writers occupying different stand-points of observation.- Experience and common sense attribute the complaint chiefly to the inoculation of the poison derived from the urethra, or from an eye already involved in the disease. So long as the urethra yields a purulent discharge, be it a longer or a shorter Jme from the commencement of the blennorrhagia, it is doubt- less capable of generating an ocular blennorrhagia also. But even this idea is not without its difficulties ; for when we con- sider that in the vast majority of instances, in which the ure- thral pus is brought in contact with the eyes, no morbid action follows, we see that disease is the exception rather than the rule. The ophthalmia is confined almost entirely to the male sex. But very few well-marked instances have ever been seen in female subjects. Besides contagion, another mode by which blennorrhagic ophthalmia is believed to arise, is found in what is called metastasis; a term, the precise meaning of which is not fully agreed upon. In this form of the malady, it is supposed the patient suffers in a manner analogous to those successive at- tacks which are observed in rheumatism and gout; * and yet * " In these complaints there is every thing to show a morbid condition of the blood, which is surcharged with the compounds of carbon and of nitrogen, and the local action is the expression and effect of constitutional deterioration."—Johnson on Gonorrhoea. See also Simon's Chemistry of Man, page 225. 130 GONORRHOEA AND SYPHILIS. in the two latter diseases it is very probable that the vital fluid is in an abnormal state, so that any proof or argument derived from the doctrine of analogy, amounts to little or nothing. Perhaps as satisfactory an example as any, of what is understood by metastatic action, is to be found in cases of cynanche parotidea. Here the inflammation, originating or set up in one gland, is translated to another, and the sufferings of the testes in the male, or of the mammae in the female, are believed to take place in consequence of some mysterious oc- cult agency through the medium of the nervous tissue. And now the query suggests itself, can this with any show of rea- son be said of blennorrhagic ophthalmia? To me it seems that there is not sufficient evidence to sustain the theory of a metastatic form of this disease. Sir Astley Cooper derived his notions from the statements of others; and was inclined to favor the doctrine of metastasis. Ricord inculcates the hypothesis that there are three varieties of the affection: the contagious, the metastatic, and the sym- pathetic. Speaking of the second form, he says: " Abernethy admitted an irritative state in order to explain the develop- ment; this is what we understand by metastasis. The origin of the term comes from the wandering character of the com- plaint; it oscillates, disappearing in one place to re-appear in an- other, and in this respect does it not resemble a rheumatic affection ? Do we not admit metastasis in rheumatism ? " He argues, that beyond the possibility of contagion, patients are found affected with ocular blennorrhagia following that of the urethra; and that such cases are most frequently related to some rheumatic symptoms. Acton admits of but two varie- ties, one from contagion, the other from metastasis. Mr. Graves * is inclined to the belief that a species of severe oph- thalmia may be generated through the medium of the consti- tution in persons liable to gonorrhoeal rheumatism or arthritis. Mr. Lawrence advocates a similar doctrine. Mr. Walton, re- ferring to the origin of the disease, says : " To metastasis has it been attributed, and what is stranger still, there is ' gonor- rhoeal ophthalmia without metastasis or inoculation' spoken of. By this is meant that the gonorrhoea and the ophthalmia * Clinical Lectures, 2d Edition, p. 401. GONORRHOEAL OPHTHALMIA. 131 are one and the same disease, and that without any metastasis or inoculation, one passes into the other. I have no faith in the metastasis; and as to the last supposed mode, or origin of the disease, I receive it as a great twaddle." * Mr. Johnson, speaking of contagion and of metastasis, tells us that his ex- perience induces him to extend a considerable degree of in- credulity to the ordinary agency of either. His ideas of sympathy are, that it means nothing, explains nothing, and im- plies nothing, save that such and such conditions often co-exist. In some individuals, he believes there exists a constitutional tendency to the ophthalmic affection. I take pleasure in transferring to these pages the following communication from Dr. Henry W. Williams, an eminent oph- thalmic surgeon of this city. His views are expressed with candor and perspicuity: — " I am entirely satisfied that a violent form of inflammation usually designated ' gonorrhoeal ophthalmia,' may result from contact of the urethral discharge with the mucous membrane. A few well-attested instances, where the disease has been thus produced, are worth more than any amount of negative evidence; and that these instances are not infrequent, seems to be admitted by most of the authorities on ophthalmic sur- gery. Before citing cases, which have occurred in my own experience, I will refer, for a moment, to the facts which indi- rectly corroborate the theory of contagion. Among these may be mentioned the far more frequent occurrence of the disease in men than in women; the different situation of the urethra in the female and her different style of dress render- ing her far less liable to the introduction of the discharge into the eyes; while, if the disease were occasioned by metastasis or sympathy, she ought to be equally subject to it. " Another proof is found in the limitation of the disease, as a general rule, to one eye, which is not true with regard to other forms of severe inflammation of the conjunctiva. The experi- ments of Yetch, which have often been cited, were by no means conclusive in their character, and if they had been performed in a mode which would have given them more value, * Medical Times, Nov. 4, 1848. 132 GONORRHOEA AND SYTHILIS. the proof would still have been only negative; viz., that in those instances inoculation did not take place. "The same evidence that convinces us that the disease may result from contagion, leads to rejection of the theory that it ever arises from metastasis or sympathy. Why should we assume such an origin upon mere supposition, while we have no obvious and sufficient explanation confirmed by facts ? Were one of the internal parts of the eye the seat of the dis- ease, we might plausibly ascribe it to metastasis; but the morbid phenomena have their origin and seat in the conjunc- tiva, which is exposed to constant danger of inoculation from uncleanly fingers, which have become impregnated whilst examining the state of the urethral disease. Were metastasis the cause, we might also expect a subsidence of the local urethral symptoms, as they were transferred, in greater severity, to the eyes ; but such is not the fact. " I select a few of the cases which have come under my observation: — " Case I. — Some six years since, I saw while making a visit to the House of Industry, with Dr. Buckingham, the physician of the institution, a woman who was acting as one of the hospital attendants. After the visit she washed the speculum which had been used in examining a patient with gonorrhoea. Within a few hours severe inflammation of the conjunctiva came on, and two days afterwards, when next I saw her, the cornea had given way in both eyes, the iris protruded, and vision was entirely lost. I have never seen a case where the disease was more rapid than in this instance; but one of my friends assures me that he has seen the cornea lost in ten hours from the appearance of the first symptoms, and other similar cases are on record. " Case II. —In 1851,1 saw, in consultation, a gentleman who had a severe attack of ophthalmia, co-existent with gonorrhoea, and where circumstances seemed to fix the moment of inocu- lation of the eye. The cornea was very largely ulcerated and perforation imminent; but the eye was saved, and vision is not much impaired by the opacity forming the cicatrix of the ulcer, as the centre of the cornea has become clear. GONORRHOEAL OPHTHALMIA. 133 " Case III. — About two years since I saw a case similar to the last in all its important features. Here the moment of intro- duction of the virus appeared to be definitely fixed. In this instance the termination was most favorable, although the symp- toms were very severe. Yery slight traces remain of ulcera tion of the cornea. " Case IY. — A year since I was consulted by a young man residing at a distance, who had fixed in his own mind the time when inoculation occurred. His physician, however, did not believe this. He placed himself for treatment in the care of a hydropath and in a few days the eye was destroyed, the pro- gress of the disease being favored by the absurd remedies made use of. " I might add other cases; but these appear to be sufficient to illustrate the views I have brought forward. " I am, Sir, very respectfully your obedient servant, Dr. Durkee. Henry W. Williams." Diagnosis. — One writer affirms that he has found a symptom 'n gonorrhoeal ophthalmia, which he regards as extremely valu- able in a diagnostic point of view, namely, the existence of a small round or oval tumor beneath the skin, peculiarly sensitive to the touch; situated in front of the ear of the affected side and consisting of an enlarged lymphatic ganglion. This he terms " bubon preauriculaire;" and as he has met with it in nine cases where he was able to trace the disease to direct contact; and as he has remarked its absence in some hundred instances of purulent ophthalmia, not connected with gonorrhoea, he is inclined to look upon it as a symptom pathognomonic of this form of the disease. * No other author appears to believe in the existence of these pre-aural buboes, and it is very gene- rally agreed that so far as relates to mere symptoms, the affec- tion has nothing characteristic which may not exist in other purulent ophthalmiae. If the patient can detect the potential cause, and trace it to a co-existing gonorrhoea, as in three of the cases related by Dr. Williams, or to contagion, derived from a second person, that is another thing. The evidence * De l'Ophthalmie Gonorrhoique, — Louvain,1846. — Vide Egan on Syphilis, p. 110. 12 134 GONORRHOEA AND SYPHILIS. of its specific character is complete. Experience sustains the opinion, that, apart from a knowledge that the disease is received by inoculation, the physician has no reliable means of diagnosis between this complaint and what is called Egyp- tian ophthalmia, or catarrhal ophthalmia. Treatment. — From the commencement of the attack, the symptoms present various degrees of intensity in different cases, and of course the character of the treatment, both local and constitutional, must possess a somewhat corresponding variety. If the complaint be ushered in with great violence, and the patient is sufficiently vigorous, blood may be taken from the arm. Lawrence and Erichsen place great reliance upon this method of depletion. Cupping, or leeches applied to the temples, or behind the ears, will be indispensably re- quisite. The frequency of the bleeding must depend upon the urgency of the inflammatory action, and upon the powers of endurance of the patient. In the most vehement and ap- palling attacks of gonorrhoeal ophthalmia, the largest bleedings have been attended with the least success; and at the present day, blood-letting is not carried to any thing like the extent which was once considered proper. It is now well under- stood that inflammatory action of the mucous membranes, es- pecially if attended with an increased flow of their secretions, requires a much more moderate sanguineous depletion, than inflammation set up in other tissues. Hence in diarrhoea, in dysentery, etc., bleeding from the arm is now an obsolete idea. Saline aperients are preferable to any others. The indi- vidual should occupy a large room which should.be darkened; he should be confined to the bed, with the head considerably raised, and an antiphlogistic regimen must be prescribed and rigidly adhered to. Topical means are of primary importance in this affection. The eye, if saved at all, will be saved by remedies applied directly to it. When, from the history of the case, the medical attendant has arrived at a clear conviction that the attack proceeds from the virus of urethral blennorrha- gia, no time should be lost in applying that most active local agent, the solid nitrate of silver to the conjunctiva of both lids. The under one should be touched first. It should be everted, and the nitrate drawn over the surface so as to whiten GONORRHOEAL OPHTHALMIA. 135 it. Before the surgeon lets go his hold of the lid, it is to be washed with warm water by means of a small syringe that will throw a fine stream. The upper lid should be subjected to the same treatment. In ten or twelve hours it may be ne- cessary to repeat the application, meanwhile the eye should be syringed every half hour with tepid water for the purpose of keeping it as free as possible from the muco-purulent dis- charge, which, in a few hours from the commencement of the ophthalmic symptoms, becomes very abundant, and is a source of constant annoyance. The sulphate of copper, in substance, drawn gently over the inner surface of the lid, in the same manner as the nitrate of silver, is attended with good effect. A solution of the copper may also be applied in some cases with entire success. Sometimes it will act favorably, where no benefit is derived from the silver. The strength of the cupreous solution may vary from two to four grains to the ounce of rose water, which should be applied every eight hours, provided it appears to act favorably. During the night, the lids will become agglutinated unless something be done to prevent it. They should therefore be smeared with rose-oint- ment. In the early stages of the attack, warm opiate fomentations will be of service in soothing the inflamed organ; but if the vascular congestion continue to increase, and the disease be complicated with chemosis, warm applications will do injury. The lids ought to be kept covered with compresses soaked in weak alum-water, two grains to the ounce, or the liquor plumbi, in the proportion of one ounce to eight ounces of wa- ter. * The constant application of ice, secured in a delicate linen bag, sometimes acts favorably in checking the high inflam- matory action. The infiltration of the serous or sanguineous fluid between the ocular conjunctiva and sclerotica, and which constitutes the chemosis, performs an important part in the work of de- struction, to which the cornea and other tissues are exposed. The late Mr. Tyrrell employed scarification so as to radiate * Some surgeons object to lotions containing lead, zinc, etc., on the ground that solid particles of the salt employed are sometimes found deposited on the inflamed surface, and thus increase the morbid action. They, therefore, prefer vegetable as- tringents as topical remedies to the eye. 136 GONORRHOEA AND SYPHILIS. from the margin of the cornea. This practice was based upon the theory that the cornea perished from strangulation of its vessels. Whether this idea is purely theoretical, having no foundation in fact, has been doubted; but the advantage of adopting prompt measures for the removal of the infiltrated matter, does not admit of any question. If the chemosis bo severe and oedematous, forming a turgid ring around the cor- nea, it should first be excised; if it be phlegmonous, and the eurved scissors cannot be advantageously employed, it should be scarified. Either procedure will relieve the engorged ves- sels of the overhanging conjunctiva, and will promote the favorable action of other remedies. After scarifying or excis- ing the membrane, the bleeding may be promoted by warm water fomentations. Excision causes severe suffering, and ether ought to be used at the time of the operation, and an opiate given afterwards. When sloughing of the cornea has commenced, the anti- phlogistic treatment must be abandoned, and a stimulating and tonic plan adopted. A solution of alum, six grains to the ounce of rain-water, makes a proper collyrium at this crisis. The undiluted liquor plumbi diacetatis is also a valuable topical remedy. Two or three drops are to be inserted under the lids every six hours during the day. It diminishes the secretion and the inflammation, and there is no danger of its doing in- jury at any stage of the disease. The nitrate of silver, three grains to the ounce of rose-water, may be applied three or four times a day, so that the immediate effect of the application may not pass away before it is repeated. One or the other of the above local applications can be made use of as the phy- sician may choose, but it would scarcely be good practice to employ any two at the same time. Their use must be per- severed in until the purulent secretion ceases, when the disease may be considered as virtually at an end. Care must be taken that none of the discharge from the affected organ come in contact with the eye of the medical attendant or nurse, as it is contagious, and will almost to a certainty re-produce the same disease. Instances are recorded in which the attendant's vision has in this way been suddenly destroyed. The application of the extract of belladonna around the orbits or upon the temples should not be omitted. Permanent GONORRHOEAL OPHTHALMIA. 137 adhesions of some portion of the iris to the capsule of the crystalline lens or to the inner surface of the cornea, may form in consequence of the inflammation ; and the belladonna will be the surest means of preventing such an accident. After the most violent and dangerous symptoms of the first stage have abated, the morbid process occasionally assumes a passive character. The disease becomes atonic; and the most effec- tual mode of treatment will consist in supporting the system by generous diet, quinine, and the like. Blisters to the nape of the neck will now be proper, although during a high state of inflammation they would be prejudicial. As a constant lotion during the day, the extract of lead in the proportion of one drachm to three ounces of water will be useful; and at night, the following ointment should be employed. R. Hydrargyri Ammoniati,...............................gr. vi. Oxydi Zinci Impuri Praeparati,........................ Boli Armenia, a a,...................................gr. xviii. Unguenti Rosarum,...................................3 ss- M- The concentrated nitric acid will be found an excellent remedy in cases of long standing. It may be applied to the everted lids by means of a camel's hair pencil, which should be made merely damp with the acid and drawn lightly and quickly over the mucous membrane. The lids should then be washed in tepid water by means of a second hair pencil which should be at hand. The acid turns the surface white like the nitrate of silver. It can be used every second or third day. In all instances of severe and obstinate character, opiates will be demanded throughout the whole course of the disease. The patient must have nearly the normal amount of sleep, by some means, or he will not progress favorably towards a cure. In regard to mercurials, it may be said that their use is not only of no advantage, but absolutely detrimental in the early stages. In the more advanced and chronic period, a blue pill every second or third night for a few times, and followed next morning by a small saline laxative, will usually be beneficial. In all mild cases of blennorrhagic disease of the conjunctiva the treatment should also be mild; and a majority of cases are of this description. An aperient every other day, low diet, half a dozen leeches to the temple occasionally, a small blister 12* 138 GONORRHOEA AND SYPHILIS. behind the ear, astringent injections or collyria to the eye, exclusion from the action of light, warm opiate fomentations repeated three or four times each day, the use of belladonna to, or near, the affected organ, embrace about the entire list of remedies that we are to rely upon. In conjunction with any or all of these, whatever hygienic plan can be practically enforced should be put in requisition. CHAPTER XIII. OPHTHALMIA NEONATORUM. MOST FREQUENT CAUSE OF THE DISEASE—SYMPTOMS — TREATMENT. The direct application of the acrimonious vaginal discharge to the eyes of the newly born infant during parturition, is by far the most frequent cause of purulent ophthalmia among this class of subjects. The discharge may consist of leucorrhoeal or gonorrhoeal matter. When the disorder is consequent upon contagion from the latter, it is of the most inveterate nature. Most of the cases that occur, are among the low and dissolute ; and if neglected, as they often are, the morbid action soon reaches the cornea, purulent infiltration takes place between its laminae, and sloughing, followed by an escape of the humors, loss of the lens, and of vision, finally ensues. On the other hand, if the child be seen by the physician at an early period, and the case properly attended to, it will be found, ordinarily, to be quite manageable, and recovery will in a short time take place. In the crowded wards of a hospital, where it is impos- sible for the inmates to have the benefit of pure air and other hygienic conditions, pyophthalmia is much more frequently a severe and intractable affection than in private practice. The conjunctiva of the upper lid is usually more deeply involved than the other. It is frequently the seat of ulcera- tions when none exist on the lower lid. The malady is visible in three or four days after the child is born, sometimes later. The lids first swell; and in a day or two, are glued together by a thick puriform discharge secreted from the mucous mem- brane of the conjunctiva. In some instances, a transverse, red line can be seen on the eyelid before the purulent exuda- tion appears. The firm closure of the lids serves to retain the morbid fluid, and, as a consequence, they become puffy and sometimes greatly distended. The affection is not usually attended with much pain unless the child is exposed to a 139 140 GONORRHOEA AND SYPHILIS. glare of light. This is particularly the case as regards the first stage of the attack. Infants with their eyes entirely closed in consequence of swelling of the lids, accompanied with copious discharge of pus and the other ordinary phenomena of the disease, will pass days, or even weeks, without manifesting signs of distress from the local affection. They nurse with fair appetite and are much of the time in a quiet sleep. In the more advanced stage of the complaint, when the inflamma- tory action extends to the conjunctiva of the eyeball, and to the cornea, and when the tumefaction of the lids has greatly augmented, the sufferings of the child are severe. In some cases, the swelling of the lids themselves from the serous effusion into their cellular texture, is so great that eversion occurs when any attempt is made to examine the eye by separating the palpebrae; or it will take place by the crying of the child, when the whole globe will appear as if pushed forward. There is intolerance of light from the very com- mencement of the affection even in its mildest form. In the attempt to open the lids, the eyes of the little patient are invol- untarily turned upward in the socket, so as completely to con- ceal the cornea from view, and the physician has no little diffi- culty in ascertaining the real condition of this membrane. Sometimes the intolerance of light is so great, that when the child opens its eyes voluntarily they are instantly closed with violent spasmodic action, and the lids are squeezed together with great force, attended with a gushing out of the purulent accumulation between them. If it be carried near a window, it will frequently open and close its eyes twenty' times in a minute, in the manner here described; and the process will be accompanied by a simultaneous jactitation of the limbs as if affected by a galvanic shock, and the only way in which the child can be at rest, is by being in a dark place. I have now under treatment a case precisely of this kind. The infant is five weeks old; it weighed eleven pounds at birth. It nurses and thrives sufficiently, is very fat and apparently does not suffer pain from the ophthalmia. The mother states that she has for several months had blennorhagia. Treatment. — The character and success of the treatment will depend not a little on the time when the physician first ophthalmia neonatorum. 141 sees the patient. Should he be called early, a mild course will usually suffice to check at once the further progress of the affection, and to save the visual organ from serious injury. One of the first things to be done is to remove the purulent deposit from the eyes. This may usually be accomplished by gently washing them in tepid water. Sometimes the lids are so firmly adherent, that a soft cracker poultice must be applied for a few hours. As soon as the lids can be separated, mild astringent injections and collyria should be ordered. An injection of one grain of the oxymuriate of mercury to eight ounces of distilled water may be used every hour during the day. The thick purulent mat- ter may not be entirely removed until several repetitions of the injection. It is not expedient to attempt too thorough treatment at the first trials. The local symptoms might thus be aggravated. As soon as the surgeon fairly gains access to the conjunctival mucous membrane, the mother or nurse can be instructed how to proceed afterwards. A few injections, judiciously employed, will be quite certain to bring about a change for the better; and the secretion will soon diminish in quantity. Injections are better than mere lotions, provided they are properly given. Topical measures are mainly to be relied upon, and in a majority of cases satisfactory results will follow. * A weak infusion of chamomile, or a weak decoction of white oak bark, makes a suitable injection, and either may be used in alternation with the one just mentioned. A solution of the nitrate of silver, in the proportion of four grains to eight ounces of distilled water, may be advantageously ap- plied to the diseased membrane two or three times a day. The eyes should be thoroughly cleansed with warm water be- fore using the solution, a few drops of which are to be inserted at the outer canthus. Alum makes a valuable collyrium, three grains to the ounce of soft water; also, the liquor plumbi- greatly diluted. The following lotion, due to Mr. Wharton Jones, is extensively used in European hospital practice, for various forms of purulent ophthalmia and chronic conjunctivi- tis : — * Mr. Critchett, Surgeon of the Royal London Ophthalmic Hospital, says: "Local stimuli should be applied early, often, and thoroughly, to the conjunctival surface in purulent ophthalmia of infants." — Lancet for August, 1854. 142 GONORRHOEA AND SYPHILIS. R. Cupri Sulphatis,....................................gr. ij. Vini Opii,............................................3 i- Aquae Destillatae,.....................................3 vii. Fiat lotio. It may be applied freely with a soft camel's hair brush three times a day. — Association Medical Journal, 1856. The following preparation I have employed for several years in ordinary cases of the disease under consideration. There is no local remedy which I have occasion to regard with more favor: — R. Hydrargyri Ammoniati,...............................gr. vi. Oxydi Zinci Impuri Prseparati,......................... Boli Armenia?, aa,....................................gr. xii. Unguenti Rosarum,...................................3 ss* M. The wine of opium constitutes a suitable local remedy in chronic cases, after the purulent discharge has nearly ceased. The conjunctiva is in a relaxed condition and the vinous pre- paration will serve as a valuable stimulus and anodyne. It should be applied to the parts three times a day. Bleeding, even by means of leeches, is a practice never required in these cases. Small doses of magnesia, or if the child has a jaun- diced skin, as sometimes happens, of hydrargyrum cum cretli, may be ordered every second or third day. If much febrile action be present, a few drops of the dulcified spirit of nitre in sweetened water, and repeated according to circumstances, will be of service. CHAPTER XIY. GONORRHOEAL RHEUMATISM. SPECIFIC CAUSE UNKNOWN — STRUCTURES INVOLVED — SIR A. COOPER'S FIRST CASE — THE DISEASE DESCRIBED BY MR. BRODIE — DR. JOHNSON'S OPINION — DIAGNOSIS — TREATMENT. Medical science has not as yet shed any light upon the specific cause of this disease. But the circumstances which appear to bring this cause, whatever it may be, into active operation in certain individuals, are for the most part within our comprehension. The practitioner usually ascertains upon inquiry, that the patient in whom the affection is developed as a complication of urethral discharge, possesses some marked peculiarity of temperament, — very probably the lymphatic; or has a hereditary tendency to rheumatism or gout; or perhaps is suffering from dyspepsia, or constitutional debility; or has exposed himself to some adverse agency, as cold, and wet, and wind. It is frequently associated with orchitis. It occasion- ally seizes upon the fleshy parts of the frame, as the shoulders. the intercostal muscles, the hips, the thighs, soles of the feet, etc. But the most usual, and by far the most important and inveterate form, which the complaint assumes, is that which is known under the designation of articular or gonorrhoeal rheu- matism, or gonorrhoeal inflammation of the synovial membranes. Some men are sure to have articular rheumatism whenever they contract blennorrhagia; and it is by no means uncommon for patients who have the synovial inflammation, to have, simultaneously, some form of ophthalmia. Sir Astley Cooper mentions that the first case of gonorrhoeal rheumatism he ever met with, was in an American gentleman, who had had gonor- rhoea twice before he saw him. During both these attacks he had double ophthalmia and articular rheumatism in both knees; and the third visitation of blennorrhagia was also remarkable for the same complications. To the wakeful and discriminating genius of Sir Benjamin 143 144 GONORRHOEA AND SYPHILIS. C. Brodie, the profession is indebted for the first description of this complaint, a few cases of which are to be found in his "Diseases of the Joints." This singular affection, like that which diffuses itself among the muscular and fibrous tissues as a complication of blennorrhagic discharge, may come on at any period; although it seldom shows itself until the latter has materially declined or entirely ceased. The knee is by preference most frequently the seat of the disorder, but other superficial articulations are liable to be attacked. The synovial sheaths of the extensor tendons on the wrist and instep are sometimes involved. In most instances, only one joint is im- plicated at a time ; in other cases the disease invades several , articulations at once. The inflammatory action is suddenly lighted up, and without previous warning, is not particularly violent in its features, is wont to linger as a subacute affection for an indefinite period, to the discomfort of the patient and the embarassment of the physician. In consequence of syno- vial effusion, the joint becomes much enlarged; and if the complaint occupy the knee, the fluctuation of the effused fluid can easily be detected at an early period. The effusion remains for several months after the other symptoms have disappeared. In spite of every exertion of the medical attendant for its re- moval, the swelling yields with great reluctance ; and often, on slight provocations, returns with surprising rapidity, first in one knee, then in the other ; and in this way the patient is tormented for years. There is ordinarily but little constitu- tional disturbance. The integument covering the joint pre- serves its natural temperature and color for a considerable time, even when there is a great increase in the size of the joint. In some rare instances, the accompanying symptoms become general and severe. The pulse is full and quick, the stomach and other organs of digestion sympathize, and the patient falls into a decline. In other individuals, the inflam- mation will proceed through its whole course without being attended with any symptoms of effusion. In still other cases, endocarditis and effusion into the pericardium have taken place; also compression of the spinal cord and of the brain, and which appeared to follow the articular affection. The usual symptoms of acute rheumatism are seldom developed, and when they are manifested, they are moderate in degree ; GONORRHOEAL RHEUMATISM. 145 the constitutional disturbance being quite trifling, when con- trasted with the severity of the local arthritic affection. Mr. Johnson thus expresses himself in regard to this disease : " I am disposed to imagine that there is not quite so much of the peculiar and specific about gonorrhoeal rheumatism as is com- monly believed. It has all the features of what is properly called ' rheumatic gout,' and I have seen no case which, the gonorrhoeal discharge away, could readily be distinguished from it. Rheumatic gout is an inflammatory affection of the synovial membranes, erratic in its habit, rather giving rise to rapid effusion than to violent inflammatory action, chiefly af- fecting the articulation of the knee, sudden in attack, tedious • in course, and treacherous in recurrence. What are these but the characters of gonorrhoeal synovitis?" Suppuration has taken place where the patient has received the most judicious treatment, and has in all respects been under the best hygienic influences. Suppuration, however, or the formation of abscesses within or around the joint, is a rare accident. Diagnosis. — The almost total absence of pain, the normal aspect and warmth of the skin, and the apyrectic condi- tion of the system, usually attendant on the complaint in its early stages, are to be set down as the most reliable charac- teristic marks which it exhibits, and may serve when taken in connection with the history of the patient, as sufficient grounds for separating it from ordinary rheumatism, and from those neuralgic and nocturnal pains, which a person not unfre- quently experiences in the latter stages of constitutional syphilis. Instances, however, arise, in which a differential diagnosis is difficult and even impossible ; but fortunately, as regards the treatment, this is a circumstance of small moment. Treatment. — It was once considered proper surgical prac- tice in cases of gonorrhoeal rheumatism, to court a return of the urethral discharge, if that discharge had disappeared or had materially diminished on the accession of the synovial disease. And in order to re-establish the blennorrhagia, it was the custom of some practitioners to irritate the canal by hav- ing the sick man wear a bougie for a portion of each day; or, 13 146 gonorrhoea and syphilis. to inoculate the mucous membrane with the infectious mat- ter borrowed from another person. The same course was advised in ophthalmia arising in connection with urethritis. The idea of metastasis suggested these plans. Whether the theory be sound or not, the inoculation of the urethra with gonorrhoeal virus or even the introduction of the bougie, for the purpose of exciting and irritating the urethra anew, is now reprobated by all judicious members of the profession. Were it within our power to obtain the history of a large number of instances of rheumatism directly related to gonorrhoea, it would probably be found that the influence of the former upon the latter, in ordinary cases, is not of a very decided character; and that the decrease or total cessation of the dis- • charge, when it does take place, is merely an incidental cir- cumstance. Although the complaint is apt to be one of great obstinacy, yet it is in the power of the physician to do much to relieve the severity of the symptoms, and sometimes to cut short their duration. In the commencement of pain and swelling of the joint, the patient should be directed to take his bed. The treatment must of course be both local and constitutional. Leeches should be applied to the affected joint. The quantity of blood to be extracted must be in proportion to the violence of the inflammatory action and the ability of the patient to sustain depletion. The employment of general blood-letting will rarely be called for. The abstraction of a small quantity of blood by means of leeches, repeated at short intervals, will be the safer practice. In a majority of cases, the patients we have to deal with, although young or in the meridian of life are far from being robust. Not a few of them are of strumous diathesis, or have impaired their constitutions by imprudence, and are unable to endure loss of blood to any great extent. Warm fomentations, evaporating lotions, and vapor baths to the joints, should always be used several times in the day; also large poultices, containing laudanum, belladonna, or the Amer- ican hellebore, should be applied at night. In many instances of articular rheumatism, I have known veratrine applications bring alleviation of pain in a very short time. I am disposed to place a higher therapeutic value on poultices containing a large portion of the pulverized veratrum viride, than on either GONORRHOEAL RHEUMATISM. 147 of the other agents mentioned in this connection. The poul- tice should be large enough to cover the whole joint, and be. put on as warm as can be borne. If there be much arterial excitement, the saturated alcoholic tincture of the veratrum may be administered internally. This preparation has been used quite extensively by physicians in various parts of the country; and its efficacy as a diaphoretic and arterial seda- tive, abundantly proved. Professor Carnochan of New York city, has prescribed it successfully in many cases at the Emi- grants' Hospital. In one instance of articular rheumatism, by the exhibition of the saturated tincture in doses of from five to eight drops every three hours, a pulse of one hundred and twenty was reduced to thirty in fifteen hours. I have recently attended a lady, who had a pretty severe attack of articular rheumatism, which migrated from joint to joint during a period of several days. The veratrum was given in tincture, in doses of four to eight drops every six hours, according to the urgency of the symptoms. In this instance, the remedy appeared to act promptly in allaying pain, controlling arterial action and procuring sleep. No opium in any form was used. The Drs. Cutter, father and son, two highly intelligent and reliable physicians of Woburn, near Boston, give ten drops of the saturated tincture of veratrum every two or three hours in severe cases.* When the disease has existed for some time, blisters are among the most efficient local means that can be employed. Or, if the physician prefer, the surface can be kept thoroughly irritated by frequently painting it with the compound tincture of iodine. This will be found a useful substitute for blisters, where the latter disturb the urinary apparatus. Compression, by means of imbricated bands of adhesive plaster and a narrow roller, is another method by which the fluid remaining in the articulation, may be gradually absorbed. The electro-magnetic battery is likewise worthy of a trial when the complaint has assumed a chronic form; also frictions with mercurial ointment, care being taken to avoid salivation. Long continued rub- * Since the above was written, an important communication, prepared by a committee of the Middlesex East District Medical Society, Massachusetts, relative to the veratrum viride, as a safe and valuable arterial sedative, has appeared in the American Journal of Medical Sciences, for October 1858. 148 GONORRHOEA AND SYPHILIS. bing with the bare hand, or with a hair mitten, should likewise be practised many times in the day. The wine of colchicum, tincture of sanguinaria canadensis, the ammoniated tincture of gum guaiacum, the iodide of potas- sium, the nitrate of potash, calomel and opium, have all been tried, sometimes with satisfactory results, sometimes with the very reverse. Where the febrile action is considerable, and the patient of a plethoric habit, brisk cathartics are demanded, and ought to be repeated every four or five days. Their em- ployment may be persevered in for a long time. But in ordi- nary cases, and where the affection has become chronic, and the patient is in rather poor general health, cathartics will not be indicated. They will do injury. Mild aperients, tonics, alteratives, diaphoretics, and a generous diet, will be suited to the condition and wants of the individual. A residence in a warm climate with ordinary attention to all the rational principles of health, will sometimes result in the recovery of the patient, after the physician has exhausted the entire treasury of all remedial agents that have ever been tried in this disease. CHAPTER XY. VEGETATIONS. ARE NOT SYPHILITIC—ARE KNOWN BY SUNDRY NAMES—THEIR SITUATION — THEIR ANATOMICAL STRUCTURE — TREATMENT—PAPILLOMATA. These morbid excrescences were once, but are not now, re- garded as the product of the syphilitic poison. They are sometimes the result of irritation from the deposit of gonor- rhoeal matter; and sometimes they are generated by the com- bine'd agency of moisture, heat, and filth, especially in uncleanly females, who may or may not have some vaginal discharge at the same time. They differ in appearance; and sundry terms have been employed to designate them according to the as- pect they present to the eye or the fancy of the physician or surgeon, as warts, vegetations, tubercle, cauliflower, raspberry excrescences ; and when seated between the nates or on the inner surface of the prepuce, where they are subjected to con- stant pressure, they have been compared to the crest of the cock. The situations in which they are chiefly found, are the meatus urinarius, the glans, the mucous membrane of a narrow prepuce, and at the junction of the two preputial surfaces; when they select the latter site and are allowed to remain, they fill up the orifice so as to impede the escape of urine and otherwise interfere with the functions of the penis. In the female, they come upon the vaginal surface, vulva, nymphae, orifice of the urethra, and upon the inner aspect of the labia. They usually begin to appear in the lower part of the vagina, near its orifice, and extend upwards along the junction of the mucous membrane and skin towards the superior commissure. They grow with great rapidity. Even if excised with the knife or scissors, they immediately return, provided the blen- norrhagia continues; and if undisturbed, they soon become large and vascular, occasioning more or less haemorrhage and severe pain when cut off. They are generally soft and spongy 150 GONORRHOEA AND SYPHILIS. when situated in these parts, and constitute one of the greatest inconveniences that attend gonorrhoea in the female. In some instances, large warty excrescences spring from the walls of the vagina at a little distance from its orifice, and their pres- ence will keep up a discharge for a long time after the blennor- rhagia, in which they originated, has ceased. The patient, perhaps, makes no complaint; but if she engages in any active exercise, the discharge will probably return and be as abun- dant as ever; and the ordinary treatment for arresting it will be employed with little or no relief. Under these circum- stances, if the speculum be used, the locality of these verrucae can be ascertained and they can be removed with the ecraseur, or be destroyed by the application of the acid nitrate of mer- cury. In both sexes, vegetations collect around the verge of the anus, on the perineal integument and within the cleft of the nates, where the natural moisture and other irritating matters are retained. In the recent state, and while lubricated with the substance exuded from the mucous surface, they are comparatively soft and white; if they remain for a consider- able time and come in contact with the air, they dry up and become quite hard and of a dark color. Sometimes they are broad, thick, and flattened; or they may have a small pedicle or stem, by which they are attached to the corium from which they germinate, and present a form not unlike a grain of wheat or rice. Their anatomical structure consists of a thick, firm investment of epithelial laminae and newly formed cellular tissue, which is usually well supplied with blood vessels and nervous loops, and hence the pain and bleeding when the growths are removed with the scissors. The epithelium is not perforated, but is pushed up without being broken as the vege- tation grows. I have seen them in male and female subjects, who were and always had been otherwise exempt from disease in the parts occupied by these morbid growths, but who had no practical notions of personal cleanliness. It is by no means difficult to believe that such individuals are just the ones to furnish the elements for the formation of these adventitious appendages. The wonder is that they do not occur more fre- quently. A few months since, an Irish woman called upon me to be cured, she said, of a wart as big and as black as " a cock- VEGETATIONS. 151 roach," and which had troubled her for about one year. The abnormal mass was situated on the pouch at the fourchette. Several small papilliform warts were seen pullulating in the immediate neighborhood of the larger one. They had all been destroyed several times and all quickly returned. The patient stated that when they began to trouble her, " they were white as any snow." She was sufficiently filthy to suggest the idea that these extraneous bodies were the legitimate offspring of the soil that nourished them. In this case Goulard's extract of lead relieved, but did not cure, the difficulty. I am aware that Yidal considers these vegetations as syphil- itic in their origin; and he disbelieves that any other cause can give rise to them. This theory is repudiated by nearly all syphilographers. It is highly probable, to say the least, that they may and do exist without any constitutional taint of a specific character. They are incapable of generating any vene- real affection ; are seen in their worst forms in the female, and, like warts on the hands of children, spring from causes which it is not easy to explain. Mr. Acton says : " In females, warts 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 have ceased to consider them a secondary symptom. It is of great importance in medical jurisprudence that these points should be properly appreciated." Yegetations of a non-specific nature are now and then com- plicated with true condylomata, which proceed from a venereal cause, and which belong to the circle of secondary symptoms. When these condylomatous excrescences exist, other syphilitic phenomena will be present also; or the history of the case will show that they have existed at some former period; and the physician will seldom have any difficulty in assuming the right position as regards the diagnosis. Some authorities make this distinction,—that simple warts are always pedunculated, while those that are really syphilitic are always sessile and seated on a broad base ; and the granular patch is of a dirty red or whitish hue, rather flat than prominent; secretes a watery, yellowish discharge, and having a most disgusting odor. But nothing short of a truthful history of the case can furnish a perfectly reliable basis, on which to establish a cor- 152 GONORRHOEA AND SYPHILIS. rect diagnosis. Mere appearances may deceive the most prac- tised eye. This they always have done and always will do. Treatment. —If the warts are in men, and situated on the inner surface of the prepuce, their removal is best accomplished by circumcision. If located on the glans, or on the reflected portion of the preputial mucous membrane, they can be snipped off with a pair of flat curved scissors, and afterwards the radical portion be touched with some sharp escharotic, as acid nitrate of mercury or the concentrated nitric acid. If very numerous, it will hardly be prudent to attempt the destruction of the whole by a single operation either with the knife or caustic, but let the work be more gradual. Excision is a pain- ful procedure to the patient, and will rarely succeed, alone, in annihilating these disgusting formations. As a constant application, the liquor plumbi, somewhat di- luted, is one of the best. It may be used on dossils of soft Eng- lish lint. When the warts are not situated on the prepuce, they can generally be removed and be prevented from returning, without recourse to the knife or scissors. In addition to the astringents and escharotics mentioned above, the bichloride of mercury will sometimes act in an efficient manner. It is to be used in the proportion of two grains to the ounce of water, as directed for Goulard's extract. The chloride of zinc solu- tion is preferred by Mr. Emerson, surgeon in the Westmoreland Lock Hospital. In a communication to Dr. Egan, he says: " I would wish to impress upon you the high value I attach to Sir William Burnett's solution of chloride of zinc, in all cases of vegetations and unhealthy growths, the result of inattention to cleanliness, and the accumulation of irritating vaginal secre- tions. Indeed, such is my opinion of its utility in these cases, that I believe it cannot be dispensed with. I consider the so- lution the most effectual and in some instances the only appli- cation (the knife excepted) that can be relied upon with certainty for the cure of the disease." The zinc solution may be applied occasionally without being diluted; but for con- stant use the strength should be from two to four drachms to eight ounces of water. When the warts are clustered about the anus or the perinaeum, a powder consisting of equal parts of savin and burnt alum, makes an excellent application. VEGETATIONS. 153 These new formations, when they occur on the external integ- ument, are limited to distinct portions of the papillary stratum of the true corium, or of the sebaceous follicles. They are of- ten known under the name of acuminated condylomata, and have very properly been termed papillomata. The projec- tions, which constitute the papilloma, sometimes terminate in acute points; sometimes in truncated, clavate extremities; and are in some instances, supported on a slender neck, or on a broader basis ; occasionally quite a number, grouped together, rise on a common stock, or, crowded more closely, constitute a group, separated by lateral furrows, which give them a cau- liflower appearance. * Case. — A young printer, unmarried, came to me a few months ago with numerous pedunculated warts, situated around the anus and along the perineal integument. Five or six years since, he had a chancre on the glans penis. It was readily cured, and his general health never suffered in consequence of this primary accident. The warts began to appear seven or eight months before I was consulted. The largest were the third of an inch, the smallest, the tenth of an inch in length. The patient was directed to wash the parts thoroughly in warm water and soap, and to apply the powder of savin and alum morning and night. In three weeks, the excresceuces were completely destroyed and did not re-appear. No other treat- ment was used. This is a fair specimen of the effects usually derived from this powder. In many instances the locality of the vegetations renders its application impracticable; but where it can be used conveniently, its agency in destroying the abnormal growths is rapid without being very painful. Es- charotics all act much in the same way ; and in ordinary cases there is no great choice in them. In some instances, however, there is a preference arising from the character, locality, and extent of surface occupied by the vegetations. If they are flattened and exist in large groups, whether on the cuticular or mucous surface, and excision be not admissible, the acid nitrate of mercury will act as favorably as any topical remedy. * A minute description of these papillomata may be found in Wedl's Pathologi- cal Histology. 154 GONORRHOEA AND SYPHILIS. A convenient method is, to moisten the end of a glass rod or a camel's hair pencil with the fluid. A quantity sufficient to turn the surface of the vegetations white, is to be used, and no more. The process is somewhat painful, but per- fectly destructive to the morbid growths. If the cluster be very large, it will not be best to treat the whole at one time; but the surgeon should wait four or five days and then attack another portion. After the application of the acid, lint, soaked in warm poppy-water, ought to be placed in contact with the part, and the patient should remain quiet for some hours. A solution of chromic acid has lately come into use in the treatment of warts of the genital organs and other parts, whether resulting from syphilis, gonorrhoea, or other irritating discharges. The strength of the solution should be in the proportion of one hundred grains of crystallized chromic acid to a fluid ounce of distilled water. It is best applied by means of a pointed glass rod as directed for the use of acid nitrate of mercury. Only so much should be employed as will satu- rate the diseased growth. Care must be taken to avoid the adjacent healthy tissue; for although the solution is not suf- ficiently powerful to destroy, or even vesicate the mucous surface, it may provoke an unnecessary inflammatory action. Any superfluous acid may be removed by a piece of wet lint. The acid gives but a trifling amount of pain. Warts situated on the vulva, labia, perinaeum, anus, prepuce, glans, etc., may be treated with it, with safety and success. One application is generally sufficient. A purulent discharge ensues, and under its influence the morbid excrescences speedily waste away. The proper dressing to the parts, after the application of the acid, is dry lint, or lint wet with diluted lead-water. If the warts are numerous, the same rule should be observed in attempting their removal as was suggested in the employment of the acid nitrate of mercury, that is, to attack a part of them at a time. Whatever local measures are put in force for removing the disease, whether in the male or female, the patient must not forget that after the cure has been completed, a recurrence is to be apprehended, unless the most scrupulous attention to cleanliness be observed. CHAPTER XYI. BLENNORRHAGIA in the female. THE SPECULUM — DIAGNOSIS OF BLENNORRHAGIA IN THE FEMALE — BLENNOR- RHAGIA IN VERY YOUNG FEMALE CHILDREN—VARIETIES — CHRONIC VAGINITIS — UTERINE BLENNORRHAGIA—TREATMENT—URETHRAL BLENNORRHAGIA IN THE FEMALE. The Speculum. — Of late years, the speculum has been resorted to as an important means of diagnosis, in morbid affections that invade the vagina and uterus ; and the clinical demonstrations, which its use is capable of affording in a variety of cases, cannot be too highly appreciated. More than two thousand years ago, this instrument was employed as a means of ocular inspection; but through agencies and for reasons not now apparent, it drifted out of the current of medical and surgical practice, and for many long centuries remained in a state of oblivion until about sixty years ago it was again brought into limited use by M. Recamier, of France, and still more recently, through the active genius of Ricord, it has become one of the most popular and efficient means for obtain- ing an exact knowledge of uterine lesions. And considered in a therapeutic point of view, its merits, in certain cases, can scarcely be exaggerated. Among what we term in medical parlance female diseases, and which we are called upon to in- vestigate and treat, blennorrhagia, proceeding from some portion of the generative system of the female, is one of the most common ; and by the use of the speculum, the practi- tioner can arrive at a degree of certainty in regard to the pathological condition of the parts, which it is impossible to acquire through the blind medium of digital examinations. The latter, under the most favorable circumstances, and give but an imperfect knowledge of any morbid changes that may take place. The sense of touch needs the assistance of the eye. The advantages of instrumental explorations do not consist merely in bringing to view any particu- 155 156 GONORRHOEA AND SYPHILIS. lar lesion that cannot be otherwise detected. They relate directly and chiefly to therapeutic measures. Certain modes of treatment, certain topical and constitutional remedies, pos- sessing specific qualities, adapted to particular functional or structural derangements, and to no others, are thus suggested to the judgment by what the eye has seen. In the same manner, an examination within the buccal cavity, by means of a spatula, leads to definite conclusions in regard to any morbid condi- tion of the mouth or throat. Cases not subjected to such in- spection must necessarily be conducted, in some degree at least, according to the doctrine of chances. No sagacity or experi- ence is sufficient to guide the physician in the best way, independently of the speculum. Neither the exact locality nor the precise nature of the abnormal condition can be recog- nized in a satisfactory manner; and the line of treatment must be laid out and pursued under no little disadvantage. Here the blind lead the blind; and although neither may literally realize the catastrophe spoken of in connection with this im- plied ignorance, it is certain that both must suffer from it in more ways than one. There are circumstances and conditions in which instru- mental examinations cannot be made. To employ the specu- lum in severe inflammatory gonorrhoea, accompanied with tumefaction of the labia, would be an abuse of the instrument and of the patient. The surgeon must suspend its use until the acute symptoms have been subdued. After this, the specu- lum should be employed for the purpose of ascertaining whether any erosions, vegetations, chancres, or ulcerations co-exist with the blennorrhagic discharge. It not only gives clearness and precision in diagnosis, but it can be employed as a surgical guide to render more facile the application of caustics or escharotics, in the use of which, caution and exact- ness of manipulation are necessary. The speculum may, without impropriety, be regarded as suited to a numerous class of females, who require medical and surgical treatment, and who are always anxious to be cured in the shortest time possible. With the instrumentalities now at his command, the intelli- gent practioner asks only for a few days to accomplish a cure of maladies, which, while the speculum was ignored, were sub- BLENNORRHAGIA IN THE FEMALE. 157 jected to a tedious and oftentimes random treatment of many weeks or months. Several kinds of speculum are in vogue. The bi-valve is generally preferred. The common, conical form is easier to manage ; throws a sufficient quantity of light upon the part that is brought into view, and usually answers every purpose. Diagnosis of Blennorrhagia in the Female. — The inves- tigation of this subject is often beset with difficulty and em- barrassment. The impossibility of determining in all cases between a gonorrhoea resulting from infection and one that has no such origin, is acknowledged by all practitioners. Such instances are occasionally met with in the male subject; but in the female they are very frequent. Especially do they oc- cur in women who have long been troubled with some chronic secretion of obscure character, assuming different appearances at different epochs; being at one period mucous, at another, muco-purulent, or muco-sanguinolent; and so on, through still other transformations; sometimes attended with but little in- convenience, at other times fretting and irritating the surfaces over which it flows. To these chronic cases the difficulty of discrimination is chiefly confined. Neither chemical nor pathological investigations have as yet furnished any thing like the requisite data by which we might decide in any given case, as to the contagious or non-conta- gious properties of these abnormal exudations. Were we at liberty to make' experiments in the inoculation of these vitiated secretions, we should still fail to have any absolute criterion, or to acquire any incontestible evidence in the premises, so far as relates to the true gonorrhoeal element derived by con- tagion from another. For it must be admitted that the vaginal secretions of some females, who are perfectly chaste and en- tirely free from all gonorrhoeal taint, may give rise to urethral inflammation and blennorrhagia in some men. Leucorrhoea has the credit of doing this. The same power is claimed in behalf of normal menstrual fluid. There are not a few able writers who have implicit faith in the ability of both these se- cretions to provoke a blennorrhagic urethral discharge. Can- dor indeed, compels me to go farther, and to admit that an acrid condition of the ordinary mucous moisture, — the epithe- 14 158 gonorrhoea and syphilis. lial exudation from the uterus or the vagina, — may generate a gonorrhoea in the male. But this male, in my opinion, must be endowed with some peculiar idiosyncrasy, some remarkable aptitude, which predisposes him to receive the infection. Thus, extraordinary conditions appertaining to both parties at the same time, may occasion non-specific symptoms in a man, that cannot be distinguished in their severity, duration, or complications, from those phenomena attributable to contagion derived from a woman, who has, and who gives, a veritable blennorrhagia at the moment of sexual congress. Such in- stances, are, however, exceedingly rare. They will do to be mentioned as mere exceptions to the general rule and this is all they are worth. All these contingencies, these exceptions, and these extraordinary circumstances, demonstrate the para- mount importance of having a full and truthful history of the case presented to the medical attendant for his careful consid- eration. If, short of such a history, he attempts to form an opinion, he will find himself sometimes, and when he least ex- pects it, leaning upon a broken staff. Practitioners of no little tact and experience, have been placed in such a predicament. Professor Bennett, speaking of inflammation of the vagina and vulva, says that he considers the secretion of a great quantity of pure pus from the vaginal mucous membrane as all but pathognomonic of blennorrhagic inflammation. "An important fact in connection with vaginitis," says he, " to which I have already drawn attention, is, that it seldom exists for any great length of time as a primary disease, whether purely inflammatory or blennorrhagic, without extending to the mu- cous membrane of the cervix. Hence it is, that blennorrhagia, a disease in which the inflammation no doubt commences in the vagina and vulva, the cervix is nearly always, after a short time, found to be congested and inflamed, and eventually, if the disease is not cured, ulcerated. Like those who have pre- ceded me, I am unable to point out any absolute means of distinguishing between simple inflammation of the vagina and blennorrhagic inflammation, although I am convinced that a difference does exist. This, indeed, is proved by the fact that simple inflammation of the vulva and vagina, does not, as a general rule, communicate blennorrhagia to the male, although I admit full}7 that an occasional exception may take place. BLENNORRHAGIA IN THE FEMALE. 159 My dispensary patients are nearly all married or single women, amongst whom I seldom meet with syphilitic disease, and in the higher ranks of life it is still more rare, not existing in one uterine case out of fifty for which I am consulted. Nearly all these females in both classes of the community, are suffering from vaginitis, as described above, in a more or less acute form, when they apply for advice ; and yet although they have generally lived with their husbands up to the time they con- sult me, the wife has nearly always a tale of sorrow to record; her husband is wild, dissipated, keeps bad company, sleeps out at night, and generally speaking, has confessed to her that he has exposed himself to contagion. The only anatomical dif- ferences, however, which I have observed in blennorrhagic inflammation are, the very great quantity of pus secreted, the extreme redness, congestion, and swelling of the mucous mem- brane, the occasional extension of the inflammation to the ure- thra, and its extreme intractability to treatment."* Young female children are sometimes troubled with a dis- eased condition of the genital organs, presenting symptoms very much like those arising in the female of adult age. The trouble usually commences in the prosputium clitoridis, which, from some accidental cause, becomes inflamed ; and the affec- tion afterwards extends gradually to the labia, nymphae, and perhaps to the vagina. In some instances, small ulcerations form here and there upon the mucous membrane, which yields very little purulent discharge. In other cases, erosions take place, or there is an aphthous condition of the parts, attended with a serous exudation more or less copious, and irritating to the surface, with which it comes in contact. In still other instances, but of very infrequent occurrence, a leucorrhoeal dis- charge is noticed, apparently from the vagina, while the other associate organs remain healthy, and the child is otherwise well. In none of these cases do the symptoms assume a spe- cific character. They may awaken alarm in the mind of the mother, and sometimes suspicion may be excited that foul play has been practiced upon the child by a person having a gon- orrhoeal or venereal affection, when such is not the fact. A few months since, I was requested to examine a little girl * Bennett on the Uterus, p. 179. 160 GONORRHOEA AND SYPHILIS. about five years old. She had muco-purulent discharge from the vagina, — the external organs being free from disease. The child was sent to Rainsford Island Hospital. The symp- toms were of a mild type, but several weeks passed before a cure was accomplished. By the parents the trouble was thought to have originated with a servant girl, of bad repute, who slept with the patient. A similar instance came un- der my observation several years ago, in a child two years of age, and requiring treatment for more than two months. In this case, there did not seem to be ground of suspicion against any individual, nor was the cause of the difficulty apparent. Dr. R. H. Salter informs me that he has recently had under his charge two female children, one aged eight years, and the other eleven, affected with urethral and vaginal blennorrhagia. The mother was under his treatment for the same disease at the same time. The only way of accounting for the occurrence of the complaint in the children was, that the mother used the same napkins for wiping the children, after bathing, which she had just before employed on her own person. A few years since, two similar instances were re- ported by Dr. Burke Ryan before the London Medical Society. Two children, sisters, aged respectively one and four years, were found laboring under a profuse vaginal discharge. There was high fever ; the parts were much swollen with great pain in micturition. The explanation as to the mode of communica- tion of the disease to these children was this : It was ascer- tained that a young woman in the house had profuse gonor- rhoeal discharge ; that she washed herself in the same vessel used for washing the children ; that she used about her private parts the same sponge, which was employed for them, and sat upon the same vessel which they did. * As the foregoing cases are well authenticated, they are important in reference to matters of medical jurisprudence. Similar accidents might happen to females of adult age. If a young female, with mucous or purulent discharge, showing itself at the external genital organs, is presented for examination and treatment, it will usually be an easy matter to determine whether any attempt at intromission of the virile * London Medical Gazette, April, 1851, p. 744. BLENNORRHAGIA IN THE FEMALE. 161 organ has been made by an adult male. Any such effort will be very likely to be followed immediately by inflammation and swelling of the soft and delicate structures of the labia and nymphae ; and laceration, or other injury, about the entrance of the vagina, will be detected. If no marks of violence can be discovered, the morbid condition of the parts must be attributed to some other cause — as the accumulation of filth, irritation from the clothing, or some intestinal derangement. Situation. — Blennorrhagic inflammation, attended with a specific discharge, eminently contagious, attacks the mucous membrane of the vulva, the vagina, urethra, and uterus. In very mild cases, the abnormal action is confined to this mem- brane ; but, in most instances, it penetrates into the subjacent tissues. It is usually limited to some portions of the genito- urinary apparatus, although in certain cases, which have been neglected, or which, from some special circumstances, resist the ordinary therapeutic measures, the malady propagates itself throughout all the organs. Among the ulterior acci- dents, resulting from blennorrhagia, may be mentioned cystitis, nephritis, inflammation and obliteration of the Fallopian tubes, ovaritis, sterility, peritonitis, inflammation and suppuration of the inguinal lymphatic glands aud of the labia majora, chronic enlargement of the nymphae, etc. Varieties.—As the morbid process takes place in certain localities, while other portions of the genital organs are not implicated, the disease may very properly be considered under several varieties, according to the situation it occupies. The vulva and vagina are most frequently the seat of catarrhal in- flammation. Symptoms.—Among the earliest sj^mptoms, which announce the approach or actual existence of the disorder, are, — a peculiar tickling and itching sensation in the parts, amounting, in some women, to a sort of temporary nymphomania. The labia majora are swollen, and upon separating them, the whole mucous surface thus brought to view, is found to have under- gone a material change. An erythematous redness, with a turgid condition of what is called the vulvar circle, is mani- fest. Serous infiltration takes place into the cellular tissue of 162 GONORRHOEA AND SYPHILIS. the nymphae, greatly distending these bodies, which protrude through the external labia, and become oedematous, constricted and extremely sensitive. The patient is scarcely able to walk about, or even to sit down, on account of the local suffering she experiences. The bladder is disturbed by sympathetic irritation; micturition is frequent and painful, although no urethritis exists. The tumefaction of the neighboring parts interferes with the free exit of the urine, the diffusion of which, over the inflamed surface, causes no inconsiderable smarting and scalding. The inflammation soon reaches the vagina and spreads in circumscribed patches, or perhaps ex tends throughout the whole of its mucous membrane. Its numerous papillae and follicles become hypertrophied ; its walls contract and present a granular aspect; and if the in- flammation reach a high point, abrasions of the epithelium are here and there seen in the form of lenticular spots, which give to the mucous surface a salmon-like appearance; and if the force of the diseased action be not checked, ulcerations are formed. These bear considerable resemblance to diphtheritic venereal sores; but they are more superficial than the latter, and in many instances, when examined with the speculum, they can be seen in their different stages of developement. They yield to treatment more readily than any syphilitic affection, which has an apparent affinity or likeness to them. Simultaneously with the preceding manifestations, a copious mucous discharge appears. This very soon becomes puriform, and is poured out in great profusion. Sometimes a vesicular eruption, induced by the irritating qualities of the blennor- rhagic secretion, breaks out upon the perineal integument, the inner aspect of the thighs and other neighboring parts. When the eruption is impetiginous, it is apt to remain for a long time, and may be, and often is, mistaken for a true ven- ereal eruption. Its persistent character is generally con- sequent upon uncleanliness. The blennorrhagia, either from neglect or mismanagement, very frequently degenerates into a chronic vaginitis. The discharge lessens in quantity, con- tinues to be more or less purulent, and usually retains its specific virus to the last. The patient is exempt, perhaps, from nearly all the concomitant symptoms that characterized the initial stage of the complaint, — from which circumstance BLENNORRHAGIA IN THE FEMALE. 163 she arrives at the erroneous conclusion that simple leucor- rhoea is her only trouble; but if sexual intercourse be in- dulged in, the other party is pretty certain to find that he has sought pleasure at a poisonous fountain. Treatment. — Although, under ordinary circumstances, gonorrhoea in the female does not affect so severe a type as in the male, it is, nevertheless, in all its essential features, nearly as difficult to manage in the one as in the other. During the menstrual period, there is an increased afflux of blood to the sexual apparatus of the female, and also at this time an ex- acerbation of the blennorrhagic affection. To these disadvan- tages another remains to be added. While the menses are present, no local treatment can be pursued; whereas this con- stitutes an important means of cure, especially while the dif- ficulty is confined to the vulva and vagina. In the acute form of vaginal blennorrhagia, antiphlogistic treatment is always appropriate. The patient must be con- fined as much as possible to the recumbent posture. Saline aperients should be taken in quantities sufficient to act on the bowels freely. Three or four drachms of sulphate of magnesia, in the early part of the day, will generally accomplish all that is required in this particular. Warm diluent drinks, such as toast-water, rice-water, or a weak decoction of eupatorium per- foliatum, with a liberal quantity of the liquid acetate of am- monia, may be taken for the purpose of exciting and sustaining a free diaphoretic action. Weak orangeade, or lemonade will also be found beneficial. Advantage will always be gained from the employment of warm baths resorted to in the evening. They tend to equalize capillary circulation, and thus relieve the local engorgement. A low, unstimulating diet is to be ob- served. In acute cases, and while the mischief is confined to the vulva and vagina, these constitutional measures are about all, of this description, that will be necessary. It is a local inflammation that we have to deal with, more or less intense, but in which there is rarely any great constitutional participa- tion. In most instances the condition of the tongue, pulse, and skin, demonstrates this. Balsam of copaiba, which is so valuable a remedy in urethritis, is wholly impotent in vaginal gonorrhoea. 164 GONORRHOEA AND SYPHILIS. The following mixture will, in the generality of cases, be found as suitable and efficient a remedy as any in arresting the last named variety of blennorrhagia: — R. Tincture Lyttae,....................................... Tincturae Cubebae, aa,..................................3 U- Aquae Camphoric,......................................5 UJ- Morphias Sulphatis.....................................gr. v. M. Dose. — One drachm three times a day in a gill of rice-water or toast-water. If no inconvenience arise from this quantity, the patient may take four or five drachms in the twenty-four hours. It is seldom that strangury occurs to a degree that requires artifi- cial relief; but if this should be the case, a warm bath, or an ex- tra half grain of morphia, in half an ounce of camphor-water, will prove a sufficient antidote. A little inconvenience or scalding in micturition, if occasioned by the above mixture, is evidence in favor of its use, although the amount of the medicine should be less than at first. If the disagreeable impression, here referred to, should be realized, the patient may cherish a confident expectation that a cessation of the blennorrhagia will speedily follow. Local Treatment. — Injections are chiefly to be relied upon as topical remedies, in subduing acute blennorrhagia in the female. Although somewhat discordant views prevail in re- gard to the value of this class of medicines in urethritis in the male, there is no discrepancy as relates to their free employ- ment in vaginitis. Injections of a soothing or emollient nature, rather than those which exert a tonic or astringent effect, are to be preferred in the early period of vaginal inflammation. Warm water constitutes one of the best injections that can be used. In order to derive from it all the benefits which it is ca- pable of affording, it should be repeated many times in the day. It not only keeps the inflamed mucous surface and the other parts comparatively exempt from the irritation of the abnormal secretion, but exerts a decidedly curative influence upon the diseased tissue itself. A thin mucilage made of the powdered slippery elm bark, constitutes a soothing and quite useful injection; flax-seed tea, and a weak decoction of poppy, are likewise beneficial, and may be used as directed for simple BLENNORRHAGIA IN the female. 165 warm water injection. Either preparation here spoken of, will serve a valuable purpose in appeasing the irritable and engorged condition of all the parts implicated in the blennor- rhagic complaint. In order that the injection may irrigate the upper portion of the vaginal cavity, and be prevented from es- caping prematurely, the patient should lie on her back with the pelvis elevated, at the time of using the syringe. What is termed the " pump-syringe," with a vaginal tube, is efficient and convenient. The tube should be inserted to the distance of about three inches. A pint or more of water or mucilage can be thrown up in a few moments, without removing the syringe. As the patient's recovery is based in no small degree upon the use of injections, every practicable facility should be afforded for the best method of employing them ; and no ex- pense necessary for procuring the right kind of apparatus, will be lost. If a pump-syringe cannot be procured, a metallic in- strument, having a long curved tube or pipe, and capable of holding six or eight ounces, or a vulcanized India-rubber bag, with a long tube made for the purpose, will answer. * A tampon of soft lint should be placed between the labia, and warm fomentations applied during the intervals between the injections; and while the active stage continues, warm baths should be used daily. As soon as the severity of the local symptoms has materially abated, injections different from those mentioned above, must be substituted. Those contain- ing the French chloride of soda will be found useful. Gener- ally, it will be advisable to commence with one ounce of the chlorine solution to one pint of water, and let the patient in- ject two or three ounces repeatedly. It should reach every part of the vaginal canal. If, after a trial of six or eight days, the chlorinated water does not yield satisfactory results, it should be abandoned, and the nitrate of silver be employed in its stead. If the condition of the parts will allow the speculum to be inserted, the mucous membrane can be examined, and the solid nitrate of silver applied, either wholly or partially, over its surface, according to the seat of the disease. The cases, really demanding this local treatment, however, are few * Very good syringes for vaginal use, are manufactured by Dr. Mattson, and by Mr. Thomas Lewis of this city; also by Mr. Davidson of Charlestown, Mass. 166 GONORRHOEA AND SYPHILIS. in number, compared with those in which its use is not called for. The immediate effect is to augment the discharge ; but after a few applications, which may be repeated every third or fourth day, it will generally arrest it in a short time. If the surgeon decide to try the silver, the entire surface of the mu- cous membrane should be thoroughly cleansed with warm wa- ter injections, previous to its employment. While the vagina is thus treated with the silver, a solution of alum, to the amount of two scruples to twenty ounces of water, may be in- jected several times during the day. A solution of nitrate of silver is a favorite with many surgeons. In some instances, objections obtain against its use, from the fact that it soils the linen. It also requires a glass syringe, which, especially in the hands of the patient, is not an entirely safe instrument. Tincture of iodine is a serviceable remedy in the gonorrhoea of females. Like the nitrate of silver, it stains the linen, and on that account is sometimes objected to. A single applica- tion is frequently sufficient to arrest the discharge. The vagina will tolerate an injection of higher strength than would be proper for the male urethra. In the proportion of 3 ss to 3 viii of water, it may be thrown up three times a day, and it may be prescribed in the early period of the complaint, even if there be considerable inflammation; but its efficacy will be more apparent, when there is ulceration of the vaginal mucous membrane, or about the cervix uteri. M. Boinet, of France, uses the tincture of iodine with an equal quantity of water, with great success as a local curative in this affection. The recent infusion of red bark with nitric acid, furnishes an excellent tonic and astringent injection, and is suited to all forms and varieties of the complaint, after the more acute symptoms have subsided. Let me add that it is equally valua- ble in cases of ordinary leucorrhoea. R. Infusionis Cinchonas Rubrae,.........................3 x- Acidi Nitrici,.......................................gtt. xx. M. To be used repeatedly during the day. The chlorate of potash is likewise worthy of a trial in gon- orrhoea and vaginal inflammation. It has been prescribed with the same well-known success that attends its use in stomatitis. The subjoined prescription is appropriate : BLENNORRHAGIA IN THE FEMALE. 167 R. Potassse Chloratis,................................Si- Aquae Fontanas!,.................................3 xvi* ^. Injection. The patient may use an ordinary female syringeful at a time, and repeat the operation ad libitum. Its beneficial effects generally declare themselves in a few days. Chronic Yaginitis. — This is a gleety condition of the parts, with a thin muco-purulent discharge, which it is often difficult to distinguish from common leucorrhoea. It can usu- ally be successfully managed with astringent and tonic injec- tions. Mention has already been made of one or two of this class of remedies. Besides these, there is a long list of others bearing a similar character. The liquor plumbi is one of the most trustworthy. It should be used repeatedly during the day, in the proportion of half an ounce to eight or ten ounces of water. A saturated solution of alum is good. It may be employed once in the twenty-four hours, and in the interim the surface of the vagina ought to be freely bathed with cold water injections. The latter may be regarded as both tonic and astringent in their curative action, and may be resorted to with the greatest freedom. The speculum is to be introduced every few days to ascer- tain the precise lesion of the parts, provided the case does not progress favorably under ordinary treatment. Through this instrument, the mucous surface can be touched, from time to time, with the nitrate of silver or with the compound tinc- ture of iodine. A small probang is to be moistened with the latter and applied wherever any aphthous patches, erosions, or ulcerations, exist. I prefer the iodine to the silver. The nitric acid likewise affords a suitable application, especially if ulcerations are detected. It should be tried cautiously every third or fourth day. Yaginitis is often prolonged in consequence of the walls of the canal coming in contact. To obviate this, let a small roll of lint be passed through the speculum and be deposited in the vagina, where it can remain until the next day, by which time it should be renewed. By having a strong thread at- tached, it can easily be drawn out. Its presence occasions some inconvenience and trouble, as it interferes with the fre- 168 GONORRHOEA AND SYPHILIS. quent employment of injections, although it does not prevent their use. Chronic enlargement of the nymphae sometimes results as a consequence of vaginitis. Leeches, warm fomenta- tions, and cleanliness, will generally remove this difficulty. The labia are frequently the seat of abscesses during the blennorrhagic affection. A free opening should be made at an early period, and they should in all respects be treated according to the principles of surgery. If the contents of the abscess are allowed to find an outlet spontaneously, they are liable to pursue a circuitous route, and thus a sinus may be formed, which will refuse to heal for a long period. I have known such sinuses to occur, and to remain more than six months, before the parts were restored to a sound condition. It is quite surprising to witness the protracted resistance, which, in these circumstances, the diseased structure offers to all ordinary surgical efforts. BLENNORRHAGIA OF THE UTERUS. In chronic vaginitis, a catarrhal affection is very commonly developed in the uterus. The os, the cervix, and more or less of the mucous membrane of this organ, are involved. If an examination be made with the speculum, it will be found that the follicular or Nabothan glands, and very likely all the parts as far as visible, will afford evidence of some abnormal action. The inflammation is generally moderate in its type, with some induration and engorgement of the cervix; and vegetations and superficial ulcerations are often found to oc- cupy some portion of the os uteri or its immediate neighbor- hood, the mucous membrane being everywhere thickened. A copious, tenacious, semi-transparent, or muco-purulent secretion escapes from within the os, which is patulous and granular, and of a deep red color. The secretion is the joint product of the glands of Naboth and of the internal lining membrane of the uterus, and may continue for a very long time after all traces of vaginal disease have vanished. The sterility of prostitutes, it is generally believed, is due to the presence of this discharge, which so frequently exists in this class of females. In manipulating with the speculum, and in employing a sponge or rag-mop for the purpose of removing the stratum BLENNORRHAGIA IN THE FEMALE. 169 of thick, vitiated fluid, which partially occupies the uterine orifice, the parts are easily made to bleed at various points. The operator sometimes finds it necessary to pull away the abnormal deposit with a pair of forceps introduced through the speculum, or to twist it around and entangle it in the swab. In a few minutes after being removed, the material can again be seen trickling down the sides of the os tincae and lodging on the vaginal surface, where it rapidly accumulates in im- mense quantities. I have frequently witnessed these pheno- mena in women who find their way to Deer Island Hospital, and other similar institutions. Dissolute and broken-down prostitutes, and those of a strumous or leuco-phlegmatic tem- perament, are liable to this variety of blennorrhagia. The affec- tion gives rise to more or less constitutional disturbance. The patient becomes pale, has a poor appetite, is troubled with indigestion, pain in the lower part of the spinal column, attended with a sense of weight or bearing down of the uterus; is unable to walk or to take other exercise with- out aggravating the local symptoms; is nervous, dejected, has cold hands and cold feet, a clammy condition of the skin, a quick feeble pulse; is subject to fits of hysteria, and is in all respects a miserable specimen of humanity. Treatment of Uterine Blennorrrhagia.—In the local treatment of this malady, the application of the solid nitrate of silver to the cervix, to the lips of the os tincae, and in some instances, higher up within the walls of the uterine cavity, is an effectual procedure. Before using the silver, it is requi- site to remove the morbid secretion and to cleanse the parts as thoroughly as possible by wiping them with soft cotton or lint. Unless this preliminary measure be carefully observed, the caustic cannot fairly attack the lesion. The employment of the silver should be followed immediately by an injection of warm water, or of decoction of poppy. It will be necessary to insert the speculum in order to bring the parts into view, to which the nitrate is to be touched. The repetition of this process must depend upon the results which follow, and of which the surgeon will best judge by introducing the speculum in three or four days after the application of the silver. The 15 no GONORRHOEA AND SYPHILIS. potassa cum calce is preferred by some practitioners, among whom are Bennett and Acton. It penetrates deeper into the tissues than the silver. It is hard, and requires to be rubbed against the affected part. Hysterical convulsions and profuse haemorrhage, are among the symptoms occasionally superven- ing upon its use. It requires no little practice to know how to apply it to the best advantage. Prof. Simpson selects the potassa fusa in preference to all other escharotics. He states that he finds it far more manageable, speedy, and certain than any other substance. The chloride of zinc is a favorite with some surgeons. It is highly deliquescent, and it is difficult to prevent it from spreading in all directions, and before it is possible to employ a solution of carbonate of soda or other neutralizing agent, the caustic will have time to injure the healthy parts. Similar objections exist in regard to the pot- assa fusa. If the medical attendant be thoroughly drilled in the business, as are the surgeons mentioned above, perhaps no fear need be entertained in the employment of the zinc or potash; but otherwise, I think these escharotics are to be regarded as too potent, too quick, too unmanageable for com- mon use. But few Actons or Bennetts or Simpsons are to be found in the medical or surgical ranks. The French practi- tioners are in favor of the acid nitrate of mercury in syphilitic and other uterine or vaginal ulcerations. In ordinary cases, it is best to begin with the nitrate of silver or with the compound tincture of iodine; and failing of success with these, the more energetic topical measures may subsequently be adopted. In the free use of caustics of almost any kind, the os and cervical canal are in danger of becoming contracted to such a degree as nearly to obliterate them, and thus interfere with the normal process of menstruation. To prevent this accident, it is sometimes necessary to pass a bougie through the canal whenever the caustic is resorted to. In rare instances that have resisted the measures above pro- posed, deep scarifications into the os have been made, and the nitrate of silver applied immediately afterwards with the in- tention of destroying the follicles, from which the morbid se- cretion comes. The operation is said by M. Huguier to have been successful in his hands, and not to have been particularly painful. BLENNORRHAGIA IN THE FEMALE. 171 Injections.—Under this head a few words only need be offered in addition to what has been presented in previous pages in connection with urethral and vaginal gonorrhoea. For occasional use, an intra-vaginal injection of a concentrated decoction of black walnut leaves will be beneficial. * The speculum is first to be introduced, and the neck of the wTomb exposed; then, with a large enema-syringe, the decoction is to be thrown up, in direct contact with the cervix, and a tam- pon of lint is afterwards to be placed upon it so as to isolate it from other parts. This injection is to be used only twice a week, and on the days when it is not employed, the patient is to make use of some of the milder astringent liquids. An infu- sion of walnut leaves, with half a drachm of sulphate of alu- mina to the pint, can be injected every two hours during the day. A decoction of the inner bark of the common white pine makes a valuable injection in all chronic cases of vaginitis, whether the uterus be involved or not. It should be used with a long syringe, in the same manner as the walnut infu- sion. It is slightly stimulating as well as astringent, and causes a sensation of warmth in the parts, but no other incon- venience. A composition consisting of four ounces of glycerine and one ounce of tannin has been employed with advantage in chronic vaginal and uterine blennorrhagia. The method is this : after the puriform matter that lines the walls of the va- gina, has been thoroughly washed away with cold water injec- tions, two or three plugs of lint, well soaked in the glycerine and tannin compound, are to be introduced so as to occupy the entire length of the vaginal canal. On the next day they are to be drawn out; the cold water injections again em- ployed and fresh plugs introduced through the speculum. Yarious other topical means will suggest themselves to the) physician, if those already mentioned prove inadequate to ac- complish the desired end. The Constitutional Treatment best adapted to the condi- tion of most patients laboring under chronic vaginitis or uter- ine blennorrhagia, is that, which has a large tonic element of some sort. The bowels should be kept in a healthy state; the * This was a favorite remedy with Vidal. 172 GONORRHOEA AND SYPHILIS. diet should be simple, nutritious, and liberal in allowance ; and bathing, cold or warm, as the patient may prefer, is to be prac- tised every day or every other day, at all seasons of the year. urethral blennorrhagia in the female. Urethritis, as a distinct morbid condition, is not often met with in the female. If a healthy woman has sexual intercourse with a man while a blennorrhagia is upon him, the vulva, vagina, and uterus sustain the injury, while the urethra, from the al- most total concealment of its orifice within the surrounding tissues, is comparatively exempt from danger. Nevertheless, it is occasionally doomed to receive the contagious matter, while the other parts escape. Symptoms.—Itching, smarting, pain, scalding, difficulty in micturition, with frequent inclination to urinate; redness and tumefaction of the meatus, announce the advent of the disease. Other unusual phenomena, relating to the parts directly in- volved, soon appear. It is scarcely necessary, however, to draw an exact portrait of all the minutiae belonging to this va- riety of blennorrhagia in the female. It is sufficient to remark that the symptoms are essentially the same as those which ex- ist in urethritis in the male. If the physician be in doubt whether the secretion proceed from the urethra or the vagina, the question can be decided by passing the finger into the lat- ter, and pressing gently from behind along the course of the urethra. This will occasion an escape of the purulent fluid from the orifice of the urinary canal, if that be the seat of trouble. Treatment. — Rest, low diet, fomentations, hip-baths, etc. as recommended in the other forms of gonorrhoea in the female, will be appropriate in the present variety. Bland, diluent drinks are more essential here, and more beneficial, than when the urinary organs are not involved. The bladder is prone to manifest a great degree of excitability, to allay which the free use of opiates will be important. The internal administration of balsam of copaiba, cubebs, and other anti-gonorrhceal remedies, may be relied upon with the BLENNORRHAGIA IN THE FEMALE. 173 same prospect of advantage as in urethritis in men. If, during the acute stage of the complaint, much febrile excitement pre- vail, all specifics for the local affection should be laid aside, until the constitutional symptoms have been subdued by anti- phlogistic measures. To allay the general disturbance, let the patient be put upon the use of the following: — R. Sodae Sesquicarbonatis,...............................gr. xv. Potassae Nitratis.....................................3ij. Spiritus iEtheris Nitrici,..............................3 i. Vini Antimonii,.....................................3 ij- Syrupi Simplicis,....................................3 ij. Aquas Fontanas,.....................................3 v- M. Dose. Two drachms every hour during the day. The liquid acetate of ammonia is a suitable diaphoretic, and may be ordered in liberal doses if any febrile symptoms are present. When there is no great constitutionalderangement, and it is seldom that there is, the patient must at once be put upon the use of remedies that act particularly on the urinary organs. As a standard prescription, adapted to the greatest number of cases in the female, the subjoined formula will be found one of the most reliable : — R. Copaibas,............................................. Mucilaginis Acacias,.................................... Pulveris Cubebae, aa,...................................3 K Spiritus iEtheris Nitrici,................................3 Js- Misturas Camphorae,....................................3 vni- M. Dose. — Half an ounce, in as much cold water, three times a day. The quantity may be increased if the stomach will tolerate it. Although a suspension from all active motion is in a high degree subservient to the favorable action of remedies in this disorder, and places the patient in a condition to be relieved of the local inflammatory engorgement and all its attendant symptoms, yet a majority of persons of both sexes, who have the complaint, are either unwilling or unable to submit to that degree of confinement and restraint so indispensable to a speedy cure. The advantages of rest are in no disease more remarkably displayed than in acute inflammation of the mucous tissues generally. This we see verified in conjunctiv- 15* 174 GONORRHOEA AND SYPHILIS. itis, in dysenteric and pulmonary affections,. The same fa eminently true of the genital system. On the other hand, let this fact be impressed on the patient's rmnd,-that there is no malady, in which indiscretions and .rregulantaes of any kind, are followed by more injurious consequences, than m blennorrhagia. CHAPTER XYII. SYPHILIS. BUT ONE SYPHILITIC VIRUS — ITS INTRINSIC NATURE UNKNOWN — INDURATED CHANCRE OF RARE OCCURRENCE--GENERALLY SOLITARY--INDURATION DE- CEPTIVE -- INTERVAL BETWEEN EXPOSURE AND MORBID PHENOMENA -- ABORTIVE TREATMENT OF CHANCRE. The researches prosecuted by those who have enjoyed most ample opportunities for studying the syphilitic disease, in all its phases and consequences, as displayed in the human organiza- tion, point almost without exception, to the fact that its primal type and characteristic qualities are one and the same. The virus has its best expression, — its most distinct em- bodiment, as well as its earliest incarnation, in the chancre ; and we must regard this lesion, with here and there an excep- tion, as the starting-point or focus, from whence result all the malign and diversified influences and developments known to the medical man as syphilitic. We may consider the fact as established beyond reasonable doubt, that in all the varieties of the disease there is but one true poison of syphilis, which poison produces different effects according to the nature of the tissue and the peculiar idiosyncrasy of the constitution in which the disease is manifested ; — all these different phenom- ena depending on the same morbific cause. It is wTell known that if several men have intercourse with a woman diseased with syphilis, they may not all exhibit pre- cisely the same symptoms, although all receive a venereal infection. Mr. Acton relates the following : Three students had connection with the same grisette during one evening. One was affected with a phagedaenic sore; one with an indurated chancre ; and the third had a simple excoriation, which was slighter than that which existed on the genital organs of the female, who was examined a few days after the debauch. Holmes Coote mentions the case of a surgeon who had connection with a female. Immediately afterwards he 175 176 GONORRHOEA AND SYPHILIS. noticed an abrasion on the inner surface of the prepuce which he disregarded, but which spread into a non-indurated chancre. From the discharge, which was purulent, proceeding from an open ulcer, five sores formed by inoculation. Of these, only two acquired the characteristic induration at the base. Simi- lar instances, exhibiting the most varied abnormal conditions, occasioned by the syphilitic virus, now and then present them- selves in ordinary practice; and they render the complaint in question one of the most obscure and difficult subjects to understand, that comes within the range of medical and surgi- cal observation. * Of the essence, — the intrinsic nature, of the microscopic forms of this animal poison, we know nothing. As yet it has proved too subtle for detection. Whatever it may be, in any stage of its vitality, it remains shrouded in the same darkness that conceals from our comprehension the elementary nature of the variolous substance, or the morbific principle of hydro- phobia, typhus fever or cholera. Investigations, conducted by competent scientific masters, under every possible advantage, have been sufficiently numer- ous, — and we have incontestable proof both from natural and artificial inoculation, of the contagiousness of the chancrous substance, and also, as I believe, in some instances, of second- ary venereal matter; but we are not furnished with a reliable foundation, upon which to rest any conclusions in regard * It is plain, that if we admit the doctrine of duality, on which I have just di- lated, we may do so without infringing upon the unicity of the syphilitic poison; because, from all we have said, it would appear that there seems to be a duality of chancrous poison, but that there is but one actually syphilitic virus capable of infect- ing the economy. We therefore find that Ricord may side with his pupil [M. Bas- sereau] without interfering with any of the tenets he has hitherto been maintaining. He has, indeed, given in his adhesion, but in a somewhat guarded manner, and he is, perhaps, right, as certain points are not, as yet, perfectly elucidated. Amongst these, is the fact of soft chancres being rarely, or never, found in the cephalic region; about the head and face the chancres are always of the hard kind; and yet it may fairly be supposed that the region in question may occasionally come in contact with pus derived from a soft chancre. M. Diday has attempted to explain this by saying that soft chancre does not take on the head, just as scabies is known to shun the cephalic portion of the body. But it must finally be confessed that the evidence in favor of a duality of chancrous virus is overwhelming, and that it is very probable that much time will not pass before it is admitted by the whole profession. The unicity of the syphilitic virus remains, however, unshaken, Victor de Meric, Esq., Lecture, — London Lancet, Aug., 1858. SYPHILIS. 177 to the specific, primordial atom, on the presence of which, the communicability of the exudation depends. Specimens of indurated chancre, at different periods of development, have frequently been examined microscopically, with a view to ascertain their precise anatomical characters. Mr. Busk, the accomplished Surgeon of the Hospital Receiving-Ship Dread- nought, London, — and M. M. Lebert and Robin of Paris, have devoted special attention to the subject. They have arrived at the same result as to the specimens submitted to their observation. The chancrous masses were composed of fibrous tissue or stroma, — granular albuminous deposit, epithelial cells, blood-globules, free nuclei and fibro-plastic cells. Thus it will be seen that these investigations respecting the minute structure of chancre, do not add any thing to our know- ledge respecting the peculiar constituent, or entity, which endows it with its mysterious power to pervade, to poison, and to destroy the entire human fabric. Fibro-plastic cells and fibrous stroma, and indeed all the component parts men- tioned above as composing indurated chancre, are found every day in morbid growths, that are as remote in their nature, from all that is syphilitic, as the east is from the west. We must say then, that the microscope reveals the same anatomical elements in chancre that are found in other morbid products. And this is but repeating the declaration of our ignorance as to the diagnostic element — the causative poison of syphilis, — a poison that imprints upon the organism results totally different from any other. Chancre is the root of this tree of evil. Its fruits are seen in generations that live after the root itself is dead. Probably not one chancre in twenty possesses the charac- teristic induration of its base and edges and all the other peculiar attributes, which constitute what is called the Hun- terian chancre, and which was formerly regarded by many leading surgeons as the only true type or indication of the syphilitic sore, and which alone, under ordinary circumstances, was thought capable of infecting the constitution. Mr. Henry Thompson reckons only two primary sores or chancres, the indurated and the soft, and estimates that one instance of the former occurs to three or four of the latter. " That this form of disease," says Labatt, " which has been termed the Hun- 178 GONORRHOEA AND SYPHILIS. terian chancre, is of rare occurrence, must be admitted. The late Mr. Carmichael, whose experience both in Hospital and private practice was very extensive, never met with more than half a dozen cases of the disease as described by Hunter, during a long period. I have conversed with Sir Philip Crampton and Mr. Cusack, our most eminent surgeons in this city, and they are unanimous as to its infrequency. On re- ferring to the communications with which I have been favored by Mr. Lawrence of St. Bartholomew's Hospital, I find that this distinguished and accomplished surgeon is not disposed to recognize Mr. Hunter's description of primary syphilis as adequate or perfect, but considers it both partial and defec- tive."* Dr. John C. Egan of Dublin, who has had an exten- sive Hospital experience, states, that out of upwards of three hundred cases of primary ulcers, the characters of which he accurately noted, he was able to collect only thirty, which could be strictly classified under the head of the genuine in- durated and excavated ulcer of Hunter.f • This variety of chancre is more frequently seen in the male than the female. It yields but an insignificant quantity of matter. At the present day, the general opinion of the profession is, that primary sores, not endowed with the characteristic sign of hardness, have within them the contagious element, and the power also, to generate secondary accidents. It is be- Meved that the most simple chancres that have the least de- gree of induration, may be followed by constitutional symp- toms. The presence of induration is deceptive. This is acknowledged by Ricord himself. Some authorities maintain that all chancres are more or less indurated. The attribute in question is due to the presence of plastic lymph deposited in the diseased tissues, and the degree of induration depends upon the amount of infiltration. This interstitial effusion is comparatively a late symptom or condition, superadded to the vesicle or pimple or abrasion, which constitutes the original lesion, and which is unattended with pain or soreness, and progresses very tardily, almost imperceptibly, for a period ranging from five to fifteen days, before the distinctive feature * Venereal Diseases, 1858, p. 90. t Syphilitic Disease, p. 49. SYPHILIS. 179 of induration begins to be developed, and this hardness re- quires time for its completeness. In some examples, the deposition of lymph is so gradual, that it does not become a well defined and fixed fact until the third week of the chancrous sore. In most instances, the chancre we are speak- ing of appears as a solitary lesion. It occurs in individuals of the highest health. It never passes into a sloughing ulcer, unless in consequence of some mismanagement; and it gives rise to no constitutional disturbance whatever. The cartilage- like wall, which nature throws around the sore, as if to insulate it from the surrounding healthy structures for their protection, restrains the abnormal local action within circum- scribed bounds. But this does not prevent the absorption of the virus into the system. Induration is not in this respect a protective process. On the contrary, there is no variety of chancre so uniformly followed by constitutional symptoms as the one under consideration; — whereas the syphilitic poison may be, and generally is, destroyed by the sloughing or morti- fication of the part in which it is located. Mr. Lee is of opinion that the same result may take place from suppuration in an absorbent gland, consequent upon ulcerative inflamma- tion ; and also that what is termed the deciduous cell-growth, or suppuration on the surface of a poisoned wound, will effectually eliminate the poison from the part.* That this theory will apply to many primary sores is highly probable and perhaps may help us to understand how it is that some primary accidents are followed by secondary affections and others are not. But suppuration of a primary sore does not necessarily and always ensure immunity from constitutional syphilis. This latter is not an infrequent occurrence in the form of cutaneous eruptions, sore throat, iritis, etc. superven- ing upon chancres or ulcers that yield an abundant puriform fluid. A chancre may be developed upon any portion of the geni- tal organs of the male or female. In the former, it is most frequently located on or near the orifice of the prepuce, on the corona glandis, and at some point near the fraenum. It is occa- sionally detected in the urethra, just within the meatus, and is * British and Foreign Med. Chir. Review, October, 1856. 180 GONORRHOEA AND SYPHILIS. known as the concealed chancre. In the female, ife is most com- monly situated on the external labia, at the line of union of the skin and mucous membrane. It occasionally selects other sites, as the entrance of the vagina, the anus, the lips, the nip- ple, and very rarely, the cervix uteri; also different parts of the skin adjacent to the genital organs. The difference in the natural structure of the parts in which the chancre is situated, as causing induration, is sometimes il- lustrated in quite a curious way. Thus, if one portion of a primary sore is situated on the corona glandis, and the other on the mucous surface of the prepuce, the induration will form at the base of the latter only. The veritable Hunterian chancre on the glans penis is a phenomenon that was proba- bly never seen. The firm, compact structure of the part, and its almost total destitution of areolar substance, form a barrier to the deposit of lymph, on which, as previously stated, the dense cartilaginous chancre in question depends for its char- acteristic feature. The surface of the chancrous sore is frequently covered with a grayish, adventitious layer, which, on being washed away, or otherwise removed, is quickly reproduced. This false membrane has been supposed to be the substance which furnishes the poisonous matter. The idea, however, is merely hypothetical; for we have examples of chancres showing them- selves in men after they have had connection with females, who have at the time no lesion, except the slightest abrasion or excoriation of a venereal character in some portion of the mucous surfaces. The venereal virus continues in contact with the part in which it is deposited, for a short time,before any effect is per- ceptible. This is what is termed the period of incubation. The phrase is objected to by Ricord, who maintains that the poison, when brought in contact with the tissues, excites in- stantaneous action, which remains local for three, four, five, or six days, within which time the sore may be destroyed by some caustic application, and thus constitutional infection be prevented. The interval between impure connection and the manifesta- tion of local symptoms varies somewhat according to the con- dition and anatomical structure of the part in which the virus SYPHILIS. 181 is deposited. If this spot happen to be denuded of its cuticu- lar or epithelial covering, inoculation will show itself, without doubt, at an earlier moment than it would if there were no such abrasion. It is probable, also, that the specific appear- ances may be developed more rapidly on the warm, moist sur- face of the mucous tissue than on the external surface. Indeed, it is very difficult to inoculate through the sound skin. The average time between exposure and the supervention of morbid phenomena is between five and six days. The ex- tremes, as to this interval, vary from twenty-four hours to ninety days. Hunter had one case, where the period of incu- bation was seven weeks. Mr. Lawrence relates an instance of five weeks; Mr. Parker mentions two cases, in which the virus did not develop itself until three weeks in one, and one month in the other. ABORTIVE TREATMENT OF CHANCRE. If a chancre be destroyed with caustic at an early day, and before induration of its base has taken place, the system may be saved from infection. The ax has been laid at the root of the tree. This is the case, at least, ordinarily. Ricord holds, that to be effectual, this local treatment should be resorted to before the fifth day from exposure to the contagion. But to this it may be replied, that we cannot know in any given case, at what precise moment the poison may be received into the system. The time when this happens must vary in differ- ent individuals, and according to the nature of the various tissues, in which the primary affection is developed; and in regard to the rule suggested by Ricord, as a guide for the rapid destruction of the virus, I must say that I am not dis- posed to advocate a rigid adherence to it. If, as the result of contagion or of a- suspicious connection, the virile organ has upon it a papule, pustule, abrasion, or sore, which may be the forerunner of constitutional syphilis, the best thing the sur- geon can do, locally, is to make a caustic application to the spot, provided this can be done seasonably ; that is, within ten days from the appearance of the abnormal condition. The design of this simple operation is two fold; to destroy the 182 GONORRHOEA AND SYPHILIS. morbid structure, and to create a healthy recuperative action in the part. During the first six or eight days subsequent to the devel- opment of a pimple, pustule, or sore on the prepuce, glans, or elsewhere, I am not aware that it presents any unequivocal, diagnostic features or infallible signs, by which the surgeon can determine whether or not it is a genuine venereal chancre, according to the Hunterian doctrine. It is far easier to use the dialect of the pathologist, and speak of circular forms, ex- cavations, hardened edges, and the like, as appertaining to a suspicious sore, than it is to demonstrate to one's senses that these attributes are or are not present in many lesions follow- ing suspicious sexual intercourse. These remarks are applica- ble to a large proportion of cases that present themselves for treatment. Many well skilled and practical surgeons, familiar with syphilitic affections in all their phases, are honest enough to acknowledge the difficulties they encounter in determining the precise character of the primary sore. If the parties see fit to try the experiment of inoculation, perhaps the question may be settled ; but meantime, if the medical attendant should wait for evidence consequent on this procedure, before doing any thing to rescue the individual under his care from any possible constitutional manifestations, he would do an unpar- donable injustice to the case. Amid the absurdities, the fallacious tests, and the uncertain indications in which the judgment of the surgeon is vacillat- ing and perplexed, how shall he act ? This question can be disposed of in a summary manner. The circumstances relat- ing both to the history and existing condition of the patient, suggest the suspicion that syphilis may lurk in the diseased organ or tissue. Laying aside, then, the nice splitting of hairs, and other minor distinctions, let the medical attendant, without delay, institute such a rational and practical line of treatment as shall best protect the individual from the direful train of evils that wait on constitutional syphilis. Of this treatment I propose to speak presently. Dupuytren was strongly opposed to cauterization. He called it the most fatal of methods. M. Yidal seems also to have en- tertained a low appreciation of the efficacy of the abortive SYPHILIS. 183 treatment, whether the knife or the caustic was applied in the extirpation of the chancre. He held that a portion of the virus may in some instances enter at once into the system, as it does from the bite of a venomous reptile ; and that however early the local treatment may be put in force, it cannot, in such in- stances, act as a safeguard against the occurrence of sec- ondary symptoms. The local action, and that which ultimately contaminates the entire organization, in the cases here alluded to, may be simultaneous. It is admitted that the destruction of chancre at the earliest moment of its existence, does not always prevent general infection ; and the theory advanced by M. Yidal, commends itself to our judgment; and yet, the num- ber of cases brought to our knowledge of constitutional symp- toms supervening upon the radical destruction of the primitive chancre, is too small essentially to diminish the merits of such local treatment. If the surgeon be consulted within eight or ten days from the appearance of the suspicious lesion, he is jus- tified in resorting to the caustic. Whether the pimple or ulcer possesses all the reputed scientific attributes of a chancre, or not, the caustic should be applied. It cannot do harm. If properly employed, it will occasion a small slough, after which follows a simple healthy sore, that will heal kindly, and thus the surgeon may prevent a life of misery. Syphilographers differ as to the number of days from the in- oculation of the primary local disease, during which it is expe- dient to resort to cauterization as an abortive measure. With Ricord the period for this application is very limited ; Wilson is less definite, but is evidently inclined to allow more latitude as to time, than Ricord. Mr. Lane states that he should be much surprised to find any sore, which healed within a fort- night of the application of the original poison, followed by secondary symptoms. It seems rational to suppose that the chances of constitutional infection are, cozteris paribus, in pro- portion to the duration of the local disease; and, therefore the earlier we destroy any erosion or pimple induced by ex- posure, the more successful will the effort prove, and the less oc- casion will there be for any special constitutional treatment. In offering suggestions for caustic applications, Ricord remarks: " In the first place we are not to reckon the age of the chancre 184 GONORRHOEA AND SYPHILIS. from the time when its existence was first perceived by the patient, but from the moment of exposure to contagion. In acting thus, and destroying the chancre before the fifth day, the patient escapes from secondary symptoms." According to this method of computing the age of the chancre, and the rule given for its treatment, we should scarcely know how to pro- ceed in some cases. Suppose the individual does not discover any abnormal condition whatever, until the sixth or eighth day after suspicious connection, although he has had a watchful eye upon the parts, and suppose he should apply to a physician within three or four days, or even eight days, from the time the lesion was detected, would not the application of the es- charotic be a justifiable and hopeful measure ? I think it would ; and I imagine few practitioners would refrain from its use under these circumstances. Local Applications. —The potassa fusa, the acid nitrate of mercury, and the concentrated nitric acid, are the remedies, with which I am most familiar as local appliances used to neu- tralize the syphilitic virus, while it is believed to be yet con- fined to the infected spot or chancrous sore in the first few days of its existence. Either of the escharotic substances here referred to, is sufficiently potential in its action, and per- fectly manageable in the hands of the surgeon. The nitrate of silver I never employ on these occasions, nor yet the Yienna paste. The silver does not extend so deeply in its destructive agency as either of the other substances, and although it may act efficiently on the more superficial portion of the morbid tissue, the deeper stratum may and probably will escape. With organic structures it forms an insoluble compound, which acts as a preventive to its continuous power as a caustic, by pro- ducing a hard, impermeable coating on the tissue. It thus sometimes acts favorably where it is applied to check slight haemorrhage from a small surface ; but I quite agree with a remark of Professor Peaslee, in his Human Histology, — that although it blackens the epidermis, and renders opaque the epithelium of mucous membranes, it destroys nothing beneath them; and is therefore not a caustic in any scientific sense. Some surgeons rely upon it; but it is not entitled to confi- syphilis. 185 dence in our attempts to annihilate an incipient chancre. Ricord formerly employed it; — he now recommends the Vienna paste and the monohydrated nitric acid. If the lesion consist in an abrasion, the nitric acid is the substance I generally apply. It may be used by means of a small bit of lint secured to a silver probe. The sore may be freely covered with the acid, and any excess must be immediately washed off with warm water, which should be at hand for the occasion. If the surface, which requires to be touched, be very small, the end of a glass rod may be moistened with the escharotic, and then be brought in direct contact with the diseased spot. If the acid nitrate of mercury be preferred, the same method must be observed. In three or four days, the slough supervening upon the applica- tion will be detached, and a healthy, granulating surface appear. If a solitary vesicle, pimple, or pustule is to be de- stroyed, I sometimes select the potassa fusa. It penetrates deeper than either of the liquids above named. The end of the stick of potassa should be reduced to a point, which is to be brought in contact with the apex of the morbid growth in the same manner as in the ordinary use of nitrate of silver. Or, what is still better, let the dome of the pimple be broken with the point of a probe, and let it be emptied of its contents be- fore applying the potassa, which will thus give freer access to the whole of the diseased structure. To ascertain precisely what execution the alkali has done, the point of the probe may be used in breaking up and removing the debris or por- tion destroyed. As the operation, throughout, is void of pain, no haste is required in its performance ; but caution and exactness are both necessary. The potassa is highly deliques- cent, and it is difficult to preserve the solid stick in a dry state. The surgeon had better place a particle of it on the end of a probe, rather than apply the stick itself, unless it be perfectly dry. I have tried it with a pointed glass rod or pen, and have never experienced any trouble. A drop of vinegar will neu- tralize any superabundance of the caustic. The extent of surface destroyed by this corrosive substance is about twice as great as it appears to be at the time of its application. The same is the fact in regard to the depth to which it pene- 16* 186 GONORRHOEA AND SYPHILIS. trates, and it will be well for the operator to bear this in mind when he is about to cauterize with it. A moderate degree of inflammation co-existing with the pustule or sore, need not deter from the employment of any escharotic. The risk of increasing the inflammatory tendency is very small. Cold water-dressing, or a soft cracker poultice, may follow the use of the caustic for two or three days. The water-dressing will suffice, and is to be preferred. The patient should keep still and be restricted to a low diet. When separation of the eschar has taken place, the sore may be treated with the following dressing : R. Ferri Potassio Tartratis,..............................3ij. Aquae Fontanas,.....................................5 vm> ^P Lint, saturated with this solution, should be kept in contact with the sore. Nitric acid, two drops to the ounce of water, makes a clean and suitable dressing also. If the purulent dis- charge be abundant, the aromatic wine with tannin, will be the most appropriate application. R. Acidi Tannici,......................................gr. xv. Vini Aromatici,....................................§ iij. M. If the sore become painful, a piece of lint soaked in a solu- tion of the aqueous extract of opium, in the proportion of two scruples to four ounces of warm water, should be laid upon it; and the warm water dressing with an oiled silk covering or thin gutta-percha, should be placed on the organ. These topical measures are generally adequate to pre- serve the chancrous sore in a healthy condition until a sound cicatrix is formed. Slight cases frequently occur, which, after the caustic is applied, require little or no further care or treat- ment. Instances occasionally present themselves, in which healthy granulations fail to appear, after the application of the caustic and the subsequent dressings that have been men- tioned. The surface of the wound assumes a spongy or fungoid aspect. In such circumstances the following astringent and tonic lotion will be well suited to the lesion: — E Acidi Tannici,.........................................3j- Tinctura? Lavandulae,..................................3 iv. Vini Rubri,...........................................Siv- M- SYPHILIS. 187 The black wash acts beneficially in ordinary cases of chan- crous sores. For many years it has borne the test of surgical experience, and its therapeutic qualities are of a reliable ' As a protection to the sore by night, the nitric oxide of mercury ointment should be ordered. CHAPTER XYI11. CONSTITUTIONAL TREATMENT OF CHANCRE. IRINCIPLES OF HEALTH TO BE ENFORCED.--ANALYSES OF THE BLOOD BY M. GRASSI.--INFLUENCE OF IODIDE OF POTASSIUM ON THE BLOOD.--ARTI- FICIAL SYPHILIZATION.--METHODS OF TREATING SYPHILIS. Although the surgeon loses no opportune moment in at- tempting to annihilate the syphilitic virus by the destruction of the part in which it is believed to be confined, he should not feel safe or justified in all cases, in dispensing with internal remedies as a prophylactic against constitutional infection. The chancre, considered abstractly and by itself, is an affair of small moment. It is the consequences, which may be en- tailed upon the individual, and of which the chancre is the usual medium, that we are to dread. But if the abortive plan of treatment has been seasonably executed, to the extent of completely demolishing a chancrous sore, we are warranted, generally speaking, in the conclusion that its poisonous ele- ment is destroyed also; and a resort to mercurial remedies will be uncalled for. Egan advocates the employment of mer- cury even if the specific ulcer yields kindly to topical applica- tions ; and he considers that the surgeon who undertakes its cure without the aid of this mineral, is responsible for the constitutional symptoms, which his ignorance or temerity will in all probability induce. He has, however, the candor to ad- mit, that if mercury be given with a view to cure the in- durated chancre, it will not, in all cases, prevent the accession of secondary accidents. If perfect cicatrization have been accomplished, and the part be restored to a normal condition, the patient may, ordinarily, be permitted to resume his avo- cations, provided his general health has not in any wise deteriorated during the local treatment that has been need- ful. If any functional derangement of the digestive organs exist, 188 CONSTITUTIONAL TREATMENT OF CHANCRE. 189 it should be rectified by the simplest means. The stomach may require a tonic, or the bowels an aperient, or some other measure may be necessary to quicken the appetite and bring the vital organs into more vigorous play. The diet may now be of a generous description ; — exercise in the open air, ab- lution, regularity, temperance, and such other hygienic habits should be enforced as will promote the constitutional welfare. It is seldom, however, that an individual who has a chancre, applies for aid sufficiently early to render the abortive treat- ment of any avail. In his ignorance, the patient has allowed the brief period to pass within which this treatment might have resulted in perfect success, and he is compelled to enter upon a course of general medication as his only hope. The venereal poison, in his case, is no longer circumscribed within the limits of the small pustule or pimple, which had such a harmless and insignificant look to his unpractised eye. It has broken away from its barriers, and has commenced its course through the system; and, if not prevented by judicious means, it will ultimately find its way through all the tissues which constitute that system. It will do more than this ; it will increase in quantity, and will impart its qualities to the blood, " that river of life, that wondrous epitome of solids and fluids," and there revel and riot during the existence of its victim. How then, shall this infection be arrested? Let us proceed to answer. The virulent matter, although just emerging from a state of incubation, and therefore, scarcely appreciable, or shown by any external manifestation, has, nevertheless, stamped upon the patient the syphilitic diathesis, and we must now consider that his constitution is contaminated. Under these circum- stances, the first thing to be done is to put him upon a regi- men that may serve in some degree at least, as a sanitary cor- don, and fortify him to resist the threatened accumulation and encroachments of the poison. The second indication which should engage the attention of the medical attendant, has reference to the elimination of the morbific principle, through the medium of the emunctories, with which the animal economy is endowed, and which are ca- pable of being excited into preternatural activity by various remedial agents. 190 GONORRHOEA AND SYPHILIS. The personal habits of the patient are to be inquired into, and whatever in them is prejudicial to health, should be pro- hibited. Let me suggest that it is as much the duty and the right of the physician to exact an entire conformity on the part of the patient, to a rational mode of life from day to day, as it is to prescribe medicines, with the expectation that they will be taken and employed according to directions. This, I say, because I know from experience that it is but too often that the physician has to encounter strong opposition, if not downright obstinacy, when he gives salutary advice touching the daily and nightly indulgencies of the syphilitic patient. This is the ground on which the latter will attempt to make the former succumb to his unbridled proclivities. A few years ago, a Spanish gentleman just arrived in Boston from a foreign port, sent for me to visit him at his lodgings at a hotel. I found him in bed, and on examination discovered a large chan- crous sore on the prepuce, and a large bubo in the groin, in an inflammatory condition, as was also his whole system, as indi- cated by the pulse, skin, tongue, etc. The apartment he occu- pied was filled with the fumes of tobacco. He was smoking, and stated that he spent much of his time in this manner. He also spoke of his fondness for stimulating drinks. Through an interpreter, I signified my disapprobation of his habits, and remarked that they would prejudice his recovery, and that if I attended him I should expect he would give up his cigars and libations while under treatment. He was instantly exasper- ated,— said he would submit to no such restraint from any man, and that he wanted nothing further of me. Accordingly I took my hat, and was glad that I escaped so safely from this ruffian. In all cases, the patient should be induced, if possible, to forego the use of tobacco. The saliva, in its pure state, is needed to aid in the early stage of digestion. It is scarcely nec- essary to mention that stimulating drinks must be interdicted ; the diet should be plain, but nutritious. Among the articles of food to be allowed, are milk and lean meats, and all our na- tive fruits in their season, and in moderate quantities, unless some special circumstances in the case contra-indicate them. In short, whatever the physician knows will contribute to a healthy condition of the organs of digestion and assimi- CONSTITUTIONAL TREATMENT OF CHANCRE. 191 lation, and thereby tend to preserve the normal richness of the blood, should be allowed; all else ought to be denied. If possible, the patient should be placed in a healthy resi- dence, where he can have the benefit of a pure atmosphere at all times, night and day; he must avoid all extremes of tem- perature, should practise daily ablution of the whole surface of the body and limbs; and the skin, liver, bowels, and kidneys, should be kept in a healthy condition. The importance of these hygienic measures will be sufficiently apparent if we rec- ollect that the moment the syphilitic element comes into con- tact with the blood, its immediate and constant effect upon that fluid is to diminish the quantity of its red globules in a very marked degree. M. Grassi, pharmacien-en-chef of the Hotel Dieu, has recently made a series of analyses of the blood of syphilitic patients. In simple chancre, it presents no ma- terial deviation from its physiological condition. In indu- rated chancre and secondary syphilis, there is uniformly a diminution of the blood-globules, and an increase in the amount of albumen, but no perceptible variation in the quantity of fibrine. These facts are interesting in a pathological point of view. As will be seen below, the iodide of potassium may be resorted to for the purpose, among other things, of restoring the blood to an approximation of its normal constitution, as it is found to exist in healthy persons. According to the analyses above referred to, the blood of patients, affected with simple chancres, contained the follow- ing relative proportions of corpuscles: — First patient corpuscles Second " Third " Fourth " Fifth " In indurated chancre, the proportion of corpuscles, in one instance, was reduced to ninety-four parts in the thousand. This was increased by the iodide of potassium, which was taken for one month. The corpuscles, at the expiration of this period, were increased to one hundred and twenty-eight parts to the thousand. In one case of indurated chancre, with syphilitic spots, the proportion of corpuscles was reduced to parts parts. 140.4 to the 1000. 140.4 « <( << 140.5 i< << MP Carbonate of Ammonia. — This is a remedy which is capa- ble of fulfilling an important indication in the treatment of phagedaenic chancre; and before taking leave of this subject, I cannot forbear commending it to the attention of the prac- titioner. In its mode of operation on the dilapidated economy in the circumstances now supposed, it differs materially from the other articles of the class to which it belongs. The im- mediate impression upon the stomach, and the genial thrill, wdiich it sends throughout the system, are always grateful to the patient; and the stimulus which it imparts to the vascular and dermoid tissues, approaches nearer to that of normal action than can be exerted by any other remedial agent. It may, therefore, be given in almost any emergency, even when other stimulants and incitants would be inadmissible, on ac- count of any inflammatory diathesis or action that may exist. Its use is compatible with that of opium, or of the favorite ferruginous preparation of Ricord. It is especially suited to that class of patients, whose constitutions have been injured by long indulgence in the use of intoxicating drinks, late hours, and all manner of debaucheries, and who may be suffer- ing from the additional weight of the particular affection under consideration. In these circumstances, I have been accus- tomed to prescribe the ammonia for several years, as in the annexed formula: — R. Ammoniae Carbonatis,..................................3 i- Pulveris Acacia?,...................................... " Sacchari aa,..................................3 ij, Aquae Fontanae,...............................g iv. Cinnamomi Olei,..................,...........gt. j. M. Dose. — A table spoonful every three hours in half a gill of cold water. Although I have commented favorably upon several articles in connection with the treatment of phagedaenic chancre, it is hardly to be supposed that there will ever be occasion to marshal all these forces into the field of action at the same time. They would thus produce confusion, not benefit. In reference to the ammonia, I would add, that for female sub- jects, especially, it will be found an excellent substitute for alcoholic stimulants. 238 GONORRHOEA AND SYPHILIS. Thus far I have been nearly silent in regard to the employ- ment of mercury in this destructive form of ulceration. If any medical practitioner is so partial to it as to recommend it in these circumstances, he will probably not only find it valueless, but decidedly hurtful. Let us suppose the young surgeon at the bedside of a miserable human being, male or female, whose constitution is well nigh in ruins from scanty food, continual dram-drinking, the pestiferous fog of theatres and brothels, — irregular hours, and various other predisposing causes, con- nected with a dissolute life, — and who is now the victim of a foul, angry-looking, eroding ulcer, — the mere dregs of syph- ilis,— upon some portion of the genitals. In such cases the patient always has a quick, feeble pulse, indicative of great prostration and waning of the bodily powers. Even if the morbid action have existed but a short time, it is surprising how rapidly the patient fails. Let the surgeon now inquire what specific good can accrue from the presence of any mer- curial preparation in such a shattered frame. If he should administer it, it will be found not only barren of all good re- sults, but absolutely baneful both as regards the local disease, and the general system. Even in small quantities, and where it does not induce tumefaction or redness of the gums, it may play a mischievous part by increasing the tendency to slough, and its injurious effects by no means admit of easy reparation. I am confident I have seen examples illustrative of these re- marks. I will cite one instance. Case. — May ISth.— I was requested to give advice from time to time in the management of a phagedaenic chancre, of which a young practitioner of the city had charge. It hap- pened to be the first effort of his practical skill in the syphilitic department. The patient was a wandering Englishman, thirty years of age, unmarried, of nervous temperament, a hard drinker, a great smoker, a frequenter of brothels, and occupy- ing as his lodging-place while sick, a small, filthy apartment in a house devoted to licentiousness. At the time of my first visit, he was lying on a bed of rags, and was covered and sur- rounded by all the paraphernalia of filth and moral degrada- tion. He had a prostitute for his nurse. It appeared that a few days after exposure, a chancre came PHAGEDENIC CHANCRE. 239 upon the glans, near the fraenum. The patient consulted this young physician, who attempted the destruction of the sore by the abortive treatment. Nitrate of silver was applied for several days in succession; the patient being abroad meantime in the streets, regardless of any advice to the contrary. Ery- sipelatous inflammation ensued, and progressed with its wonted activity in such cases, until it resulted in phagedaena. It is not easy to convey a true idea of the unique appearance of things on this occasion. The glans was swollen. A para- phymosis tightly girded the parts, and the prepuce and integ- ument farther back, were much tumefied and oedematous. The serous effusion had infiltrated the meshes of the intersti- tial cellular membrane in a somewhat interrupted manner, so as to be confined in small elongated sacs, which took a spiral direction part of the way around the swollen organ; and thus there were three or four bands producing a twisting and par- tial strangulation. The virile member, as a whole, bore no small resemblance to a short screw auger. The patient was lying on his back. The primary chancre was close to the fraenum; but it was now nearly obliterated, — being merged in the phagedaenic mass. The pulse was quick, small, and hard; the tongue white ; the skin dry and hard; there was thirst; severe pain in the glans and along the whole penis; constant nervousness and involuntary muscular agitation, like that wit- nessed in the early stage of delirium tremens. For the two previous nights he got but little sleep. He had taken submu- riate of mercury pills for eight or nine days, but no specific effect had been produced in the mouth. It was agreed that the pills should now be laid aside, and that opium should be given in two-grain doses, every three hours, until the patient should obtain sleep; and that he be kept un- der the influence of this drug so long as any constitutional ir- ritability remained. The prepuce was scarified at several points, and the parts dressed with warm solution of the extract of opium. The paraphymosis was at once relieved by the dis- gorgement from the prepuce, and the swelling and pain in the strangulated glans subsided in a few hours. The man was put upon the free use of carbouate of ammonia julep, accord- ing to the formula just given, together with wine and quinine. The chancre was touched with the concentrated nitric acid 240 GONORRHOEA AND SYPHILIS. several times ; and for an ordinary dressing the opiate solution was prescribed for a short time; then the chloride of soda; and, at a later period, the dilute nitric acid. The pulse and tongue got nearly right in about one week from the day I first saw the case. There was loss of a considerable portion from the right side of the glans and the corresponding part of the corpus cavernosum. The fraenum was destroyed, and also a portion of the prepuce. At one time the organ had an un- promising aspect. From the walls of the chasm occasioned by the sloughing, granulations sprung up in healthy style ; the mutilated glans was soon brought in apposition with the cav- ernous body, to which it united very cleverly. The cure ended with a somewhat odd deformity although the patient was very well satisfied. He left his quarters suddenly one morning for parts unknown, allowing his young surgical attend- ant to realize his fee in the practical knowledge he had given him an opportunity to acquire. Occasionally the surgeon is consulted by a man who has been exposed, and whose condition is something like this : the penis is swollen and painful, and exquisitely tender on pressure at some particular spot along the corona glandis. The prepuce is also inflamed and of a deep livid color. It is in a state of phymosis over the. glans. There is a thin, bloody, and highly offensive discharge from the preputial orifice, which is much contracted. As no other lesion of these parts is at all likely to yield such a peculiar secretion, it may be considered, in connection with the concomitant phenomena, as furnishing al- most unequivocal evidence that there is a concealed, phage- daenic, sloughing sore on the corona or on the mucous surface of the prepuce. In these circumstances, the surgeon should without delay, slit up the prepuce along the dorsum of the glans, so as to bring the chancre into view, and then apply the strong ferruginous solution or the undiluted nitric acid. Phagedaenic chancres on the penis not unfrequently destroy the parts to such an extent that amputation becomes necessary as a final measure. It was said by Dr. Physick, of Philadel- phia, that he had amputated a hatful of such specimens. In addition to the chancres already mentioned, there are other varieties of primary syphilitic sores, which have been designated by the names of phagedaenic gangrenous chancre, PHAGEDENIC CHANCRE. 241 the pultaceous diphtheritic chancre, the serpiginous, or creep- ing chancre, etc. In all these varieties, the abnormal process is of similar character, and requires to be dealt with in a man- ner analogous to that which is found most beneficial in the form of chancre which has just been considered. In all cases of phagedaena, the patient will require a gener- ous diet. Eggs, milk, broths, and, as the digestive apparatus acquires ability, mutton-chop and beef-steak, will constitute an appropriate bill of fare. Chancres in women are wont to assume a more unfavorable disposition than in men. These lesions may exist on the nymphae, or on the inner surface of the labia for a long period, and yet the patient be unsuspicious of their nature. In fact, they give little or no pain, or irritation, until they acquire a large size, and the woman is hardly conscious of their pres- ence. The first symptom that attracts her attention, is'a sen- sation of smarting and prickling, occasioned by the act of mic- turition. If, however, the chancres are allowed to have their own way, unchecked, they sometimes penetrate into the cellu- lar tissue, and degenerate into sloughing ulcers, and total de- struction of the parts is the result. Females, in whom this description of ulcer is found, are usually of a most abandoned character, of dissolute habits, and broken-down constitution. The sore generally commences as an abrasion, or perhaps as an angry-looking pimple, on the labia, and is soon encircled by an unhealthy, lurid areola, and from inattention, as well as in consequence of a vitiated condition of the system, it does not take on a normal granulating action, but shows a tendency to spread in every direction, and yields a thin, sanious, foetid dis- charge, mixed with debris. At a later period, dark colored sloughs begin to form in quick succession, and become more and more extensive, until the vagina and the perineal and anal regions are involved. Sometimes the entire lower open- ing of th.e pelvis is deprived of the soft parts in consequence of the sloughing process. Excessive local pain at length be- comes a prominent and abiding symptom; there is high irri- tation or inflammatory fever, which ultimately assumes a typhoid character, with more or less delirium; the pulse is rapid and indicative of great constitutional debility; the ap- petite fails; all the vital functions are deranged; exhausting 21 242 GONORRHOEA AND SYPHILIS. haemorrhages take place from different points of the immense ulcerated surface, and the frail victim dies from the combined effects of bad liquor, debauchery, and syphilis. Fortunately this form of venereal affection is rarely met with. Now and then, a female, who has long suffered from it, is taken from one of the terrible dens of our large cities, and placed in some chari- table institution. But, in consequence of delay, her chances of cure are exceedingly small. If the case receive proper med- ical attention before the sloughing process has reached an advanced stage, it is not usually difficult to cure the patient. The concentrated nitric acid, a saturated solution of the watery extract of opium, a weak solution of the chloride of soda, Peruvian balsam, and warm fomentations, comprise the most reliable and efficient local therapeutic means ; and the consti- tutional treatment should consist of tonics, large doses of opium,' occasional laxatives, liberal diet, wine, porter, and a wholesome atmosphere. In the Magdalen wards of some of the London hospitals, this disease has long been known as the " Swan Alley sore.''1 Swan Alley is the name given to a place which no longer exists, having been swept away to make room for better structures, and better purposes. The prostitutes, who formerly tenanted these lower regions, lived in an im- mense underground vault for weeks and months together, without seeing the light of day, or inhaling a breath of salu- brious air. They had unlimited intercourse with foreign sailors, many of whom were Lascars and colored men. They were of slender frame, in most instances, and had fair, light complexions, light hair, and were generally from 15 to 25 years of age. They were decoyed from the country by Jews, who kept these subterranean abodes, and were sys- tematically on the look-out in the neighboring thoroughfares. They were scantily fed, and had an abundance of gin. These primary, phagedaenic, sloughing ulcers do not furnish conta- gious matter, nor do the females who recover from them, ever have secondary constitutional symptoms. So said the late Mr. Travers, who furnished a graphic description of them a few years since, in the London Medico-chirurgical Review. CHAPTER XXIII. BUBO. "BUBON d'eMBLEE"— BUBO OCCURS IN THE SAME SIDE WITH THE CHANCRE — THAT FROM INDURATED CHANCRE RARELY SUPPURATES — TRUE VENE- REAL BUBO INDOLENT--TREATMENT--SLOUGHING BUBO. Hunter regarded the syphilitic bubo as a primary accident. There is no instance recorded, in which this lesion has ever had its origin in a secondary venereal sore; nor is it, on the contrary, with a few rare exceptions, ever developed as a spe- cific affection unless a chancre has pre-existed. A few well authenticated cases of bubon d'emblee, or primitive bubo, have been met with.* Ricord mentions eight; Mr. Erichsen has seen one; Mr. Lane, a few, and so on. Mr. Parker has never seen one primitive bubo, which has been tested by inoculation, and thus proved to be of a syphilitic character; but he is dis- posed to admit that such cases have been seen and verified by surgeons of experience, and who are worthy of credit. I think it is not far from the truth to consider a virulent bubo as holding a*n intermediate position between primary and secondary s}7philis. It has been not inaptly called the half-way house between the two stages of the disease. The student will seek in vain for entire uniformity of opin- ion among the best authorities in regard to the frequency or certainty, with which bubo attends or supervenes upon a chan- cre. Some maintain that chancre always begets a bubo; oth- ers assure us that enlargement of the ganglia of the inguinal region does not, in all instances, take place ; and that the secondary symptoms may be developed notwithstanding the fact that these glands remain intact. Buboes usually occur on the same side that is the seat of chancre. If the latter be * M. Ricord, it is said, now denies the existence of the primitive virulent bubo, — 'bubon d'emble'e," produced by the absorption of a special virus, and where there has been no suspicious antecedent — chancre, excoriation, or sore. 243 244 GONORRHOEA AND SYPHILIS. situated on the fraenum, a bubo may be developed in either groin or in both right and left. Buboes that arise in conse- quence of indurated chancre, rarely suppurate, — being sub- ject to the same law of morbid action, that governs the chancre. Such buboes are regarded by some writers, as noth- ing more nor less than chancres, seated in these glandular bodies. They are also denominated indurated, indolent, con- stitutional buboes, and as they never suppurate specifically, some surgeons consider that no local treatment is ever service- able in their removal. The period at which a bubo appears after the occurrence of chancre, is not limited to any definite time, although it generally begins to show itself about the second week after the formation of the parent sore. In the male subject, the bubo is most frequent when the antecedent chancre is situated on some portion of the prepuce, or on the fraenum; and in the female, when the chancre forms at the meatus urethral, or near the anterior verge of the anus. If the patient has a good constitution, and is seen sufficiently early for the successful application of the abortive treatment, a bubo will not super- vene. Surgeons formerly had an idea that if the chancre was destroyed at an early period, the virus might be driven into the system, and that a bubo would consequently be more likely to form. The true syphilitic bubo is very indolent.in its progress, remaining nearly stationary for several weeks, — causing but little pain or other inconvenience; — but the mere fact of its existence is of no trifling significance. It shows that the system is impregnated with the specific virus, which has found its way into the channels of intercommunication, and through the medium of the blood and other fluids, has poisoned the whole animal economy. The bubo of other va- rieties of chancre is more acute, more painful, and generally involves the glands of only one side. Buboes are sometimes produced, not by absorption, but by irritation, in scrofulous and other unhealthy subjects. These cases are not difficult to be distinguished. Simple inflammation is set up, chiefly in the deep-seated glands, which do not become the recipients of the venereal element through the medium of the lymphatic vessels. Sometimes there is a deviation in the locality of inguinal BUBO. 245 bubo. It may be seated farther down the thigh, or farther towards the pubes, or close in front of Poupart's ligament. I once met with the latter deviation in a young man. In this case, the swelling attained a large size, was round, and pushed forward the cutaneous and cellular membranes, as if a small flat onion were underneath. The unusual position of the swelling is due, of course, to the abnormal locality of the glands, and it is well to bear in mind the possibility of this anatomical peculiarity, otherwise some embarrassment or error might occur in our diagnosis. The virulent matter of the true syphilitic bubo retains its contagious property, so long as it remains in the ganglion, that is, it is inoculable. In regard to the frequency of inflammation and suppuration, the general rule is this: if the bubo be the result of a non- indurated chancre, its tendency is to advance to suppuration; whereas, the contrary is the fact if the original chancre be of the indurated variety. It is a matter of great consequence that we should be cor- rect in our diagnosis of the kind of bubo we meet with be- cause important therapeutic indications are founded on the opinion we form of the character of the swelling. Let me illustrate by presenting the following Case. — A short time since, a young man, whom I had formerly attended for constitutional syphilis, called upon me, one morning, in great distress on account of a bubo in the right groin. lie first noticed a slight tenderness and swelling four weeks before he made this morning call. He had already consulted a young medical friend of his in reference to his case, which was pronounced to be syphilitic; and among other things that were done by the advice of this young medical gentleman, a blister, about four inches square, had been applied several times to the groin, in the hope of dispersing the swell- ing. The patient, being connected with an extensive mercan- tile house, and having, on a former occasion, been detained from business for several months, had great reluctance to incur a second suspension from duty, especially for such a reason, and consequently continued, as usual, at his employment, but suffering constant pain, which increased from day to day with 21* 246 GONORRHOEA AND SYPHILIS. the growth of the bubo, this being now exceedingly hard and voluminous. It occupied nearly the whole of the inguinal fossa, and all the lymphatic glands, situated in this region, seemed to be involved in the swelling. The mass was per- fectly immovable, and in all its features, taken in connection with the history of the patient, it appeared to exhibit the character of a scrofulous bubo, as generally understood and described. The patient had a coated tongue, quick pulse, loss of appetite, and loss of strength and flesh; he relied on opium for sleep by night; the bowels were costive and there was intense mental distress, amounting almost to insanity. He was truly an object for pity. He pretended to consider the bubo as the relic of his former venereal trouble. I assured him that this was not the fact, and inquired if he had not been recently exposed to infection anew. He gave a negative reply in a prompt manner, as if to repel the inquiry with indignation ; but the style of his denial betrayed guilt. 1 examined the penis, and it did not take long to discover the cause of the bubo, as I had occasionally met with other similar instances. A vesicular eruption, with a delicate, pinkish color and slight oedema, occupied the entire border of the prepuce. Some of the vesicles had discharged their contents several days pre- viously, and a thin, flat scale had formed upon their summit; other vesicles had been broken more recently, and were with- out any covering. They appeared like minute open cups, barely visible to the naked eye; and yielded a slight limpid secretion. There were other vesicles still younger, that had not ruptured the epiderma. After I had carefully examined the organ, the patient asked what I thought of it. I told him that I strongly suspected that he had lately had intercourse with an impure female; I would, however, hear any explanation he had to offer relative to the diseased condition of the prepuce, which I regarded, in part, as the cause of the bubo. He acknowledged that he had been on intimate terms with a woman whose husband was in California. The eruption in this case was herpes praeputialis. It had existed about two months; some of the time being quite troublesome^ at other times nearly well, according to the hab- its of the patient. Instances of this vesicular affection, pro- duced by non-venereal vaginal discharges, are occasionally BUBO. 247 met with. The herpetic eruption, when developed in highly sensitive subjects, will sometimes give rise to tenderness and pain in the inguinal glands. In the present instance, the pa- tient had been told that he had a chancre on the prepuce, although this was not the fact; and he was at once, and very naturally, apprehensive of a syphilitic bubo. He was on the alert for abnormal sensations and developments in the groin. His fingers were almost every moment thrust into his trowsers and pressing upon the glands, and thus their tenderness was increased. At length his fears, confirmed by the unfortunate diagnosis of his young medical friend in regard to the pre- putial affection, prevailed in the case. There are instances in which it is difficult to distinguish a true chancre in its early vesicular stage, if it appear as a ves- icle, as it sometimes does, from herpes of the prepuce. In such cases, if we wait until ulceration commences, the charac- ter of the disease will become sufficiently distinct. The young physician, who preceded me in charge of the present case, decided at first that the herpetic eruption of the prepuce was a chancre. This was by no means a singular or uncommon mistake, and yet it was a very serious one, and led to an equally great one in the immediate treatment, both local and constitutional. The slight trouble in the inguinal region was also misinterpreted. It was regarded as the result of absorption of the venereal virus. I am happy to say here, that the young physician, to whom I have referred, had an opportunity to study out the case, and ultimately arrived, sua sponte, at the just conclusion that there was no syphilitic element in it. In further explanation of the case, which is an interesting one to dwell upon, I have to remark, that the repeated application of the blister, and the active business habits which were main- tained with such reckless pertinacity, under so many disadvan- tages, soon aggravated the inguinal difficulties of this young man, who possessed a scrofulous diathesis. For several weeks he would listen to no advice as to the importance of keeping quiet, and the consequence was, that he continued to lose ground, until he broke completely down, charging his failure to lack of medical skill. The bubo at length suppurated. The constitutional symptoms were severe, and the patient con- tinued to suffer more and more, until his condition became 248 GONORRHOEA AND SYPHILIS. alarming. When the bubo on the right side had nearly healed, a similar one appeared in the opposite groin, and pursued a like tardy, and chronic course. For nearly ten months a general cachexy seemed to pervade the economy, and extreme ema- ciation and debility ensued; but, fortunately for the poor fel- low, he ultimately recovered sufficiently to return to his home, which was far distant from New England. I have stated that this patient had on a former occasion, suffered severely from constitutional syphilis, and he had not wholly recovered from its ravages. In designating the particular variety of buboes which he had, however, I know not a more appropriate epithet to employ than the one I have chosen, for the inguinal swell- ings, which the patient had, and their entire history, corres- pond in character with the scrofulous bubo, so graphically de- picted by Hunter. The patient had no sore throat, no disease of the skin, bones, or periosteum, during the period embraced in the foregoing account. Nevertheless, if we go back a step farther, and inquire whence this scrofulous diathesis was de- rived, we need not hesitate to admit that the previous consti- tutional syphilis contributed a large share to its production, using the term scrofula in the sense adopted by Hunter. Per- haps in more modern phraseology, sympathetic bubo would sound better. Treatment of Buboes. — To the patient it is a matter of great importance that the bubo should be dissipated as soon as possible, without being allowed to suppurate. But what de- gree of efficacy will be exerted by any remedies we can em- ploy with a view to control the tendency of the diseased action, is uncertain. Vidal says that a bubo which should sup- purate, will suppurate, no matter what we do; and the bubo that should disappear by resolution, will thus disappear in spite of the ordinary suppuratives, except they be too vio- lently used ; and yet, Vidal would not dispense with treatment. In private practice, one of the greatest obstacles to success in our endeavors to annihilate a bubo, is the inability or re- luctance of the patient to observe that repose which is so es- sential. He should be confined to his bed or couch. Here is his surest place of safety. He should take a warm bath morn- ing and evening, and remain immersed during thirty or forty BUBO. 249 minutes, unless he experience a sensation of faintness. The effects of this simple bath, in allaying any constitutional irrita- bility or feverishness, are highly important, and their agency in reducing the glandular engorgement cannot be doubted. They should be followed up faithfully. Of the multiplicity of local measures, for the treatment of adenitis, counter-irritation has acquired great popularity among practitioners. It has for many years been employed over the swelling in every stage of its progress, as a means of removing its contents. The plan proposed by M. Malapert, and which has been extensively followed in the hospitals of Paris, consisted in the application of a blister over the bubo, with a subsequent dressing to the vesicated surface, of a so- lution, on lint, of the bichloride of mercury, in the proportion of twenty grains to the ounce of water. This was kept in contact with the part for two hours, and afterwards poultices were substituted. When the bubo was very large, the solu- tion was repeated. The success attending this harsh proced- ure in removing the swelling, and effecting absorption of the purulent matter, even when suppuration has advanced to a considerable extent, is acknowledged by those who have been accustomed to employ it in all stages of the complaint. The plan, however, is now laid aside by many who formerly prac- tised it. It is most beneficial when pursued in the forma tive stage of bubo, and when the inflammatory action is mod- erate. A strong solution of nitrate of silver has afforded good re- sults. The first systematic trial of this agent was made at Guy's Hospital. Mr. Lee, in his edition of Sir Astley Cooper's Surgery, states that he never saw a bubo suppurate, when the dry nitrate of silver had been applied freely over its surface every second or third day. Mr. Henry Thompson confirms the statement in regard to the efficacy of the nitrate, which he has prescribed in cases of adenitis where fluctuation has been so complete and unmistakable as almost to forbid any attempt to discuss it on the ground of its apparent hopeless- ness. * A blister often proves advantageous as a counter-irritant. * Vide London Lancet, 1855, p. 340. 250 GONORRHOEA AND SYPHILIS. Even where suppuration seems inevitable, the application of a vesicatory will sometimes cause the swelling to subside un- der its operation, and perfect resolution will take place; and the case need not be wholly despaired of until the blistering has been tried and found unavailing. If the integuments, cov- ering the tumefaction, have become attenuated and of a deep purplish hue, thus showing that they are more or less disor- ganized, and are passing into a gangrenous state, then the blis- ter will be of no service. Such a morbid condition will require that the contents of the abscess be liberated at once, and its walls saved, if possible, from further destruction by the em- ployment of concentrated nitric acid or a saturated solution of the potassio-tartrate. of iron. There is one other method of treating buboes locally, and which I have employed more frequently than any other, in cases where I have attempted their early destruction. The moment there is a manifest enlargement of the inguinal glands as a consequence of chancre, I direct a blister about two inches square to be applied over the tumor. As soon as ves- ication takes place, the cuticle is removed and the denuded surface dressed with the following ointment: — R. Unguenti Hydrargyri,..................................§ i. Pulveris Ammonias Muriatis,...........................3 ss- M. The ointment produces some smarting and pain, which, however, the patient can tolerate very well, if he keeps quietly in his room. In about thirty-six hours, a pretty deep sore will be formed. This may be dressed with rose ointment for a couple of days, the mercurial ointment being laid aside. When it has partially healed, the first named ointment is to be re-applied ; and this alternation in the dressings should be ob- served until the total obliteration of the swelling has been ac- complished, or until something transpires in the progress of the case to contra-indicate such a course. This plan of local treatment I consider as good as any, and I have tried all the recognized methods. I have pursued this with success in many instances; but in still more, have derived from it no benefit whatever; and this, I fancy, is about the truth in re- gard to nearly all topical appliances. Collodion has been applied to buboes when there is not BUBO. 251 much local inflammation. It is recommended to be brushed over them in successive layers, until quite forcible compres- sion is produced. Other methods of exciting pressure are de- scribed and practised. In Acton's valuable work, are two wood cuts; one showing a truss for compressing buboes ; the other an inguinal bandage, designed for the same purpose. The idea of compression, we are told, had its origin in the ac- credited circumstance or fact, that bubo seldom forms on the side on which a truss is worn. If it be true that a truss will prevent a swelling of the inguinal glands, it does not follow that this apparatus, or that a bandage, in the style advised by Acton, will cure a bubo that has already formed. The great objection, however, to the employment of pressure, arises from the fact that the proceeding is a most hazardous one. Mr. Johnson in his admirable treatise on gonorrhoea and its consequences, assures us that he has met with many cases, in which he has observed bad effects from it. He relates two in detail, and which are characteristic of the dangers attending it. One of the patients was a young man, the other a young wo- man. Both died after protracted and dreadful suffering, caused by the application of bandages and compresses. In both cases, the process of inflammation and suppuration, instead of pro- gressing and terminating in the usual manner in the inguinal glands, was intercepted, and pursued divers other routes, es- tablishing seats of suppuration and sinuses, involving the iliac fossa, bladder, intestines, etc. The indolent or chronic bubo may generally be successfully treated with small blisters, and the internal administration of the iodide of potassium to the amount of half a drachm in the day. If absorption does not take place after a fair trial of these measures, the ammoniated mercurial ointment should be employed in the way just mentioned. Sometimes this variety of glandular engorgement will remain stationary for a long period, and then, provoked by some new source of irritation, suddenly inflame again, and proceed to suppuration in spite of all measures to the contrary. If there be much febrile action, with pain and tenderness in the bubo, whether virulent or otherwise, — and if the patient be of a plethoric habit, some surgeons auvise that blood be taken from the arm with the lancet, or from the immediate 252 GONORRHOEA AND SYPHILIS. vicinity of the bubo by leeches. In nearly all cases, however, it is an easy matter to carry the process of reduction to the requisite point, without loss of blood. Let the patient be subjected to a gruel-diet and the like, for two or three days, and at the same time take occasional doses of a weak solution of tartar emetic, and his system will be brought to as low a mark as it is safe or necessary to conduct it. The symptoms of pain, tenderness, etc., which we are now considering, are not occasioned by the presence of too much blood in the sys- tem, but because, so far as the blood has any agency, its equi- librium is disturbed, although only in the slightest possible degree. There is, to be sure, a remora in the capillaries of the enlarged gland. If a few ounces be drawn from the gen- eral circulating current, the proportional quantity abstracted from the diseased gland by this process, would be but a drop or two at most, and the loss would again be supplied to the parts at once, and thus the engorgement would be kept up unless prevented by other means. If a bubo should become softened and give evidence that suppuration has occurred, all attempts to bring about a reso- lution, will, as already remarked, be very liable to fail. I have many times endeavored to disperse the tumor after fluctuation has become evident; but in a majority of cases the suppura- tive process has continued to progress slowly, and I have been defeated in the effort to bring about absorption, and have re- gretted that an early opening had not been made. For the purpose of giving free exit to the matter, the lancet affords the best method. It is more simple and more control- able than the Vienna paste or the potassa fusa, and the sur- geon can instantly release the contents of the abscess by an incision, which will not give a tithe of the pain caused by these escharotics, and will not leave so distinguishable a mark for future observation, as would be likely to be made by either of these substances. The walls of the abscess should be thoroughly cleansed with warm water, or with a very weak solution of chloride of soda, — that is, one drachm to two ounces of warm water. For subsequent dressing, the satu- rated solution of opium should be ordered for the first day or two after the opening of the bubo. So long as the suppurating surface presents a healthy character, and shows a disposition BUBO. 253 to heal, although at a slow rate, the surgeon may look forward to a happy termination of existing troubles, and the case need not be regarded with particular solicitude with reference to this or that local specific. The sore should be kept in a cleanly condition. For this purpose, as well as with a view to promote its advancement towards a cure, the chlorinated water will be advisable dur- ing the day, and at night, the nitric oxide of mercury oint- ment somewhat diluted. For a simple bubo, ordinary dress- ings, only, will be required. But when the bubo assumes an unusual character, — as for instance, when its edges show a disposition to ulcerate, — when it extends from day to day, or when it remains stationary, Ricord and Acton are in favor of the topical use of powdered cantharides. They recommend that the abscess should be filled with the powder, which should remain in contact with the diseased surface for an hour or two. If induration exist at the edges of the bubo, they advise the mercurial ointment to this por- tion, while its interior should be washed with some astringent lotion. I have never brought these suggestions to the test. To me they seem to involve a procedure more complicated than will be found convenient in general practice. There are many applications, which will work a favorable transformation in the aspect of an unhealthy, indolent and in- tractable ulcerating bubo. My predilection is for the ferru- ginous solution, which occupies so prominent a position in these pages. The strength should vary according to the amount of stimulus, which the ulcer may need from day to day. At first, a drachm of the salt to eight ounces of water, will generally form a suitable preparation for continuous use. As soon as a clean, granular surface appears, which usually takes place very shortly, the lotion must be diluted so as to contain s drachm of the iron to twelve ounces of the water. Sloughing Bubo. — In this form of bubo the constitutional treatment should consist of generous diet, the liberal use of wine, chalybeates, ammonia-julep; and at night, opiates in sufficient quantity to procure sleep and thus remove the irri- tability of the system, which is apt to be a most annoying symptom. Mr. Key {Guy's Hospital Beports) recommends 254 GONORRHOEA AND SYPHILIS. the iodide of potassium; so also does Mr. Acton, particularly in serpiginous chancres and ulcerations. But the latter sur- geon holds the potassio-tartrate of iron in higher estimation than any other remedy, as may be inferred from the follow- ing closing sentence from his section on the treatment of phagedaenic chancre. " I must again repeat that too great stress cannot be laid on the admirable results which follow the use of iron in phagedaena." In brief, it may be remarked that the same treatment which has been proposed for phage- daenic or sloughing chancre, is in all respects, both locally and constitutionally, appropriate for the cure of the phage- daenic or sloughing bubo. To the injudicious administration of mercury and the meagre dietetic fare to which patients were subjected, is to be attrib- uted the frequency of phagedaenic or sloughing bubo in former times. Happily, it is a variety of ulceration extremely rare at the present day. 22 CHAPTER XXIV. SECONDARY SYPHILIS. PERIOD OF LATENCY—LONGEST TIME BETWEEN PRIMARY AND SECONDARY LESIONS — SHORTEST TIME — DIFFICULTY AND IMPORTANCE OF CORRECT DIAGNOSIS. However scientific and successful the remedial course may have been for the cure of indurated chancre, which is the com- mon origin of all secondary and tertiary symptoms of a venereal character, it often happens that the virus of this chancre steals the march upon the medical attendant, and at an early moment finds its way either by lymphatic or venous absorption, into the blood. Here it dwells in a state of incubation for an in- definite period before its presence is decidedly pronounced. It may remain a long time, and not make known its existence by any palpable manifestations, while the individual retains his accustomed health; but if he becomes debilitated, the syph- ilitic element will very likely declare itself in some well- marked local affection. The period of its latency is wholly uncertain and indefinite. It has been known to appear in a few weeks in what is called the syphilitic inflammation, or fever, the most prominent features of which are seen in the throat in inflammation and hypertrophy of the tonsils and the adjacent mucous membrane, neuralgic pains in the head, or pains in the larger joints by night, or more frequently perhaps, in blotches and roseolous congestion of the cutaneous tissue of the face the neck, abdomen, arms, etc. On the contrary, the poison may sleep, as it were, in the system, for months and years, until some exciting ageut shall intervene, and bring it from its hiding place to the light of day. At whatever period the secondary constitutional develop- ment occurs, some accessory agent seems to be required to bring it forward in a tangible, appreciable form. The most frequent accidental cause, is, exposure to an inclement atmos- phere. If the patient should work in the open air, or take a 255 256 GONORRHOEA AND SYPHILIS. ride in a cold, stormy day, or remain in a damp cellar, or encounter any trying vicissitudes of weather for a short time only, the hidden enemy which he may have carried about him in embryo for years, will be provoked to make known its pre- sence, when and where it was little expected. The average period between the existence of primary chancre and the accession of any secondary cutaneous affec- tion, is variously estimated. Dr. Egan reckons it at five or six weeks. From the cases that have come under my own observation, I should say that generally, a much longer inter- val than this, passed between the chancre and the outbreak of any consecutive, cutaneous accident. M. Legendre, formerly a pupil at the St. Louis Hospital, and author of a thesis on syphilitic eruptions, says: " I have obtained, as a general me- dium, from the time of the appearance of the primary to that of the secondary accidents (syphilida) five years, precisely the same result as that mentioned by M. Martins in his Memoir." There are so many differences in the constitutions of patients, such diversities of treatment for the cure of the original acci- dent, so many varying circumstances, in which the individuals implicated are placed, such dissimilarities in their personal habits and occupations, such gradations, fluctuations, and ex- tremes of climate, and such changes in the seasons of the same latitude or region, that it is impossible to determine what is the natural term of latency, which the modified syphilitic virus would observe. The primitive, unadulterated, venereal poi- son, that which generates the chancre, obeys a nearly uniform law of incubation; but the diluted element, that which has been incorporated into the blood, appears to be subject to many contingencies, that have a direct control over it in pro- ducing its visible effects upon the constitution. Sex has something to do with the interval between the pri- mary lesion and the consecutive manifestations. The latter developments appear at an earlier day in women than in men. Victor de Meric, Esq., reports the cases of nine individuals. males, who presented eruptions, and had not undergone any treatment. In three cases of papules, the eruption in one ap- peared in seven weeks after the primary symptom; in the other, the interval had been six weeks; and in the last, eight weeks. Two cases of roseola or efflorescence appeared, one twenty- SECONDARY SYPHILIS. 257 four days after the occurrence of chancre; and the other, one month. Psoriasis appeared in two subjects at the distance of four and eight weeks. Regardless of the kind of eruption, the author here cited reckons a mean of six weeks' time, which separates the primary sore from the cutaneous affection, where no treatment whatever has been resorted to. * The longest interval of time between the primary disease and the secon- dary cutaneous affection, has been, in my own practice, twenty years. The case was an interesting one, and I will here trans- cribe it chiefly from my note book. November 26, 1853. — Dr. H. I. Bowditch of this city, called with a patient of his, and desired my opinion respecting the nature of the disease. Upon examination, the limbs, trunk of the body, neck and face, were found covered with tubercles, — most numerous and much the largest, on the forehead. Here, they were in juxta-position, and were about two lines broad at the base, and were of a dirty, reddish brown color. The nose, back of the neck and shoulders, afforded the next largest crop. On the body and extremities they were sparsely disseminated, and were smaller than on the other districts. Upon the legs and arms, the eruption approached the ordinary lichenoid pimple, and was strictly papular. The man com- plained of no suffering or inconvenience of any kind as arising from the eruption, except a slight itching or tingling sensa- tion when he rubbed his forehead, or pressed his back against a chair while sitting. Sometimes the sensation thus awak- ened, was like the prick of a pin or the sting of a musquito; so said the patient. Upon the summit of the papules on the forehead, a thin scale formed and was cast off every five or six days, as in ordinary, non-specific psoriasis guttata. Upon looking into the throat, the mucous lining of the poste- rior part, and downward as far as the eye could reach along the walls of the pharyux, was found hypertrophied from chronic inflammation. The mucous membrane of the whole buccal cavity was oedematous, and presented a mixture of white and red points, the papillae being swollen, and the epithelium dis- placed from a portion of them, and rolled up into white granules. A few days before I saw the case, the right tonsil had * Lancet, November, 1858, 258 GONORRHOEA AND SYPHILIS. been removed by the late Dr. Samuel Parkman. Previous to the operation, there had been much difficulty in deglutition and respiration. The disease in the throat had existed about one year; the cutaneous eruption came four months later. The patient was a tall, gaunt, slenderly built man, fifty years of age, and was extremely pallid. He complained of debility, had a poor appetite ; a feeble, quick pulse ;. pains in the large joints, and in the head ; his nights were restless; he stated that his health had been declining for more than a year ; he had been accustomed to an active life, but was then unable to attend to business. He also stated that twenty years ago he con- tracted a chancre, was treated without mercury, recovered in a few weeks, and was never subsequently exposed to infection. Dr. Bowditch had told this man that his disease was constitu- tional syphilis. He ridiculed the diagnosis, as he had been in good health for so many years before the present symptoms were developed. I confirmed Dr. B.'s opinion. The patient gave up his disbelief, and was thrown into no little mental agony. He had not a particle of delicacy in regard to his con- dition or the cause of it, and consequently had not the motive of shame or mortification to induce him to falsify as to the time when he received the virus. At the request of Dr. B., I took charge of him, but he shortly went among quacks, and died of syphilitic consumption. To the foregoing instance, I desire to append one other, which is not without instruction, although the time between the primary chancre and the con- secutive lesions on the skin, was only eleven years. June, 1856.—Patient A. B., age 36 years ; — married. Re- markably stout built, florid complexion, full face, speaks of un- common muscular strength; weight 190 pounds ; is of medium height. In 1844, he was inoculated in the natural way with chancre on the underside of the glans penis, near the fraenum; was successfully treated by an experienced surgeon, and in a few weeks was well. He has led an active life nearly ever since as an engineer on the Western rivers, and has enjoyed uninter- rupted health until 1852, seven years, when a moderately sore throat troubled him for a few weeks in the autumn; and on sev- eral occasions since, he has had an uncomfortable bronchitis, in cold, stormy weather About a year ago, a crop of tubercles, occupying a portion of integument as large as a penny, came SECONDARY SYPHILIS. 259 on the right temple. Their habits were as follows : Some of them softened and ulcerated more or less perfectly, while others gradually wasted away, retaining their tubercular character to the last. About the time they disappeared, whether ulcerated or not, a new crop, usually numbering from four to six, was sure to spring up near the borders of the cicatrices left by their predecessors. This individual was under my care, at in- tervals, for more than eighteen months before the morbid con- dition of the skin was entirely subdued. The disease was a perfectly well marked syphiloderma, and for a long time was confined to the right temple. It finally crept along just above the superciliary ridge, until it ended at the median line by a solitary tubercle, located about half an inch above the junc- tion of the eyebrows. Strange to say, this lone specimen, which never attained the size of a split pea, maintained its ground more than six months. The general health, in the above case, was not disturbed in the slightest degree. The patient has a daughter five years old, remarkably rugged, and in constitution and features, copy- ing after the father more than the mother. Thirty years have been known to elapse between the cure of chancre and the approach of cutaneous disease as the first consecutive symptom; and, so far as we have any record, the shortest time that has been known to intervene between ex- posure and the secondary affection on the skin, is three weeks. At whatever period the eruption begins to show itself, it is very common to find inflammation of the mucous membrane of the fauces coeval with it, and extending low down into the throat. The patient frequently mentions that he has bron- chitis; and the peculiar sound of his voice announces at once that the organs of speech are in an unsound state. The vas- cular plexus both of the mucous and cutaneous membranes, shows an increased afflux of blood, and a moderate febrile action prevails ;—but these conditions are rarely suspected by the individual as having any connection with his former venereal trouble. His complexion presents an unnatural, pale, dirty, or brownish yellow tinge; — there is gradual enlargement of the cervical glands; the skin is wrinkled, dry and harsh to the touch; — he complains of loss of muscular energy, loss of ap- petite, loss of flesh; — has pains in the cerebellum, back of 260 GONORRHOEA AND SYPHILIS. the neck and in the larger joints, especially by night; — is nervous, languid, depressed in spirits, and rarely obtains sound and refreshing sleep. All these symptoms, it is true, may originate in other causes, — and taken separately, might not suggest that they had any relation to syphilis; but taken in the aggregate and as they frequently present themselves in a young man, they are significant of this malady; — and there is a meaning and an importance to be attached to them, not to be overlooked by the medical practitioner. I have sometimes been amused and astonished at the eloquent expression of t patient's demeanor, which serves as a sort of tableau or mir- ror, declaring, in unmistakable language, the nature of his malady, before a word has been uttered by him, and before I have commenced an examination in quest of physical signs or marks upon him. I claim no superior tact in this matter. What knowledge I have gained is the result of observation; and I share it in common with many others in the profession situated as I have been. The physician, however, must not allow his judgment, on any occasion, to be biased by fancy sketches. He is to deal with realities; and when these are properly interpreted by him, and he communicates his views in regard to them, to the patient, he will very likely find the latter filled with surprise, and perhaps with incredulity. He has had no warning or anticipation of such a state of things; — has been told, perhaps, that he was thoroughly cured and safe from all future trouble of a Venereal character. This was the fact in regard to the two last cases I have related. It is incumbent on the physician, therefore, to be clear and accurate in the matter of diagnosis, not only lest he should compromise his own reputation, but because the welfare of the other party is directly and deeply involved. A chancre or bubo is usually recognized without any great difficulty, what- ever may be the variety of either, unless their real character has been greatly modified or wholly lost, in consequence of some indiscreet medical interference. But far different is the case, when the keenest eye and the shrewdest intellect are brought in contact with the dubious pathology of the various consecutive maladies, that affect the cutaneous and mucous tissues, and other portions of the corporeal system, and which may, or may not, be the offspring of the syphilitic virus. Oc- SECONDARY SYPHILIS. 261 casions and circumstances will present themselves, calculated to bewilder, to astonish, and to unsettle the judgment of the physician, however rich he may be in practical experience or logical discipline. I once saw a case of chronic eczema, which had been under the care of two highly respectable physicians residing in different towns, and had been pronounced to be, and treated by both of them as, secondary syphilis. The mis- take led to very serious difficulty. The patient was a married woman of high standing in her neighborhood. The husband denied the authorship of such a disease. The wife and her immediate friends, guided and sustained by the erroneous diagnosis above mentioned, believed him guilty ; and they decided that she should return to her parental home, never again to live with her husband. The day of separation was fixed; but before the measure should be consummated, it was arranged that I should examine the patient. This I did, and had no difficulty in satisfying all the parties that there was no syphilis in the case. A change at once came over the domes- tic scene. Instead of lamentation and bitter wailing, the voice of reconciliation and peace was heard, and the contem- plated separation did not take place. The above historiette is not the only one of the kind that I could relate. Its direct bearing in illustrating the importance of accuracy in the mat- ter of diagnosis, will be sufficiently obvious, and for this pur- pose it has been introduced. Of all the morbid developments, consequent upon primary chancre, none are more frequent or interesting, none more worthy of careful study, none more difficult to treat, than the numerous group, comprehended under the nomenclature of syphilodermata, which I propose to consider in the ensuing chapter. CHAPTER XXV. SYPHILODERMATA. ACTION OF VENEREAL POISON SLOW—IS IN THE BLOOD — DIAGNOSIS OF SYPH-" ILITIC ERUPTIONS. The plastic hand of " nature in disease " scarcely acknowl- edges any limit to the variety of forms which she is able to produce from a few pathological types. Especially is this true, when the human skin is selected as the chart, upon which her mysterious operations are delineated. I know that in the mind of the general practitioner great confusion, obscurity and doubt, sometimes overhang these morbid phenomena, like a thick cloud. I know also to some extent, that by patient study and critical observation, the cloud can be removed, and the darkness give place to light. In speaking thus, I say no more than the student, engaged in the pursuit of any of the natural sciences, is able to say in reference to the department of study that may occupy his attention. In syphilitic Dermatology the elementary forms of disease are few, but their modifications are many. At whatever period these eruptions may present themselves, their manifestation is to be interpreted as an effort on the part of the eliminative powers of the system to get rid of a poi- sonous element, which interferes with its well being. The disease is in the blood. Here it commences its life, as a mi- nute inappreciable atom, received into the vital current by im- bibition ; and from that moment to the time when the cutane- ous derangement is about to declare itself, it continues to cir- culate and mingle with the various fluids, and to pervade the different organs and tissues of the body. The furtive and silent process of contamination seems to be endowed with a strange vitality, strange, not by reason of its energy or activ- ity, but by exactly their opposite. Its operation is exceedingly slow and gentle. It is feeble to an infinitesimal degree, when 262 SYPHILODERMATA. 263 contemplated in contrast with the activity of the poison of hydrophobia, the virus of serpents, of small pox, of glanders, of dissection wounds, or of paludal miasmata. Although the ulterior effects resulting from the persistent action of the venereal poison may be delayed, the blood at last becomes so profoundly deteriorated, that the organism can no longer endure the presence and the encroachments of the morbific principle, — and as is the case with all other poi- sons, so with this, nature institutes a process with a view to expel it; and although the external investment of the animal economy is usually summoned to inaugurate the great strug- gle of elimination, other organs and structures are required to share in the labor, and participate in the disasters, which the enemy is sure to inflict. The accumulated poison makes known its presence by a development, first in one tissue, then in another, by successive steps, and at long intervals; — each tissue and each development presenting a group of symptoms peculiar to itself. Hence we can see the propriety and ad- vantage of classifying the morbid phenomena of the disease into primary, secondary, and tertiary stages or accidents; — an arrangement originally devised by Thierry de Hery, — and recently revived and rendered popular by Ricord. In the adult subject, nearly all the syphilitic eruptions belong to the second stage, — a few only are reckoned as tertiary mani- festations. They all proceed from the same original, primitive poison. The syphilodermata of the infant, who derives the disease by inheritance, are the product of a secondary virus, which has been modified, diluted, and weakened in conse- quence of its admixture with the blood and other fluids of the infected parent, before it is transmitted to the offspring. Under the influence of the constitutional taint, we have eruptions, that are named and known according to the ele- mentary forms which they present; but all these forms exist also, independently of any syphilitic parentage. Ricord does not include the bulloz among his divisions of the syphilides. He considers ulcerous affections as possessing peculiar marks, that are almost invariably absolute and distinct from other ulcers. Gibert regards the ephelides as entitled to a place among the syphilodermata; but the syphilitic origin of such discolorations is extremely problematical. 264 GONORRHOEA AND SYPHILIS. To all who are familiar with the venereal eruptions, it is well known that time brings about important modifications in the physiognomy and general characters of these eruptions; — and with a view to render them more easy of comprehen- sion, Professor Wilson, in the last edition of his work on dis- eases of the skin, has classified them in a tabular form, accord- ing to their chronological development. Thus, the eruptions belonging to secondary syphilis are : — 1. Syphiloderma Erythematosum. Roseola syphilitica, Maculae syphilitica?. 2. Syphiloderma Papulosum. Lichen syphiliticus, Lichen pustulosus. 3. Syphiloderma Tuberculosum. Tubercula syphilitica, Tubercula ulcerantia. 4. Syphiloderma Pustulosum. Rupia syphilitica. 5. Syphiloderma Pilare. Alopecia syphilitica. 6. Syphiloderma Ungueale. Onychia syphilitica. The eruptions belonging to the Tertiary Syphilitic period are as follows: — 1. Syphiloderma Erythematosum. Erythema (vel psoriasis) palmare vel plantare, Lupus erythematosus. 2. Syphiloderma Tuberculosum. Tubercula mucosa, Tubercula ulcerantia, superficialia, Tubercula ulcerantia, profunda, Lupus ulcerosus, syphiliticus, Tubercula gummata. 3. Syphiloderma Ulcerans. The Syphilodermata Haereditaria are arranged thus, which is the order of their development, in the offspring of syph- ilitic parents. 1. Syphiloderma Erythematosum. Erythema syphiliticum infantile. 2. Syphiloderma Tuberculosum. Lupus syphiliticus. 3. Lepra. SYPHILODERMATA. 265 The foregoing is a list of the maladies which appear upon that vast and important organ, the skin, in consequence of the venereal affections. At a superficial glance, the number may seem large, even formidable and embarrassing; but it is no mere, ideal enumeration. It is based upon facts as they pre- sent themselves with great uniformity in the history of vene- real subjects. And I am confident that the more frequently and attentively the arrangement is referred to in the study of the syphilodermata, as they come within the observation of the practitioner, the higher will be the estimation, with which he will regard it. There is no nomenclature more classical or scientific in principle, or more in harmony with the cutaneous lesions, produced by syphilis, than the above. The Willanean system is more simple than the foregoing, and if we are guided by it, and consider the specific syphilo- dermata according to their elementary forms, we shall have the following varieties, which are not at all at variance with Wilson's plan: — Exanthematous Affections, Macular Affections, Papular Affections, Squamous Affections, Bullous Affections, Vesicular Affections, Pustular Affections, Tubercular Affections. DIAGNOSIS OF SYPHILITIC ERUPTIONS. Color. —The color of venereal eruptions, in most cases, is sui generis. I say, in most cases ; in some instances of gen- uine syphilis, this mark or sign is totally wanting. The red- dish, coppery tint is by no means a constant feature, and when we examine an eruption with reference to its color, allowance is to be made for the natural complexion of the patient, and sometimes for the influence due to the topical remedies that have been employed. The period, or duration of the erup- tion, is also to be considered. We are to take into the ac- count the particular region which is the seat of the complaint. The age of the individual and his exposure to atmospheric or 23 266 GONORRHOEA and SYPHILIS. solar influences, will likewise be entitled to consideration. If a person, with a roseolous or papular syphilitic affection, be exposed to the action of cold, the red, vermilion tinge will be more conspicuous than under other circumstances. The temperament and the general condition of the system, exert an influence upon the color of the skin, both in health and dis- ease, and should not be lost sight of when we examine a pa- tient laboring under a suspicious cutaneous affection. Some- times the catamenial function has an agency in modifying the character of an eruption ; so has pregnancy, more especially if the malady be located upon the face. In the latter case, the color of the skin will be no guide at all in our attempts to ar- rive at a differential diagnosis. The color of syphilitic erup- tions is not uniform. Sometimes it has a violet tint, or it may present a coppery appearance, varying in the degree of inten- sity in the same individual, as the disease progresses towards a cure or otherwise. At the commencement of an eruption, especially if it be seated in a fine, white, delicate skin, the tint may be quite a brilliant red, and as the eruption acquires age, and is influ- enced by treatment, it may, and probably will, assume a dark shade, that is, a reddish, or yellowish brown. If the diseased skin be closely examined when the complaint is in its last stage, or when it is in fact, passing away, the brown copper color, which has for so many years engaged the attention of observers, and which is still regarded by many practitioners as characteristic of syphilis, is usually apparent in a satisfac- tory degree. But if the disorder be in an active state, or in the incipient stage, with much roseolar blush upon the gen- eral integument, it will often prove a vain task to hunt for the pathognomonic copper color of the older writers. In some instances, indeed in many, well known from other circum- stances, to be of syphilitic origin, I have searched for the ex- istence of this special tint upon the integument, and have not been able to detect the slightest trace of it. Once, it was re- garded as absolutely essential to meet with the copper stain, or to suspend any declaration of our diagnosis, if that diagno- sis involved the idea that the affection was venereal. But that day, with me at least, has gone by, and I can say, animium ne crede colori." SYPHILODERMATA. 267 A reddish brown, with a slight ingredient of yellow or orange, is the best representative of the dull, copper color, and may be considered as a fair exponent of the hue which frequently characterizes the syphilodermata. It is not, how- ever, an easy matter to present a true description or analysis of the various predominating shades and varieties of color that are met with in venereal maladies of the skin. To the practiced eye, these affections, having any of the peculiar col- orations alluded to, are recognized with sufficient ease, be- cause these shades or tints rarely ever accompany any corres- ponding diseases, which arise from non-specific causes. In cases where syphilodermata ulcerantia have existed, the marks remaining upon the integument may perplex the mind of the surgeon not a little. The ulcers of rupia, and the ordinary ulcerations of syphilis, when they heal, leave behind them permanent and ill-looking cicatrices, presenting more or less of a purplish, dirty hue, or a brownish aspect upon the parts where the sores had been seated. This condition of the surface is generally considered indicative of syphilis. It is a concomitant of ulcerative venereal affections very frequently met with; but this brown appearance is also present in non- syphilitic complaints, where the person is greatly debilitated-, and Wilson considers it to be an indication of cachexia, rather than of syphilis ; and the frequency of cachexia with syphilis, explains the occurrence of the coloration. The copper color, when present, affords strong circumstantial evidence of a ven- ereal taint in the system. I have heard eminent practitioners, both surgical and medical, decide that such and such a cutaneous affection could not be venereal, because the copper color was not to be found in con- nection with it. And knowing, as I do, that too much stress is still laid upon the circumstance of color by some respectable men in the profession, whose calls are far from being restricted to the private chamber or to the consulting room, I do not re- gard what I here offer upon the subject as a labor of superero- gation. But there is another diagnostic sign, more important, more constant, and more undoubted than color, and more reliable in every form of venereal eruptions. I allude to 268 GONORRHOEA AND SYPHILIS. ANESTHESIA, OR DEFICIENT SENSIBILITY OF THE SKIN. It is well known to most practitioners, that the ordinary, non-specific, cutaneous maladies, of every type, and through- out all their various stages, are accompanied by itching, smart- ing, tingling, and other painful sensations in a greater or less degree. When a patient has any cutaneous trouble upon him, that is not venereal, he will, first of all, complain of the itching and burning pain which he experiences, especially by night. There is always an exaltation of nervous susceptibility in the part after the fatigues of the day, and it displays itself in the disagreeable sensations just enumerated. So uniform is this fact, as an accompaniment of ordinary eruptions, that its an- nouncement may be expected as a matter of course. But in the syphilides, there is entire absence of all these sensations. The individual seems to have lost, as it were, all cutaneous sensibility. Large districts of integument will be involved in a papular, tubercular, or squamous form of disease, which may ultimately pass into broad ulcerations, and these latter take on an unfavorable phagedaenic or rodent action, all which would be attended with severe suffering in ordinary cases, and yet it is truly astonishing to witness the slight inconven- ience, which the syphilitic patient realizes under these circum- stances. He never so much as complains of itching at any period. If ulcerations are seated over, or involve the muscles of locomotion, he will complain of course of inability to move about without suffering pain, but otherwise he would scarcely be conscious of their existence, at least, so far as any discom- fort is concerned. It is difficult to explain satisfactorily this almost total absence of sensibility in the skin. All we can say is, that it would seem that the virus, under the influence of which the syphilodermata are developed, has the power of diminishing the normal function of the nerve-filaments or loops, while at the same time it affects the nutrition and health of the parts implicated, in the most serious and detrimental man- ner, even to their ultimate destruction. I will not in this connection, dwell longer upon the insensi- bility of the skin, when any of the forms assumed by the ven- ereal eruptions are present. To my mind, the fact is of more importance than has usually been attached to it in guiding to a correct diagnosis ; it is certainly of more value than the cop- SYPHILODERMATA. 269 per color, which we have sometimes known to be in the mind's eye, and nowhere else. In regard to the itching, or the ab- sence of that condition of the skin, the testimony of the indi- vidual is always at our command. If he has a complaint of any considerable amount upon any part of the surface, and re- ports that it is attended with no irritation, we have very strong presumptive evidence in favor of its being a venereal disease. In our examination of a doubtful case, we can always dwell upon this feature in questioning the person, until we are fully satisfied that he has stated the fact as it is, and he can never know the drift of our interrogations on this point unless we inform him. Apart from the copper color, and the absence of cutaneous sensibility, there are other features and resemblances, which distinguish and associate the maladies under consideration, into a separate class. The solitary patches are uniformly of a round figure; and when aggregated, are arranged in circles or segments of circles. Particular regions also appear to be more frequently the seat of the disease than others, as the face, alae nasi, forehead, and the back of the neck, especially the upper portion, just below the hair and near the mesial line. This is the case with nearly all the syphilodermata, commencing with the papular. When the morbid affection proceeds to excoriations or open sores, the incrustations which are formed, are thick, and of a dark brown or dark green color. A venereal affection of the external surface will sometimes pass through all the types or orders before it reaches its state of maturity; that is, it will commence as a mere roseolous blush, then become vesicular or papular, tubercular, pustular, etc. Cicatrices. — The cicatrices remaining after the ulcerations or sores have healed, are circular in form, decidedly depressed, and in a majority of instances a bronzed color is perceptible for several months after the lesions have disappeared. At a later period, the integument, on which the local disease has existed, becomes preternaturally white. If broad patches of skin have been involved, the mark that is left, exhibits an aspect not unlike that occasioned by a superficial burn. 23* CHAPTER XXVI. SECONDARY symptoms without primary. Before proceeding to the consideration of the syphilo- dermata, as they appear under different types, I propose to relate a few cases, which happened in my practice, and which were somewhat perplexing to me at the time of their occur- rence, inasmuch as their origin or mode of reception, was not conformable to the theory inculcated by Ricord. Such instances arise occasionally in the practice of other medical men. Indeed they are numerous; and the fact is calculated to shake one's faith in certain views promulgated by that prince of syphilographers just named. Case I. — Mrs. A. twenty-four years of age, was married eight months before I saw her. About three months after marriage, a small, dry, papular eruption broke out on various portions of the skin, but was most abundant upon the fore- head, face, shoulders, and arms, and upon the palms of the hands. The papules were seated on a dusky-red ground, and were of a pure lichenoid character. They gradually increased in size, as is generally the case, until they became about half as large as a common garden pea at the base. They were dis- crete ; and in a few weeks acquired the well-defined, ana- tomical characteristics of tubercles in size, prominence, and hardness, and occasioned no itching or burning sensation; in fact no inconvenience of any kind. Upon the tongue were some ten or a dozen well-marked mucous tubercles, which came at a later period than the cutaneous lesion, and were mostly situated among the circumvallate papillae. A preter- natural redness, amounting to decided erythema, with moderate hypertrophy of the mucous membrane of the fauces and phar- ynx, was distinctly seen. The tonsils were swollen; there was some pain in the throat when she swallowed, or inhaled a breath of cold air; otherwise she made no complaint. The 270 SECONDARY SYMPTOMS WITHOUT PRIMARY. 271 husband was of a roving character, and it was known that he had the venereal complaint about the time of marrying this woman, who had never before been afflicted with any skin dis- ease, nor had she any trouble in the genital organs either ante- cedent to the symptoms here described or synchronous with them. The family physician, Dr. W. E. Coale, had questioned her on all these points. He was well acquainted with the history of both husband and wife, and his diagnosis was, that the latter was suffering from secondary syphilis. I saw the case with him several times, and fully concurred with him in his views. That this woman ever had primary symptoms in the organs of generation there was not a particle of evidence. Case II. — A few years ago, a young, unmarried man, a morocco dresser, consulted me for an eruption, which made its appearance about a twelve month before I saw him. He frankly admitted that he had been on intimate terms with sundry girls of the town, but had never, to his knowledge, had chancre or other trouble on the penis or in the groin, nor had he ever had any suspicious urethral discharge or soreness. The case had been under the care of Dr. Winslow Lewis, who considered it syphilitic, and referred it to me as such. When I first saw this young man, the complaint consisted of tubercles and sores, situated principally on the legs, where they were numerous, and in all particulars, well marked with the usual syphilitic features, which need not here be rehearsed. The forearms were the seat of numerous superficial ulcera- tions, resulting from the softening of former tubercles. There were a few similar spots on the thighs. The face and trunk were nearly free from disease. Several cicatrices, scattered here and there upon the limbs, had the characteristic brown stain, and were depressed below the adjacent skin, as is the case generally where syphilitic tubercles ulcerate and heal. The patient had been troubled, more or less, with sore throat, which came on at the time when the cutaneous difficulty was first noticed. He was under my care sixteen months before he was able fully to resume his employment. I never enter- tained any doubt in regard to the specific character of the cutaneous and other symptoms in this instance, nor in relation 272 GONORRHOEA AND SYPHILIS. to the statements of the patient as to the non-existence of any primary lesion. Case III. — About a year after the occurrence of the pre- ceding case, a frail young girl consulted me with reference to an extensive crop of pustules and ulcers, which had troubled her for more than two years, and which had gone on increas- ing very gradually in severity and in their terrible work of undermining the general health, until she was reduced to a truly miserable condition. She was greatly emaciated and enfeebled, and was scarcely able to walk without assistance. On the day she called, she had traveled by railroad fifty miles with the expectation of being received into the Massachusetts General Hospital, but in accordance with the standing regula- tions of that institution in such cases, was refused admittance. On entering my office, she was so exhausted that she immedi- ately lay down upon a sofa. She had taken no nourishment for fifteen hours. She was accompanied by a young man, her friend, who lost no time in making explanations. The skin of this patient, where free from the eruption, and its indelible imprints, had a leaden hue, with a blending of sal- lowness, thus showing a malformation and extreme poverty of blood, which frequently, and especially in delicate females, is seen to supervene after a long-continued action upon it of the venereal virus. So far as the invasion upon the ex- ternal surface was concerned, the disease appeared to have a partiality for the face, the scalp, the fore-arms, and the knees. Upon the latter, three or four broad, superficial ulcers were in a pretty active state, requiring the protection of several folds of rag, and rendering it difficult for the girl to walk. The face was covered with numerous tubercles and ulcers, varying in size, and as to the different stages they had gone through. Some of the ulcers were nearly dried up; others, more recent, yielded a moderate discharge. The countenance was greatly disfigured, and formed a living counterpart to the horrible rep- resentations we meet with in some of the modern treatises on syphilitic dermatology. The mouth and throat had undergone equal ravages. In addition to the inflamed and hypertrophied condition of the amygdalae, and the congested state of the SECONDARY SYMPTOMS WITHOUT PRIMARY. 273 fauces and mucous membranes generally, on the sides of the tongue there were several small ulcers. It was difficult for the patient to speak above a whisper, and even then the words were uttered in slow succession, partly from general exhaus- tion, and partly, no doubt, because the morbid process had reached the chordae vocales, and the arytenoid cartilages. The patient knew that her complaint was syphilis, and she regarded her condition as nearly hopeless. She stated that she never, to her knowledge, had had primary symptoms. She was free to answer any questions, and appeared to have no sense of shame or delicacy. Case IV. — March 6th, 1857. Was called to see Mrs. H., who had been troubled for six years with venereal symptoms in the throat, on the tongue, and skin. During the past two years she has also suffered at intervals with pains in the cra- nial and other bones, has had chronic ptosis of the right upper eye-lid, severe, intermittent vertigo, and partial paralysis of the right leg. She has been under the professional care of two ex- cellent physicians, both of whom to my knowledge regard her case as venereal. To-day, I found upon examination, a small cluster of tuber- cles upon the anterior aspect of the right arm, immediately above the elbow. They began to appear about four months ago. The patient stated that on several occasions she has had similar lesions on various districts of integument, as the back of the neck, the shoulders, fore-arms, wrists, etc. No marks of pustules or ulcerations could be seen. On the right side of the os frontis, near the median line, and just above the su- perciliary eminence, was a small node. During the past ten months, several similar growths in this neighborhood have come and gone. On the left side of the tongue were two small fissures or clefts. This organ had suffered much and for a long period, from ulcerations, but at the time of my exami- nation it was nearly exempt from disease. The patient was an excellent and highly intelligent lady, and her statements were entirely reliable. She said that she was not conscious of hav- ing had any complaint in any portion of the genital system during her whole life. Her general appearance did not indi- cate that she was laboring under any syphilitic cachexia or taint. This remark holds good, also, in regard to the husband, 274 GONORRHOEA AND SYPHILIS. who is a large, fleshy man, with a full, rubicund face, ne states that he had chancre one year before their marriage, which took place in 1828. Both parties continued in health until 1848, when secondary accidents displayed themselves upon the husband, and continued to trouble him for two or three years. He now has several subcutaneous syphilitic gum- mata on the right arm and elsewhere. In 1852, that is, twenty- three years after her union with this man, the woman first no- ticed any venereal affection, and this was secondary. She has never been pregnant. Case V. — February, 1858. I saw, in consultation, Mrs. R., a married woman aged 34 years, the mother of two healthy children. The patient reports that about eighteen months since, an abundant tubercular eruption appeared upon various parts of the cutaneous surface. In the course of a few weeks, a portion of the tubercles on the limbs began to soften, and be- came pustular; at a little later period, some of the pustules passed into superficial ulcerations, but yielded only a trifling discharge. The legs, the arms, backs of the hands, and several of the fingers, are now involved in the disease in its different stages. In some spots, hard tubercles, in others, tubercles with a soft or incrusted summit, and in still other places, patches of lepra syphilitica are seen. Where the latter are partially healed, the integument is extremely livid. The whole of the face, including the nose, is now dotted over with hard tubercles in juxtaposition, but not confluent. Some of these tubercles are unusually prominent. At a distance of a few feet, the woman presents the aspect of a person having va-- riola, at about the seventh day of its existence. There is no sore throat, and never has been. During the past two months, there has been pain in the head and limbs, exasperated by night and greatly interfering with sleep. She states that some four months ago, when she was more feeble than now, her hands and feet were as blue as if she had cholera, were cold and swollen. Mrs. R. is an intelligent, well-educated woman. She reports that she has never experienced any morbid symptoms in the genito-urinary organs. She has resided in North Carolina, and was there when the present trouble first broke out. She was SECONDARY symptoms without primary. 275 under the care of a highly reputable gentleman, who, in the incipient stage of the complaint, regarded it as venereal, but subsequently, as the lady states, changed his diagnosis, and considered it a simple, non-specific ecythma. The case has re- cently been examined by several physicians in Boston and vi- cinity, and they all agree that it is purely venereal. I am quite well aware that it sometimes requires no little tact to evoke the truth from the polluted recesses of the mind in syphilitic subjects. In regard to this tact or skill, I claim only an ordinary measure, as I have already confessed. Gen- erally speaking, I know that the denial, on the part of the pa- tient, that primary symptoms have existed, does not amount to the weight of a feather in the scale of evidence, unless it is substantiated by other testimony. If this testimony be strongly corroborative of the denial, then the statement of the witness, I think, should be allowed its full claim to favorable consideration. I do not propose, however, to enter into any special pleading in behalf of the individuals, whose symptoms have been sketched above. They have not been introduced in this connection for mere effect, but for the purpose of pre- senting what I consider to be facts in the history of syphilis, and which are important to be known by every practitioner, who has any professional dealings with this strange disease. According to Ricord and his school, syphilitic eruptions are always consecutive to chancre, and therefore the subjects of the cases, which I have related, must all have had primary chancre. I must say, nevertheless, that no theory or hypoth- esis is sufficient to convince me that the facts in the instances I have adduced, were other than what is stated. If any one will consult Wilson, he will find cases similar to those above related. Wilson's opinion is, that the syphilitic poison can be taken directly into the system through the circulation, without entering the lymphatic channels; and in this way the second- ary manifestations may appear, without antecedents of a pri- mary character. He relates the case of a medical gentleman that is directly in point as confirmatory of what I have stated. I will here transcribe the last paragraph. " On mentioning to him," says Wilson, " my conviction of his case being constitu- tional syphilis, he told me that although he had been repeat- 276 GONORRHOEA AND SYPHILIS. edly exposed to the dangers of contagion from impure connection, he had never had a symptom of primary disease ; that is, nothing that ever attracted his attention, or called for treatment. With regard to the disease, there is no doubt as to its nature in my mind, and I can only come to the conclu- sion that this case is an illustration of absorption of the syphil- itic poison by the system, without the development of the local or primary disease." At a recent meeting of the French Academy of Medicine the subject of transmissibility of secondary syphilis was brought up for discussion ; and M. Velpeau stated that he did not hesitate to maintain that all or nearly all, the manifesta- tions of secondary syphilis are contagious. He founds his be- lief of this upon the long-standing opinion on this subject, the general assent of physicians to its truth, and the daily expe- rience of the profession, as well as upon clinical observations, the fact of its hereditary transmissibility, and the results of inoculation itself. Probably no man in the profession has seen more of the operations of the " venereal ferment " than Sigmund, of Vienna. He is a firm believer in its communica- bility from secondary affections, such as plaques muqueuses, etc. Dr. Henry K. Oliver of Boston, who has recently en- joyed the instructions of this distinguished German professor, states: " I have seen him produce a true chancre by inocula- tion from a plaque muqueuse. He does not lay so much stress upon the Hunterian chancre as Ricord does, insisting that con- stitutional syphilis is by no means always preceded by an in- durated chancre, especially in females. He says it is an every day occurrence for females to enter his wrards with constitu- tional symptoms and a chancre quite free from this indura- tion; and he thinks if Ricord had seen as much of this disease in females as he has, he would have become convinced of this fact." * Hebra, of the same University with Sigmund, teaches the same doctrines to the medical classes. Langston Parker relates two instances, in which the second- dary taint was communicated by the husband to the wife. In both cases, the females were entirely exempt from all disease in the urino-genital organs. They were carefully examined * Vide Boston Med. and Surg, journal, Aug. 20, 1857. Letter to Dr. J. M. Warren. SECONDARY SYMPTOMS WITHOUT PRIMARY. 277 with reference to this fact, and not the slightest degree of ir- ritation, sore, excoriation or discharge, could be detected in either. In both instances, the wives had almost precisely the same symptoms that were developed in the husbands. Mr. Porter, Professor of Surgery in the Royal College of Surgeons, of Ireland, is a believer in the doctrine that lues venerea can be communicated by the seminal fluid. " How- ever unprepared we may be," says he, "to admit the doctrine, and however contrary it may seem to the general laws of the animal economy that two distinct, nay, totally different, fluids should be vehicles of one and the same poison, — I think a careful examination of facts will convince any unprejudiced inquirer that the seminal fluid possesses this most unhappy quality, and that in the mysterious process of generation it may be the medium of contamination without the intervention of a single drop of purulent matter." The facts which this eminent surgeon has observed, are, he thinks, sufficient to establish as a law of syphilis that the semen of a diseased man deposited in the vagina of a healthy woman, will, by being absorbed, and without the intervention of pregnancy, con- taminate the woman with the secondary form of the disease, and that without the presence of a chancre or any other open sore either on the man or woman. Mr. Waller of Prague, published in 1851, the results of his researches on the contagious character of secondary syphilis. Among other things he states that inoculation with the secre- tion of secondary syphilitic ulcers on healthy subjects, may produce in them secondary syphilis. Sperino, of Turin, has produced syphilis by inoculating with matter taken from sec- ondary ulcers. Contagion of the Blood.— There are well-authenticated instances of secondary venereal symptoms being caused by contagion from the blood of an individual affected with sec- ondary syphilis. Waller made an experiment on a lad of 15 years by inoculating him with the blood of a young girl, who had had primary sores on several occasions, and who, at the time the boy was inoculated, had tubercles on the face, and venereal blotches on the surface of the whole body. In thir- ty-four days after the operation, a few distinctive venereal 24 278 GONORRHOEA AND SYPHILIS. tubercles were developed near the point of insertion. These were followed by an extensive exanthematous eruption, — that is, a characteristic roseola, — and the latter was suc- ceeded by pimples and tubercles on various parts of the sur- face, and which were easily diagnosticated as syphilitic. The following report of three cases of venereal disease originating in an infant affected with hereditary syphilis, is from the Records of the Massachusetts Hospital: — Mrs.----was admitted to the Massachusetts General Hos- pital, March 11, 1853, suffering from tertiary syphilis. The history she gave of herself is as follows: — She had always enjoyed good health until seventeen months previous. At that time, she and her little daughter, a child of nine years, on the same day, drew the breasts of a woman living in the same house with them, and who had for some time been wet- nurse to a child, which, it subsequently became known to her, was affected with hereditary syphilis. The sudden death of this child had left the nurse with the inconvenience of over- distended breasts, — and it was to relieve her discomfort, on her return to her house, that the patient, with her child, sev- eral times during one day, performed the charitable act above mentioned. The woman had, at the time, sore nipples and an eruption on the skin, the true nature of which she was igno- rant of. In about a week from the time of drawing her breasts, the patient and her daughter began to have very sore mouths ; and the throat of the patient became so much affected as to prevent her swallowing any thing but liquids. She was under medical treatment for a month, taking mercurials, etc., and at the end of that time was well of her primary trouble. Twice, since the first attack, she has had similar symptoms, in one instance continuing three months. At the time of her admission to the hospital, her hair was quite thin and the scalp was swollen, painful and tender on pressure in various places. Her mouth could only be partially opened; its roof was slightly ulcerated, and there was great hoarseness. Ten months before, a node appeared on each tibia; and that on the left suppurated, was opened several times, and had now healed. The one on the right remained of half the size of a hen's egg, and was still enlarging and quite painful. There had been more or less rheumatic pain in her legs for the same SECONDARY SYMPTOMS WITHOUT PRIMARY. 279 period. There had been no eruption on the skin nor any affection of the genital organs. The patient was treated with iodide of potassium internally, and by the local application of tincture of iodine, and was discharged well on the 27th of the following month, there remaining only a trace of the node on the right tibia. The daughter of the above patient, aged fourteen, entered the Hospital, October 6, 1857. At the time of her mother's first attack, she was similarly affected, although with less se- verity. From these primary symptoms she soon recovered under medical treatment, although she has been several times troubled with sore mouth since. Nine months before entrance, she presented herself as an out-patient, with ulceration of the soft palate and back of the throat. For this she was treated with the iodide of potash and by the local application of tinc- ture of iodine without benefit. At the time of her admission to the Hospital, the ulceration had progressed so far as to have destroyed the uvula and a portion of the velum on both sides, leaving a triangular opening with ragged edges. The anterior pillars had been destroyed. There was much inflam- mation of the whole fauces; and upon the back part of the throat were large, whitish patches of ulceration. During the time of her treatment as an out-patient, her nose had become considerably depressed, particularly at the upper part. After admission to the Hospital she was treated with iodide of pot- ash and compound infusion of gentian, subsequently with tar- trate of iron and potash, gr. xx ter die, and by the injection of a solution of sulphate of zinc into the nose, the septum having become perforated by ulceration. A weak mixture of tincture of iodine and water was afterwards substituted for this injection. Under this treatment the patient improved, portions of bone coming away at times, one of which appeared to be the vomer. She entered under the care of Dr. Gay, and passed into the hands of Dr. H. J. Bigelow, who continued the treatment, and she was discharged well, November 25. Transmission of the virus from the nurse to the infant, and vice versa. — Upon this subject, M. Trousseau recently communicated the following facts and opinions in a lecture at the Hotel Dieu of Paris: — 280 GONORRHOEA AND SYPHILIS. " I come now to the recital of cases which thus establish the possibility of the communicability of the disease from the child to the nurse. " One of my professional brethren of Paris invited me to a consultation in the family of one of his patients. He informed me that the lady of the house was delivered seven months be- fore, of a healthy child, which became sick fourteen or fifteen days after birth, but without any manifestation of disease of the skin. " Toward the end of the second month and at the commence- ment of the third, a cutaneous affection supervened, of a nature to suggest the idea of syphilis. A little later, the nurse showed on her breast symptoms not at all encouraging ; engorgement of the axillary glands of the corresponding side, an eruption of roseola over the whole surface of the body, and sore throat. " The physician inquired of the father of the child whether he had ever had syphilis; this he denied emphatically. To address a similar question to the mother was a thing next to impossible, so my friend was content with satisfying himself that she presented no traces of the disease. The nurse grew so much worse that it became necessary to confide the child to another woman. Three weeks after, the second nurse be- came affected in the breast. I was called in a short time after, and satisfied myself, by my own observation, of the existence of the most unmistakable signs of the diathesis. As for the child, it had a hypertrophy of the liver, as well as lesions of the skin and mouth. " Will you admit that both of these women had been pre- viously infected ? This would, to say the least, have been a singular coincidence; but the first of them was a married woman and had been remarkably healthy, as well as her hus- band, before she began to nurse the child. The second was a young girl from the country, confined four months previously, and having no knowledge of this disease. Nevertheless they were both infected, and both in the same way ! " Such facts are very serious, and their number begins to be quite considerable. Secondary affections are, without doubt, transmitted with much more difficulty than primary ones, but they are, nevertheless, transmitted; and when communicated SECONDARY SYMPTOMS WITHOUT PRIMARY. 281 from the child to the nurse the contagion depends upon special conditions, on which I wish to fix for a moment your atten- tion." The following quotation from Professor Bennett of Edin- burgh, is worthy of a place in connection with this subject. Speaking of Syphilis, he says: "The secondary forms of the disease are always the result of inoculation; but this may arise not only from the poison being absorbed directly from a primary sore, but may be communicated by the mother to the foetus in utero, by the infant to the nurse, and again by the nurse to the infant. The following case which was most care- fully investigated, and was the subject of legal proceedings, illustrates how nurses may be affected by syphilitic infants. " In 1842, the late Dr. W. Campbell brought to me a woman with a child in her arms, to obtain my opinion whether a skin eruption on the latter was or was not syphilitic. I pronounced that it was, and that the woman should cease to nurse it, although her nipples were at that time in no way affected. The child was the offspring of respectable parents, and had been sent to her to nurse. In consequence of my opinion, the infant was returned to the friends, whose medical attendant maintained the eruption to be non-syphilitic. The woman who applied to me (nurse 1) was received as wet nurse into another family, and the child was sent to another nurse (nurse 2). In a week the child died; and a few days afterwards, nurse 2 was attacked with sore nipples. Nurse 1, shortly after entering her new situation, also perceived sores round her nipples ; and the medical attendant of the family, after con- sultation with me, caused her to be discharged. She, in con- sequence, brought an action against the medical man, who had caused the syphilitic infant to be sent to her, and mis- taken the disease. The lawyer she employed, then took me to visit nurse 2, whose whole body was covered with a syph- ilitic tubercular eruption. Both nurses ultimately succeeded in obtaining compensation from the medical attendant."* In the New York Journal of Medicine for November, 1857, Dr. J. L. Smith, physician to the North-Western Dispensary of that city, relates an instance of syphilis, communicated from * London and Edinb. Journal of Med. Sciences, 1852, p. 570. 24* 282 GONORRHOEA AND SYPHILIS. a nursling to the nurse. The infant, at the age of five months, was brought to the dispensary for treatment, and was under Dr. Smith's care, as was the nurse also. The syphilitic character of the disease, in both patients, was very apparent. Dr. S. takes occasion to cite cases reported by Dr. Bulkley of New York, Dr. Campbell, etc. Mr. Holmes Coote, assistant surgeon to St. Bartholomew's Hospital, speaking of secondary syphilis, remarks that some of the severest cases occur in young and delicate females, in whom there is no account of primary disease. He relates cases; and he regards secondary syphilis as contagious; and says that it behooves the medical attendant to be well ap- prized of the fact. Vidal says: " As to the transmissibility of secondary acci- dents, aside from hereditary descent, the doctrine is proved by the fact of the infection of the nurse by the child affected with consecutive tubercles, and the contagiousness of the mucous tubercle in the adult." Cazenave, whilst admitting the rarity of the contagion of secondary symptoms, acknowledges that it is impossible to deny its occurrence, but that certain local circumstances are indispensable to such a result; these are a humid or moist secreting surface, and prolonged contact. Precisely the views entertained and advocated by Sigmund. M. Diday regards the lesions of hereditary syphilis as con- tagious as primary accidents. At a recent meeting of the Boston Society for Medical Im- provement, the subject of the communicability of secondary syphilis gave rise to an animated discussion, the substance of which is reported as follows : — * " Nov. Sth. — Communicability of Secondary Syphilis.— Dr. W. E. Townsend made further mention of the case reported by him in January last; that of a woman who, two years pre- viously, had a venereal ulcer on the breast, followed by se- condary syphilis, this being caused by the secretions from the nose of a child which she was nursing, dropping on a scratch at that place. "At that time some gentlemen expressed a doubt as to the * Vide Boston Med. and Surg. Journal, January 6,1859. SECONDARY symptoms without primary. 283 character of this ulcer, thinking the probabilities were against its being of a syphilitic nature. " Two years and a half afterward, in August of this year, the same woman was confined at her full time; the child at first looked well, but in the course of four weeks bullae appeared on its ankles and feet, followed by inflammation of the mucous membrane of the nose and mouth, filling up those passages and obstructing the passage of air and nutriment, in conse- quence of which it died within six weeks of its birth. " This child died, undoubtedly, of hereditary syphilis, derived from its mother. The previous children of these parents have been, and are now, stout and healthy, and the father, to the best of Dr. T.'s knowledge and belief, never had any syphilitic disease. Similar cases have lately been reported by Langston Parker, Esq., in his lectures on Infantile Syphilis, in the Lan- cet for August, 1858. " Dr. Coale alluded to a similar case, reported in the Medical Times and Gazette. " Dr. Townsend said he regarded the question as to the com- municability of secondary syphilis a very important one, as bearing on marriage, the physician being often asked as to its advisability, when the husband had had primary disease. " Dr. Townsend here briefly alluded to another case. Mrs. K., seven months after marriage, had a stillborn child. Two years after marriage, she had a second, likewise stillborn. Three years after, she had a third at full term, which lived for eight months, during five of which it had well-marked infantile syphilis. Four years after, she had a fourth, which has never been ill, but is still a feeble child, though its mother has al- ways been, and is now, a hearty, robust woman. " About a year before marriage, her husband had syphilis, and was attended by a physician of this city, having a large expe- rience in such cases. He supposed himself entirely cured, and presented no appearance of disease. " Dr. Putnam alluded to a case in which a patient who had had syphilis, had supposed himself cured before marriage ; his wife gave birth to a child at seven months. There was no question as to the nature of the cause. " Dr. Abbot mentioned the opinion of Trousseau, that when the disease had once existed, there is no security against its ^°* GONORRHOEA and syphilis. re-appearance in the offspring. Several cases are on record where the disease is thus entailed. That there is no certainty as to its re-appearance is evident from another case mentioned by Trousseau, in which the patient, a cavalry officer, who had had syphilis several times, and was married, had children who exhibited no trace of the disease. " Dr. Hayward, Jr., in connection, reported the following case as tending to confirm the theory of the communicability of secondary syphilis. " In describing this case, the two first letters of the alphabet are used to indicate the ladies referred to, but with no refer- ence, of course, to their real names. " December 17, 1856.— Mrs. A. was confined in the coun- try; she soon had fissures in the left nipple, and, her own baby not being strong enough to draw the breast well, she borrowed one nine weeks old from a poor family in the neighborhood. This child nursed her four times; the fissures in a few days became sores, and extended until they involved the whole nipple. During the first week in April", a dark red eruption appeared all over her body, arms and limbs; this gradually assumed a copper color, and continued to spread until, by June, it involved the whole face. The infant had a similar eruption appearing about the same time. "July 18,1857. — Mrs. B.,the mother of the above-mentioned patient, came to Boston to consult Dr. Hayward, concerning her daughter and grandchild, and, finding he had gone to Eu- rope, she called upon Dr. Hayward, Jr., for advice. From the statement of the case given above, which she then made ; from the fact that the infant who nursed Mrs. A. died in about two weeks after she was taken sick, covered with an eruption, and (as she expressed it) " rotten " with what the child's father said was small pox ; and from the circumstance that the child's father refused to allow any physician to attend upon his child, Dr. II. came to the conclusion that Mrs. A. and her infant were suffering from syphilis, and requested to have them brought to Boston that he might see them before prescribing. Mrs. B. said that her daughter was so mortified at her appearance, her whole face being covered with the eruption, that she positively refused to travel in any public conveyance. Dr. EI. therefore prescribed for her hydriodate of potassa and decoction of SECONDARY SYMPTOMS WITHOUT PRIMARY. 285 sarsaparilla internally, and black wash, composed of a drachm of calomel to eight ounces of lime water, externally: the in- fant to drink the sarsaparilla, and have the black wash applied. " Aug. 14. — Mrs. B. called again and reported her daughter and grandchild, as much better, the eruption very much di- minished ; she was directed to continue the same treatment. Mrs. B. at that time supposed herself well. " Sept. 11. — Dr. H. was sent for to see Mrs. A., who had come to Boston. She had, at that time, extensive traces of the copper-colored eruption on her face, and on various parts of her body, but this was dull except when exposed to changes of temperature, and Mrs. A. said that it was steadily fading away. She complained of much suffering in the left eye, and, on examination, it was found that she had a severe attack of iritis ; the attack began in the right eye, and shifted to the left one. She had taken the hydriodate of potassa and sarsap- rilla up to that time. She was then ordered to take a pill composed of one grain of calomel and one-third of a grain of opium three times daily, till the gums were slightly affected, and the mercurial action was kept up moderately for several days longer. Under this treatment the iritis speedily im- proved, and when she left town, Sept. 25, the eye was very much better, and it is believed that she had no trouble with it since. " On the first or second visit to Mrs. A., at this time, Mrs. B. requested an examination of her throat, which she said was sore. Dr. H. examined it and found, to his surprise, that it presented every appearance of syphilitic sore throat. On questioning her, it was found that she had had the entire care of the sores on her daughter's breast, and had sometimes washed cloths which came from them, but that although she had had little cracks about her fingers repeatedly, she had never had any sores on her hands or arms until about two months and a half before this time. At that time, being about the middle or latter part of June, when the baby was six months old, Mrs. B. held it while the physician lanced an ab- scess on the right side of its neck; this discharged freely a greenish-colored matter, which ran over her left hand and wrist. On the back of the wrist the skin was broken at the time, and in about a fortnight after the abscess was opened, a 286 GONORRHOEA AND SYPHILIS. sore resembling a common boil was formed upon the back of the wrist where the abrasion had been. This suppurated; but, when it discharged, Mrs. B. noticed that there was no core to it, as in the case of a common boil; and, moreover, that the matter discharged from it was of a greenish color and resembled that which came from the infant's abscess. This sore on the back of the left wrist was followed by red and copper-colored spots, similar to those which Mrs. A. had had, and finally by sore throat. The sore throat yielded to fumigations of cinna- bar and applications of nitrate of silver, and when that was well, she was ordered hydriodate of potassa and decoction of sarsaparilla, under which the copper-colored eruption slowly improved, though she has been at times troubled with it since, and is not quite free from it now. Dr. H. thinks that there was no loss of hair in Mrs. A.'s case, and is positive that there was none in Mrs. B.'s, except where the eruption was upon the scalp. In the course of the treatment, he saw and conversed freely with both Mr. A. and Mr. B., and from their appearance and characters, and that of their wives, firmly believed that all this disease, misery, and mortification arose from suckling a diseased child upon a fissured nipple. With this conviction, he remarked that it seemed to him of the utmost consequence, 1st, that before allowing any strange child to nurse a Woman, the family physician should be consulted, which was not done in this case; and 2dly, that every physician should carefully examine the state of a child's health, and also inquire, as far as he is able to do so, into the character and health of its parents, before he allows it to nurse his patient. " Dr. H. J. Bigelow had expressed doubt as to the nature of the ulceration spoken of, and had perhaps been alluded to by Dr. Townsend. Without at all denying the possibility of the venereal lesion and specific secondary contagion in this case, he had felt the evidence of it insufficient to justify his own belief in it. The additional evidence now presented is, that a second child, born two years and a half after the first, presents, in four weeks, bullae on the feet and ' inflammation' of the buccal and nasal mucous membrane. These symptoms, if specific (which is not certain), must have been hereditary at this late period ; and this fact of inheritance is adduced as evi- dence of the protracted existence of the lesion in the mother's SECONDARY SYMPTOMS WITHOUT PRIMARY. 287 constitution ; which, in its turn, is relied on to show that such lesion was originally received in a secondary stage from a nursing child, and not as a primary lesion from a husband, or from any other source. While Dr. B. had great regard for the opinion of Dr. Townsend, and, in general, for the sort of con- viction which results from a detailed and personal examination of evidence of any sort, he did not think that the case cited was one which could be relied on to convince other people. Primary lesion, or chancre, is always inoculable in an unsyph- ilized subject. Secondary and constitutional lesion is well known to be almost never so. The present discussion is to the point whether secondary and tertiary syphilitic disease is ever, in exceptionable cases, communicable by contact or inoculation. Ricord, after years of honest and careful experiment, decided that it was not. Subsequent experimenters have since thought that in rare cases it may be, and it seems actually probable that it is. But as the comparative ignorance which prevailed in respect to the whole subject of syphilis, before the masterly elucidation of Ricord, was due to the imperfect analysis of previous evidence, justice to the labors of that observer de- mands a rigorous scrutiny of any case adduced in contradic- tion of his results. Grant a venereal eruption to be identified as such (which is often difficult, sometimes impossible), the question of its origion is then between a rare contagion from a previous secondary or tertiary eruption in another person, and its regular, every day sequence from a primary sore, per- sistently denied or honestly ignored, by the individual last af- fected. No other medical subject presents, like this, the sac- rifice of character and of social relations as obstacles to its elucidation, and evidence should be weighed accordingly. "Dr. B. believed that constitutional syphilis was, on all the evidence, contagious as well as hereditary, but was rarely so ; and that the protracted contact of the nursing child was the more frequent condition of this contagion. Of course, no healthy woman should knowingly nurse a syphilitic child, and vice versa. As to the question of marriage, he thought that the lapse of a year from the complete disappearance, under proper treatment, of light constitutional symptoms, and of two or three years, more or less, in severer cases, was as 288 GONORRHOEA AND SYPHILIS. strong a guarantee of immunity as posterity had a right to ex- pect, or at any rate as they generally received. "Dr. Lyman alluded to the change of opinion in England and on the Continent, upon this subject; also to the fact that the English journals contain frequent reports of cases, which give direct evidence of the communicability of secondary disease. " Dr. Durkee considered that the preponderance of medical opinion is in favor of the communicability of secondary symp- toms. The singular doctrine, advanced some years since, by Ricord — that of all venereal affections, indurated chancre, alone, furnished inoculable matter, had been the occasion of awakening other distinguished observers to the general sub- ject of contagion arising from syphilitic manifestations. The facts furnished by such men as Vidal, Velpeau, Trousseau and Cazenave, of France; by Wilson and Langston Parker, of London; by Professor Porter, of the Royal College of Sur- geons of Ireland; by Sigmund and Hebra, of Vienna, and many other high authorities, had now become quite numerous, and they were in direct opposition to the views of Ricord. These facts are constantly accumulating, and the most respect- able medical journals teem with well-authenticated instances of infection derived from secondary lesions. Two cases of this kind, related by Professor Bennett, of Edinburgh, are en- titled to our remembrance, whatever theory we may entertain on the subject.* " In viewof such facts. Dr. D. asked if any member of this So- ciety would feel justified in giving his professional opinion that a syphilitic infant might safely be committed to the cus- tody of a healthy wet nurse ; or, to reverse the circumstances, and suppose that a healthy nursling was in want of a wet nurse, and a woman with a large breast of milk should desire the situation, but, upon examination, should be found to have secondary syphilis; would any gentleman present be inclined to encourage the friends of the child to commit it to the fos- tering care of such a woman ? "Dr. D. remarked that in his own practice he had seen sev- eral cases of secondary syphilis in both sexes, where no evi- These cases are inserted on p. 281. SECONDARY SYMPTOMS WITHOUT PRIMARY. 289 dence, whatever, of primary lesion existed. He considered that the proof, as to the communicability of secondary lesions, was as reliable as that relating to the contagiousness of chan- cre. Once, he was a believer in Ricord's theory. But facts observed in his own practice, as well as those adduced by the most trustworthy men from all quarters of the medical world, had fully convinced him that Ricord was not sound on this point. He is pre-eminently entitled to praise for the great scientific advancement he has made in regard to the pathology and treatment of venereal affections; but he is not infallible. " Dr. Strong remarked that he did not consider this a ques- tion upon which the profession is at present ready to decide. Observations were not as yet sufficiently numerous to form the basis of a correct opinion. He had for a long time differed from Ricord, having seen many cases in which the evidence of the communicability of secondary syphilis was undoubted; but was yet of the opinion, that the time had not arrived to establish a pathological conclusion. " Dr. Jacob Bigelow remarked that he had been much inter- ested in the discussion. There was one point to wdiich he would allude, that might tend to reconcile the differences in the various reports upon this subject; and this is the change of character that diseases sometimes undergo in different pe- riods. Cholera, for example, was formerly a tropical disease ; it being only about thirty years since it spread toward the north. Plague once visited Great Britain, and various parts of the Continent, committing terrible ravages; now, it is not known in those countries. Yellow fever was supposed, thirty years ago, to be non-contagious; while, at present, serious doubts are entertained whether it be not sometimes contagious. Typhus fever seems to be at some times contagious, at others not at all so. Syphilis had undergone several changes in its character within a half century. At one time the doctrine of Hunter was well established. Not long after, the chancre was found to vary so much, as to render it necessary to define what was meant by the Hunterian chancre; and it afterward became so varied in character and appearance, as to make it doubtful whether there were not as much of qualified or spurious syphilis as of the true disease. We know that the 25 290 GONORRHOEA AND SYPHILIS. contagiousness of small pox differs in different years. Is it not within the bounds of possibility that syphilis may, under different circumstances of epidemic predisposition, be more communicable at one time than at another ? "Dr. Strong was not inclined to regard these apparent dif- ferences in the communicability of diseases, as owing to any change in their character, but rather to faulty observation, or perhaps to a difference in the predisposition of patients." The general bearing of what is embraced in the present chapter, it will be seen, goes directly to impeach the doctrine of Ricord, who steadfastly maintains that indurated chancre alone, can produce consecutive or constitutional accidents, ex cept in hereditary syphilis. In a legal and moral, as well as in a medical, point of view, the subject is one that demands close and impartial study. Its investigation is acknowledged to be fraught with difficulties. It is not wholly free from the influences flowing from the schools and the high authority of brilliant names, and it is perhaps impracticable to sever it from such relations. As in many other matters, not susceptible of mathematical demonstration, so in this, the evidence that convinces one man may fail to satisfy another; and tfms the question seems likely to remain a mooted point at least for the present. I consider myself justified, however, in stating here, that in the judgment of a vast majority of the most eminent men in the profession, the communicability of second- ary syphilis is a fact as firmly established as is the contagious- ness of the poison of indurated chancre. And whatever may be the theoretical notions of the reader on the subject, he will do well, whenever he is called upon to form a diagnosis or to give an opinion in matters of this sort, wherein the health or the character of individuals or parties, is at stake, to ponder upon the facts and opinions embraced in this chap- ter. To ignore them would be unreasonable, unsafe, and un- just. The theory has been broached by Simon, an eminent path- ologist, that the primary syphilitic poison is insoluble, and that it will not act through a continuous membrane; and that the poison of secondary syphilis, on the contrary, is soluble SECONDARY SYMPTOMS WITHOUT PRIMARY. 291 and acts, as is seen in its influence on the foetus in utero, through the unbroken walls of the blood-vessels by endos- mosis, converting into its own likeness those materials of the blood, with which it comes in contact; and why may not the process be the same in the adult subject ? CHAPTER X'XVII. SYPHILODERMA ERYTHEMATOSUM. ROSEOLA SYPHILITICA—IS THE SIMPLEST FORM OF CUTANEOUS AFFECTIONS — ERUPTION PRODUCED BY BALSAM OF COPAIBA AND CUBEBS — DIAGNOSIS — IS OCCASIONALLY CONFOUNDED WITH MEASLES—TREATMENT. The exanthematous affections, including the maculae, ros- eola, erythema, and, according to some dermatologists, the ephelides, are the first manifestations of constitutional syphilis upon the skin. Roseola syphilitica is the principal eruption we meet with, either as accompanying primary symptoms, or as a precursor of other secondary accidents, which supervene at a later period, particularly the papular or tubercular affections. Roseola is the simplest form of cutaneous affection, and is not very un- common after the existence of chancre. It usually commences without any feverish condition of the system. The patient is surprised to find the color of the skin changed to red, without having experienced any antecedent constitutional dis- turbance. In some instances, especially in plethoric subjects, the eruption of roseola, of lichen, etc., is ushered in by a slight febrile excitement. Sometimes, as I have elsewhere stated, a species of urticaria or lichen is seen upon the whole surface in consequence of the peculiar action of balsam of copaiba, or of the powder of cubebs, taken in large quantities for the cure of gonorrhoea, by persons having an extremely delicate skin, and who are accustomed to drink large quantities of wine, and to other high living. In these circumstances, the man takes alarm, and presuming the cutaneous disorder to be dependent upon the urethral discharge, and indicative of real syphilis, he imagines that a chancre must be lodged in the urethra. I have recently met with two such instances. In one, no little con- sternation was felt by the patient, because he apprehended that his habits and his condition would come to the knowledge of his immediate friends. But upon the discontinuance of the 292 SYPHILODERMA ERYTHEMATOSUM. 293 medicine, the peculiar erythematous excitement of the integu- ment entirely faded away. In the early period of the eruption, the roseate tint of the surface, retiring for a moment under the pressure of the finger, masks the characteristic coppery hue ; but as it acquires chron- icity, the color diminishes only in a slight degree, and then the true nature of the affection is more distinctly declared. When it occupies the whole of the face, the abdomen, and other ex tensive regions, it has very much the mottled aspect of measles; and it then comes out in circular or crescentic blotches, is unaccompanied by constitutional symptoms, and is free from itching. Again, it will appear on one part of the skin, and, after a short period, say from eight to ten days, will vanish and show itself at quite a distance in some other district; thus migrating from spot to spot, and exhibiting its dusky shade, especially on the lower extremities, where the cutaneous capillaries are more readily congested than else- where. Not infrequently, instead of a coppery red, the eruption assumes a yellowish red, constituting the salmon-colored skin, and as the disease lessens, there is a moderate, epidermic exfoliation. The integument will present a grayish tint, which is due to the partially detached scales of epidermis, resting on a dark red base. To the eye, it seems elevated above the adjacent sound skin; but if the fingers are passed along the surface, no elevation can be perceived. The skin feels nearly as smooth and even to the touch as in health. When the eruption terminates, it leaves a peculiar dingy stain (macula syphilitica), which lingers for several months before it is entirely effaced. The spots present variations in the intensity of hue, from time to time, during the progress of the disease ; but however deep and well-marked the discolor- ation may be, it always lacks that bright scarlet which belongs to simple roseola. Sometimes it assumes the annulate form. This variety, however, is uncommon. I have met with two in- stances, both in females, one of whom, a noted actress, was of a full, plethoric habit and suffered several weeks from the eruption. It occupied the arms and chest principally. The mucous tissues were unaffected. The other was that of a respectable, married lady, infected by her husband, and suf- 25* 294 GONORRHOEA AND SYPHILIS. fering from primary sores at the same time. The eruption ap- peared upon the face, neck, and extremities; and several months elapsed before the woman was cured of either form of complaint. Roseola syphilitica sometimes presents a punctate form, in which the follicular congeries of capillary vessels is congested. The sub-occipital and other cervical lymphatic glands are usually swollen in cases where this cutaneous affection is spread over a large extent of surface. The sudoriferous pores are also prominent, and the sebaceous follicles obstructed by a dry sordes, consisting mostly of epidermic particles. The skin is in an unperspirable state, or, if covered with insensible perspiration, it exhales a peculiarly disagreeable odor. This latter idea is denied by some writers, but I think it is founded in truth. Diagnosis.—From the preceding description, which embraces the leading features of true roseola syphilitica, it would seem that the diagnosis cannot be surrounded by any great difficulty, and yet well-marked examples of the malady have been mis- taken, in the early stages, for rubeola. An instance of the kind occurred within my observation not long since. The person was a married woman, who, as well as the husband, denied ever having had any venereal symptoms. After the erup- tion had existed for several weeks, Dr. Salter and myself were called in consultation. The posterior cervical glands were enlarged. The mucous membrane of the mouth was inflamed, and upon it were several small ulcerated patches. There was great constitutional debility. Notwithstanding the parties denied the existence of primary specific disorder, either past or present, the cutaneous affection, which covered nearly the entire surface, was now sufficiently distinct in character not to be confounded with any other exanthem, especially when considered in connection with the other con- comitant circumstances. The patient had never before been troubled in this manner. Several months passed before her recovery. In rubeola, the abnormal conditions are of an acute form from the commencement of the attack, and reach their acme* rapidly. Although the efflorescence of the integument in SYPHILODERMA ERYTHEMATOSUM. 295 measles and in roseola syphilitica may present a similar aspect to the eye, it should be remembered that in the latter disease, the coryza, the profuse serous discharge from the eyes, the cough, the sneezing, the quick pulse, and the alternation of chills and fever, which exist in measles, are wanting. Treatment. — If any febrile symptoms are present, which is seldom the fact, a mild antiphlogistic treatment, pursued for a few days, will subdue them. The simple warm bath should be daily administered, — or a bath containing sulphuret of potash, in the proportion of two ounces to thirty gallons of water. The therapeutic benefit, which can be derived from warm bathing and warm water douches, as powerful means of stimulating the cutaneous vessels to healthy action, will in the generality of cases, be manifest in a satisfactory manner. The occasional use of soap with the bath, will be serviceable. In many instances, where this simple variety of disease is present, minute pellets of hardened epidermis and sebaceous matter form at the orifices of the sudoriferous tubes and impart to the surface a peculiar roughness. This dry scurf has a con- stant tendency to accumulate; and to obviate this, bathing, with liberal friction, should be faithfully attended to. The gelatine bath and bran bath are sometimes recommended. Of course there is no objection to be urged against their employ- ment if the patient choose to try them, but I am not aware that they possess any special virtues not inherent in the other modes of purifying and exciting the external surface. Moderate saline evacuants, combined with tonics, and a generous diet, — exposure to a pure atmosphere, and regular- ity in the habits of the patient, is all that will be required at this crisis, by way of constitutional treatment. CHAPTER XXVIII. PAPULAR ERUPTIONS. LICHEN — DIAGNOSIS — PASSES INTO TUBERCLES — ASSOCIATED WITH TUBER- CLES, SQUAM.ffi, AND PUSTULES — ALSO WITH IRITIS — TREATMENT. Syphilitic papules exhibit themselves under the guise of two principal forms. In the one, they are closely associated together in groups, and assume a semi-lunar or crescentic arrangement, with intervening healthy spaces, and the spots or patches look not unlike so many dusky-red, fleecy clouds, in miniature. The other mode, in which the papules appear, consists in a widely disseminated arrangement. In the latter I think it is correct to state that the individual papules are larger, than when developed in crowded clusters. Tho usual size is, at first, about that of a common pin's head. Whatever their form, or size, or mode of distribution may be, However, they are endued with the tawny, or coppery red color, which is so generally — I cannot say always — charac- teristic of venereal eruptions. At no period are they pruri- ginous, even when they terminate, as they sometimes do, in desquamation of the epidermis, which covers them; and they leave behind them, for a very long period, stains of a brown coppery color, — or the hue of the brown faded leaf, as the remembrancer of their former site. Sometimes syphilitic papules spring up in great abundance upon the forehead, — usually in clusters of ten or twenty; — at other times, they are quite isolated. When thus developed, they bear a close resemblance to acne indurata, and have been honored with the dignified sobriquet of corona veneris. They create no constitutional disturbance, unless they burst forth suddenly as an acute affection, which is not often the fact. When they do thus appear, however, the febrile condition is well pronounced. There is increased temperature of the surface, which is very rough, and in an unperspirable state; the pulse is acclerated, 296 V'T sp-xzjnnju.1. ^wi^w^k II 1,1 PAPULAR ERUPTIONS. 297 and the tongue parched and coated. But the moment the papular development is complete, the constitutional struggle subsides and the economy seems to be relieved, or entirely at rest. The chronic variety is extremely prone to make successive invasions. From the time one crop of papules has been sub- dued, not many months will elapse before another will be very likely to show itself, unless the treatment has been followed up without interruption or abatement, for several weeks after the skin has been restored to a normal condition. In regard to the obstinacy of the attacks, something depends upon the period that has intervened between the primary affection and the constitutional symptoms. If the former have been recently cured, the eruption will prove less intractable, than in those cases where a long interval has passed between the primary and consecutive disease. The treatment pursued, the state of the system, and the habits of the patient, are likewise so many contingent circumstances, which will more or less in- fluence the persistence of the eruption; so that nothing very definite can be predicated on this point. In passing the finger over the affected portions of skin the papules will feel perfectly solid, like so many shot, or like millet-seeds. They are known as Lichen. Where they are arranged in clusters of various dimensions, they are denomi- nated lichen corymbosus; where they appear separately, they are termed lichen disseminatus. Professor Wilson makes still other varieties, according to the particular mode of develop- ment ; but these subdivisions I do not. regard as very import- ant in this connection; and for the sake of avoiding confusion, I shall not introduce them here. [Plate II.] Diagnosis. — The erythematous blush, with which the mu- cous membrane is suffused, and which is often the foreshadow- ing of the ulcers that invade it in constitutional syphilis, is associated with the papular development, now under consid- eration. The pendulous veil of the palate, the uvula and fauces generally, including the tonsils, are usually inflamed. The conjunctiva is likewise deeply reddened, and the lids more or less tumefied. The breath is disgustingly foetid, and the lingual papillae are elongated and turgid. These symptoms 298 GONORRHOEA AND SYPHILIS. are available as so many well-known signs or aids which we can bring to our assistance, when we are about to form a diagnosis as to the character of the complaint; and it would seem that the abnormal condition of the several parts of the mouth and mucous membrane of the eyelids, joined to the phe- nomena spread out upon the superficies of the trunk and limbs, could not fail to conduct the mind of the medical observer aright; for these appearances do not exist in any non-specific disease. The practitioner should never neglect to make a careful examination of the mouth and throat before coming to a decision in regard to the nature of the cutaneous disorder. By an easy transition, the elevated papules of lichen, in each of the varieties which it presents, may pass into the tu- bercular form, which is one of the most common and important of all the syphilodermata. Very often, the papules are seen in company with pustules, tubercles, or squamae; or the patient may present himself with the types of nearly all the syphilitic eruptions upon him. The lichen is frequently associated with iritis, nocturnal pains in the large joints, or with some other manifestations of constitutional syphilis. Occasionally, it arises as an accompaniment of the- primary symptoms, and in such cases, is apt to awaken a febrile disturbance for a few days. Sometimes it attacks the prepuce of the male, or the vulva, orifice of the urethra, or clitoris of the female ; the ex- ternal surface of the labia is also frequently dotted over with this eruption. When seated on the organs of generation, it will sometimes excite considerable irritation and soreness of the parts. In some instances, the papules inflame, and minute ulcerations appear upon their apices, which soon become cov- ered with dry, delicate scabs or incrustations. When devel- oped upon the extremities, or upon the inferior portion of the abdomen, this eruption has been erroneously supposed to be a syphilitic form of itch; hence the name of scabies venerea mentioned by some of the older writers. Although there is no such malady as venereal itch, we occasionally meet with the vesicles of simple eczema, mingled with the papules of syphil- itic lichen. The lichenoid papules are more frequently present in the adult, than any other form of syphilitic disease. In the infant they are not often observed. When the affection is developed PAPULAR ERUPTIONS. 299 upon the face, the innumerable pimples impart to the count- enance a dark, cupreous, shining and ludicrous appearance. When it is confined chiefly to this locality, it is often ex- ceedingly difficult to ascertain its real character, so far as our dependence for proof is placed upon the eruption itself; and the most piactised eye will be unable to identify the disease as syphilitic or otherwise. Especially will this be true if it have passed into the squamous condition. The shrewdest practitioners have fallen into error in their diagnosis. So dif- ficult is it to arrive at the truth, that Acton does not place any confidence in evidence derived from the state of the skin. He and several other surgeons once made a mistake, in con- sequence of which, he has inserted the following sentence in his work: " This case led me to trust alone to concomitant symptoms, and I determined never to characterize a papular er>' ption as syphilitic, unless it was attended with other well marked symptoms, such as psoriasis palmaris, sore throat, or mucous tubercles." The same intelligent writer relates an instance, in which his distinguished master, Ricord himself, came to a wrong conclusion, as was proved by the subsequent history of the symptoms, and by the treatment of the patient. At the time Ricord examined him, he had, along with other suspicious symptoms, psoriasis palmaris, etc.; but because no evidence of a former chancre could be obtained, Ricord, true to his long cherished but fallacious theory, pronounced that the disease was not syphilitic. Acton treated it success- fully with mercury and regarded it as venereal. After the healing of a chancre, the syphilitic taint will re- main in a latent state for many years, without disturbing the healthy condition of the system in any way, and then manifest its presence and its specific action in a very feeble manner upon some portion of the skin, usually the face. It commences with a small patch of hard, dull-red papulae, located upon one cheek or upon one of the temples, where it lingers for many weeks, perhaps, without betraying any disposition to spread; some of the papules gradually passing into a pustular state, and some of them being covered with squamae, without assum- ing the usual pustular character. Otherwise, the entire sur- face looks perfectly healthy. This insignificant disc, perhaps not an inch in diameter, may constitute the only external man- ifestation of the expulsive effort of nature to relieve herself 300 GONORRHOEA AND SYPHILIS. of the " peccant humor," which she has, until now, retained within her precincts with impunity. The syphilitic features of the eruption are generally well developed in these minor patches, amid the transitions which they undergo. During the continuance of this trifling cutaneous affection, a morbid state of the buccal mucous membrane very commonly co-ex- ists. On examination, the fauces will be found swollen and of a purplish hue, but perhaps giving the individual no trouble. The medical attendant, however, will need a reliable history to aid him in the diagnosis. These cases occur with consid- erable frequency. The therapeutic principles, upon which the most successful treatment is based, are abundantly simple. Every day's experience, as realized both in public and private practice, bears testimony to this. If the lichen be acute, and appear as an accompaniment of primary symptoms, it can generally be ameliorated or entirely subdued, by means of plain warm water baths daily admin- istered ; or what is termed the emollient bath may be used in its stead. This is prepared by pouring four quarts of boil- ing water upon two quarts of wheat-bran, and after allowing it to stand for half an hour, let it be added to the bath. In the acute variety of the papular syphilide, this will be found par- ticularly beneficial in allaying any irritability of the skin, or any inflammatory action, either local or constitutional, — will rarely fail to mitigate the eruption, and to keep at bay any tendency to its increase. The sulphureo-gelatinous bath is also valuable. It will be found preferable to the artificial Bareges bath, which is liable to occasion too great excitement in the cutaneous vessels. The sulphureo-gelatinous bath is thus prepared: R. Potassii Sulphureti,...............................§ ij. Aquas,..........................................Cong. xxx. Add to this solution, Ichthyocollae,....................................lb. ij. Aquae Bullientis Solutse,..........................lb. x. M. The potash had better be omitted for the first few times, until the turgid condition of the capillaries has diminished, after which, it can be advantageously added. One or the other of these baths, according to circumstances, should be employed as auxiliary to other antiphlogistic measures. PAPULAR ERUPTIONS. 301 In the acute variety of lichen, there is usually considerable derangement in the chylopoietic viscera; and this state of things must be rectified, otherwise the skin will remain unim- proved. The Congress Spring water, under these circum- stances, frequently constitutes a valuable beverage for the patient. It acts as an efficient evacuant on the kidneys or bowels, or both. I always prescribe it, if the individual can afford the expense which its use involves. It is a capital tonic to the digestive apparatus, while it is sure, also, to act with energy and safety on the emunctory system.* The liquor ammoniae acetatis can likewise be employed to advantage. It is an excellent diaphoretic; and prescribed to the amount of two or three drachms in a gill of warm, sweet- ened barley-water, three or four times in the day, will prove grateful to the patient, and will allay any existing febrile ac- tion. Quietude and a bland diet should be enjoined. These simple measures comprise about all the therapeutics, which the case will require at this stage, and will constitute the best preparatory steps to any subsequent treatment which the con- dition of the individual may demand. Should the eruption affect a chronic type, the sulphuret of potash bath will be found beneficial in conjunction with the moderate internal employment of mercury. When the papules occupy the face, the patient is always anxious to be rid of them from that locality; and he will not be content unless some topical means are prescribed for this purpose. The fol- lowing ointment may be employed at bed-time : — R. Hydrargyri Deuto-Iodidi,...............................gr- i- Pulveris Camphoras,...................................gr- v"i- Unguenti Rosarum,....................................3 *ss- M. A small quantity is to be rubbed upon the diseased patches. * The following are the results obtained from an analysis of the Congress water, as reported by Sir Humphrey Davy and Professor Faraday: — B. Chloride of Sodium,..............................385.44 grs. Hydriodate of Soda,.............................. 4.02 " Carbonate of Lime,................................116.00 " Carbonate of Magnesia,........................... 56.80 " Oxide of Iron,................................... 64 " Carbonate of Soda,............................... 56 " Hydro Bromate of Potash, a trace,.................___00 " Solid Contents in a gallon,........................563.46 " 26 302 GONORRHOEA AND SYPHILIS. If it produce much smarting, the proportion of the deuto-iodide must be lessened, and its application repeated every other night only. A moderately stimulating impression on the skin is all that is requisite with a view to accomplish the absorp- tion of the papules. The iodide of sulphur ointment is some- times an effective local remedy in these cases. R. Sulphuris Iodidi,......................................3ij. Pulveris Camphorae,..................................gr. vi. Olei Bergamii,........................................ " Lavandulae, aa,...................................gtt. v. Unguenti Rosarum,...................................§ i. M. This preparation can be rubbed upon the papules every night. A drachm of the iodide of sulphur to the ounce of unguent may be prescribed, if it is not to be employed upon the face. The tar-ointment has been found beneficial. Mr. Acton ad- vises that the patient rub the affected parts daily with it, and recommends that he do not change his linen. By so doing, he lives in an atmosphere of tar. In hospital practice, such a course can be pursued without difficulty, but with private pa- tients it would not be convenient. Where the pimples show a disposition to soften and to yield a moderate discharge, or to degenerate into small ulcers, I have generally found the subjoined formula answer the desired purpose. Should the disease be situated upon the face, the application can be made without annoyance to the olfactories; whereas the iodide of sulphur, and the tar-ointment are not agreeable. R. Olei Bergamii,.......................................gtt, v. Plumbi Acetatis,.....................................3i. Unguenti Hydrargyri Nitratis,.........................5 ss- " Cetacei,....................................§ i. M. Fumigations. — If the eruption assume an obstinate dispo- sition, cinnabar fumigations will be of service. Mr. Langston Parker has had large experience in the use of several kinds of mercurial fumigations, in the management of syphilitic affections, both primary and secondary; and his testimony in their favor is entitled to consideration. His plan is, to have the patient seated, naked, in a chair or box, with the head and face free, as in a common sulphur-fume bath. The mercury is PAPULAR ERUPTIONS. 303 volatilized from a tin plate by the heat of a large spirit lamp, — at the same time, a current of steam is conducted into the apparatus. The person remains in the box twenty or thirty minutes. The bath may be repeated every second or third day. The treatment is not attended with any accidents, such as diarrhoea, or salivation, and is as certain, and as little hurt- ful as any remedial course can possibly be. Even in primary phagedaenic sores, Mr. Parker does not hesitate to employ these fumigations. In regard to the merits of his practice with mercurial fumigations, in ordinary instances of secondary affections, there can be no doubt; but in cases of phagedaenic ulcers, at any stage of the venereal disease, I do not incline to advocate the administration of mercury in any form, man- ner, or quantity. To me, it seems to be a matter of doubt, how the salutary influence of moist mercurial vapor is pro- duced. Does the good effect ensue in virtue of the absorption of the exceedingly minute portion of mercury, which is taken into the circulation through the cutaneous vessels; — or, is the benefit of the bath due to the amount of perspiration, which the process excites ? Of the entire volume of mercurial vapor, generated and diffused through the whole area of the box, which the individual is supposed to occupy, but a fractional part is deposited on his person; and it appears not improbable that the aqueous vapor and the fluid of perspiration must necessarily tend to hinder the mercurial substance from gain- ing free access to the interior of the system. And therefore the query suggests itself, — is it the mineral agent, that goes .nto the animal economy, or the venereal poison that goes out through the medium of cutaneous exhalation, that confers the benefit? I am led to these remarks,because I have witnessed gratifying results from the protracted use of sulphur-fume baths, combined with aqueous vapor, or with dry heat, at a temperature of one hundred to one hundred and ten degrees. f he simple, unmedicated vapor-bath, administered to persons suffering not only from papular, but from various other forms of cutaneous eruptions, exerts a highly beneficial influence. The stimulating and tonic action of the vapor of sulphur, com- bined with heat and moisture, agrees, I am certain, with indo- lent sores and ulcerated surfaces generally, whether venereal or not; and the use of such baths can hardly ever be ill-timed, 304 GONORRHOEA AND SYPHILIS. provided the individual has sufficient vigor to go through the process without fatigue. In purely papular or squamous affections, the remedial agency of the bath is scarcely less re- markable. But to secure its best effects, a high, moist tem- perature is requisite, in order to induce a copious perspiration for an hour or two every day or every other day, as the phys- ical condition of the patient may be. If, in the administra- tion of the bath, any circumstance should transpire, to prevent free perspiration, little or no benefit will be realized from its employment, — however it may be medicated, — whether with sulphur or any mercurial preparation. In hundreds of in- stances I have tested the value of the sulphur-fume bath and the simple vapor-bath. As curative means of decided efficac}', when employed as auxiliary to internal remedies, they can be administered in nearly all cases, where the patient is not labor- ing under any acute or febrile symptoms. The practitioner will find them a great help in restoring and maintaining the healthy functions of the whole cutaneous surface, and thus conducing to the cure of the local disease. The same is true in regard to the artificial sulphureous water-bath, with gelatine dissolved in it. Cold sea-bathing, in relation to which patients often make inquiries, is seldom admissible. Warm sea-baths, on the contrary, generally promote the improvement of the syphilitic invalid. I am inclined to the belief that nearly or quite all the bene- fits attributed to mercurial fumigations, can, in a majority of cases, be realized from the use of either of the other baths that have been alluded to. Before dismissing this subject, I must, in justice to Mr. Parker, insert a few particulars touch- ing the method of employing the mercurial vapor-baths, to which I have no objections to offer. If the circumstances of the patient will permit their use, they can be prescribed as a safe means of ameliorating, or curing various consecutive symptoms. " The patient is placed on a chair, and covered with an oiled cloth, lined with flannel, which is supported with a proper frame work. Under the chair are placed a copper bath, containing water, and a metal plate, on which is put from one to three drachms of the bi-sulphuret of mercury, or the same quantity of the gray oxide or the binoxide. Under each of these, a spirit lamp. The patient is thus exposed to the in- PAPULAR ERUPTIONS. 305 fluence of three agents, heated air, common steam, and the vapor of mercury, which is thus applied to the whole surface of the body in a moist state. After the patient has remained in the bath from five to ten minutes, perspiration generally commences, and by the end of twenty or thirty minutes, be- yond which I do not prolong the bath, it is generally exces- sive. The lamps are now removed, and the temperature grad- ually allowed to sink; when the patient has become moder- ately cool, the coverings are removed, and the body rubbed dry; the patient is suffered to repose in an arm chair for a short time, during which he drinks a cup of warm decoction of guaiacum and sarsaparilla." The use of the dilute nitric acid will be attended with favor- able effects. In all stages of the complaint it will be found serviceable, but particularly so in the chronic; and it may be administered for several weeks in succession, according to the annexed formula: — B. Acidi Nitrici Diluti,................................gtt. xxx. Syi'upi Aurantii,...................................§ ii. Decoctionis Saponariae,............................5 xn* M. The above is sufficient for one day. In the syphilitic ward of the Royal Free Hospital, London, Dr. Marsden has, for more than twenty years, treated second- ary eruptions by the administration of stomachic and tonic remedies and good diet, conjoined with the following: — R. Antimonii Sulphureti, Potassae Nitratis, aa,................................3 v. Sulphuris Sublimati,................................ 3 uss- M. Of this powder, the dose is thirty-five grains, night and morning, in syrup or molasses. The London Lancet* states that this plan of treatment has been pursued in thousands of cases at the above charity, and the most gratifying results have been obtained. The medicine is to be persevered in for some weeks after the cutaneous affection has died away. I have made only one fair trial with this remedy. The patient was a married woman, twenty-nine years old. She had had syphilitic lichen on the face, body, and extremities, seven weeks * Of June 27,1857. 26* 306 GONORRHOEA AND SYPHILIS. before she applied to me. The above powder was the only remedy prescribed. The eruption disappeared in six weeks and did not return. The powder was continued in reduced quantities for six weeks afterwards. The patient resided in the country at the time, lived well, and had the benefit of whole- some air. Her general health had not suffered from syphilis. In cases of peculiar obstinacy, which resist the action of the foregoing medicines, the bichloride of mercury, to the amount of one tenth of a grain twice a day, should be prescribed in conjunction with tonics. For the purpose of presenting the mode of treatment more in detail, and at the same time bringing forward an instance to show that the same venereal eruption may have a variety of color in different regions, I transcribe from my note-book the following case. It will be seen that it offers one or two other points of interest; the first is, the lightness of the primary disease. The patient had chancre, but no inguinal enlarge- ment that ever attracted his attention. In the second place, there was an uncommonly long interval between the cure of the original accident, and the manifestation of constitutional infection; and, lastly, the total absence of the copper color upon the face, and its development upon the lower extremities. October 26. — N. H., a young medical gentleman, consulted me for an eruption, which appeared upon the limbs and else- where, about eight months ago. It came upon the legs first. The malady on the face is now a well-defined lichen; is not blended with any other affection, nor is it modified by any local applications, for none have been used. The face has, the appearance of being slightly freckled; that is, very small, yel- low spots, with their outlines not well marked, are scattered over the forehead and cheeks, where the papules are most abundant. The pimples about the nose are farther advanced than the rest, and are covered upon the summit with an epi- dermic scale. They are all distinct, and are elevated very perceptibly above the adjacent integument, but are destitute of the coppery hue. The palms of the hands are dotted over with the same eruption. Here the papules appeared subse- quently to those on the face. Those on the palms are larger than the others; are perfectly hard under the epidermis, which is somewhat broken, and every five or six days is cast off in PAPULAR ERUPTIONS. 307 small, micaceous exfoliations. The integument here is also free from any coppery tinge. The hands present an appear- ance similar to that seen in the commencement of psoriasis palmaris. The arms are slightly implicated; but neither is there here any cupreous hue of the surface. The legs were next examined. On these the disease first displayed itself, and the general aspect of the integument here was decidedly of that dirty, boiled-ham color, which, when present, is so justly regarded as almost unequivocal evidence that its pecu- liarity is due to a specific cause. Along the belly of the gas- trocnemii muscles, and farther downwards, were some eight or ten round, deep ulcerations, which had penetrated through the derma and cellular tissue; some of them were covered with thick brown crusts (ecthyma), below which, on pressure, a small deposit of fluid could be detected. Other pustules or sores were less protected by scabs, and yielded a foul, sanious discharge, perhaps some half-dozen drops from each, in the course of the day. None of the sores were larger than a dime, and were all unprotected by any dressing or covering, except the trowsers. They had been in nearly the same condition for several months. So said the patient. Some of the papules on the legs retained their original, frank, lichenoid character; but the greater portion of them had grown into good sized tubercles, or had advanced still farther, and had become tuber- cula ulcerantia. The young man was pale and thin; he stated that his flesh and strength had of late greatly diminished; he could walk but a short distance without fatigue, and being obliged to rest; he complained of dyspepsia and constipation ; he consumed large quantities of tobacco, both in chewing and smoking; sat up late at night, and rose at a corresponding late hour in the morning. He took but two meals during the twenty-four hours. There was an unnatural sound in his voice, as if the calibre of the air passages were obstructed by tena- cious mucus, which gave a hoarse rale in the upper part of the trachea when he spoke. The fauces were swollen and deeply reddened. The patient remarked that he had for sev- eral months been troubled with what he supposed was bron- chitis. The right testicle was enlarged and at times painful. I had no particular acquaintance with this individual, and knew nothing of his previous habits; but from the evidence pre- 308 GONORRHOEA AND SYPHILIS. sented, I could not entertain any doubt as regarded the specific nature of his symptoms. Our interview was here interrupted, and I did not see him again until November 1th. — N. H. called and desired my opinion of his case. In return, he was requested to give his own. He re- plied that he considered his complaint to be scrofula. I stated that my belief was that he had constitutional syphilis. He re- marked that this was impossible; but as I adhered to my po- sition, he acknowledged that six years previously, he had a small chancre, which was cured in a few days, and that he had not been ill for a day from the time it healed to the time when the eruption appeared upon Jus legs. He took no mercury for the chancre. He was surprised at my diagnosis, and it was some time before he acquiesced in it; he however yielded with praiseworthy accommodation of mind. He had great confi- dence in the power of mercury to cure all forms of venereal symptoms, and requested that it might constitute a leading feature in the remedial administration, with which the treat- ment should commence. To this I saw no objection, and the following course was adopted : — R. Hydrargyri Chloridi Corrosivi,........................ Ammoniae Muriatis, aa,..............................gr. viii. M. ft. pil. No. lxiv. Dose. — One pill morning and evening, directly after eating. Of the solution of tartrate of iron and potash, according to the formula already given, he took two drachms three times a day. A warm bath every other night. As an external application to the face, he used, partly at his own suggestion, the following preparation: R. Sulphuris Iodidi, ....................................3ij. Pulveris Camphorae,... 1..............................gr. v. Olei Bergamii,.......................................gtt. vi. Unguenti Rosarum,..................................§ i. M. The patient was advised to revolutionize his habits; that is, to retire to bed at a more seasonable hour; to rise early ; to take three meals a day instead of two, and at regular hours, like other people; to have a generous diet, and to abstain from tobacco ; all which he promised to do. PAPULAR ERUPTIONS. 309 The above ferro-mercurial course was continued for about three months. In two weeks an amendment in the constitu- tional condition of the young man was quite apparent. He had a more vigorous appetite and better digestion; his strength improved, and he began to gain in flesh. The cutaneous dis- ease did not change for the better, until the third week from the commencement of the treatment. On two or three occasions the gums became slightly tender. The pills were accordingly intermitted for five or six days and then resumed. He con- tinued his avocations most of the time as usual. Fortunately, no appearance of the skin upon the face or hands betrayed any specific coloration arising from the disease. The eruption on the palms disappeared first, then that on the arms, and lastly that on the lower limbs. On the latter the characteristic copper colored stains remained for a long period, but finally faded away satisfactorily. The unavoidable exposure of the patient to all states of weather during the winter months, was calculated to retard the removal of the papules and tubercles from the face; and it was not until the mild weather of the following spring, that the integument of this unprotected region was restored to its normal condition. The orchitis was not very troublesome. It would continue for a week or two and then subside under the influence of moderate doses of the iodide of potassium, rest, and a suspensory bandage. A few words more, relative to topical applications to syphil- itic lichenoid eruptions. If they assume a chronic character, I generally select the iodide of sulphur ointment, as answer- ing all the purposes to be gained by the employment of greasy substances, a class of remedies, which we are to avoid if we can ; but which we are glad, on some occasions, to call to our aid. Where the eruption is slight, the subsulphate of mercury will frequently answer every desirable end, and will be more agreeable to the patient than the iodide of sulphur. R. Hydrargyri Sulphatis Flavi,..............................3i. Unguenti Rosarum,.....................................3 K M. While applying any of the ointments, the utmost care should be observed to keep the diseased surface in a cleanly state by the use of warm bran-water every day before the inunction. 310 GONORRHOEA AND SYPHILIS. Stimulating lotions will frequently exert a favorable in- fluence upon the papules, if applied in the early stage and be- fore their transition into the larger prominences, which are, strictly speaking, tubercular. The annexed prescription is one of the best: B. Hydrargyri Chloridi Corrosivi,.........................gr. xii. Aquae Colognae,...................................... Spiritus Rectificati, aa................................3 i- Aquae Fontanae,......................................§ viii. M. A small quantity is to be dabbed upon the papules three or four times in the day. The nitro-muriatic acid, properly diluted, makes a very ex- cellent application. It will be borne without complaint of the following strength, and will in many instances promote the dis- persion of the papules: B. Acidi Nitrici,......................................... " Muriatici, aa,...................................3 i- Aquae Fontanae,......................................§ xvi. M. Lotion. — To be used two or three times daily. The ointments and lotions above mentioned, are all about on a par with each other, as to the resolvent power, which they display; and if the eruption should occupy any part of the face, the patient will not be content unless some of them are employed. CHAPTER XXIX. SQUAMOUS SYPHILITIC ERUPTIONS. ARE MET WITH IN YOUNG SUBJECTS — THEIR MOST PROMINENT FEATURES — ERRORS IN DIAGNOSIS IN CONSEQUENCE OF THE ABSENCE OF THE COPPER COLOR — CASE—THE SQUAMA BELONG EITHER TO PSORIASIS OR LEPRA -- TREATMENT. These constitute a very common variety of venereal affec- tions. They are met with in patients, in whom the existence of any such taint would scarcely be suspected. In young subjects they are sometimes seen as an ignoble inheritance. Mr. Hunt, a distinguished dermatologist of London, states it as his opinion, that a large portion of squamous diseases belongs to this special category. The non-mercurial treatment of the primary syphilitic lesion, which was somewhat the fashion of the times a few years ago, more so, at least, than at the present day, has probably multiplied the cases of hereditary syphilis to an extent of which practitioners generally, are not aware. The skin of young children seems to be more frequently the play-ground upon which this malady delights to revel, in its secondary form, rather than to dwell among the other tissues. But the squamous affections are also seen in persons of ma- turer growth; and the great difficulty is to distinguish be- tween those that are venereal from those that are not. The most salient features of the squamous affection, whether we call it syphilitic psoriasis or syphilitic lepra, are the forma- tion of dry, thin, dark-grayish laminae or scales, reposing upon circular patches of dingy, red skin. The scales differ entirely from the white, silvery hue of lepra vulgaris or ordinary psori- asis. The diseased discs are considerably raised, and isolated, rather than confluent, and of a copper color. This is the rule in relation to color, although, as in other stages and forms of venereal eruptions, we must admit that there are exceptions to this law, in its application to the squamous eruptions. Mr. Green gives a good description of this complaint in the 311 312 GONORRHOEA AND SYPHILIS. following quotation: " The squamous forms of syphilide are generally so perfectly characterized by the coppery, and sometimes nearly black color of the eruption, by the soft, smooth surface presented by the patches when freed from squamae, and by the flimsiness and scantiness of their scales, contrasted with the abundant formation and strength of the epidermic laminae, in simple lepra and psoriasis, that there is no risk whatever, of confounding the disease arising from specific causes, with those, which invade at least under unknown in fluences." Mr. Burgess, who is usually good authority, informs us that the characteristic color is always to be found; for no matter how small the patches may be, they are never covered entirely by the epidermic scale. In the main, this statement is without doubt correct; and yet, if the young practitioner were to take it as an infallible guide, he would in some cases, be very likely to err in judgment. It seems to me that the idea in re- gard to color, introduced as a matter of such uniform con- stancy in the venereal squamous affections, has not its founda- tion in the pathological state of the skin, any more than it has in the other syphilodermata. In this connection, I. submit the following case, which affords a striking illustration of the lia- bility to blunder, to which the wisest men are exposed, when under the guidance of the old, but false doctrine here alluded to, and which was so long held in almost sacred repute. Case. — I once knew an error in diagnosis to be committed by an eminent surgeon in one of our chief cities, in reference to this particular type of syphiloderma. He gave his written opinion that a certain case was not venereal, because the pe- culiar discoloration did not exist. The patient came to Bos- ton. It was in September, 18—. He was 29 years of age. On the recommendation of Dr. Wm. J. Dale, he called upon me, in company with his father, who had formerly been a prac- tising physician, but had become a wealthy farmer. The young man was married to a health)' woman, who had suffered two miscarriages. He was of diminutive stature, emaciated and feeble; could scarcely Avalk a hundred rods; his appetite was miserable ; he had much trouble from constipation ; his tongue was coated; the pulse 100; and there was extreme uutiii Eruptim squamous syphilitic eruptions. 313 pallor of countenance. There were several squamous blotches od the face, varying in size from that of a ten-cent piece to twice that bigness, and slightly elevated above the adjacent sound skin. Some of them had healed from the centre and presented an annulate figure. Large portions of integument covering the body and extremities, were occupied by the eruption in different stages of development. The most singu- lar and interesting specimens consisted of annular, tuberculo- crustaceous patches, of various dimensions. One of these, situated on the right fore-arm, embraced within its circuit, nearly a third part of the integument of its dorsal aspect. It was produced by the union of numerous groups of tubercles, which had partially softened on their summits, and yielded a very scanty purulent exudation, — the latter having desicca- ted into a thick, dark incrustation. The area, included within the ring, had all formerly been the seat of the same deranged action, which, as the eruption healed, had a centrifugal ten- dency ; that is, as it got well in the central part, new tuber- cles would appear, just outside the borders of the cicatrix, which widened in every direction in nearly equal ratio, and which now presented a reddish brown or vinous tint. (Plate III.) On the back were five or six morbid patches, similar to the one represented in the plate. The friction of the clothing and that arising from locomotion, created, in some of the diseased localities, considerable irritation and discomfort, with a copious oozing of sanio-purulent matter. On the right buttock, there was one large patch, which interfered with any attempt at walking and with the usual sitting posture. The legs and arms were thickly covered with eruption, which, in most in- stances, took the annulate form, and varied in size from half an inch to thrice that diameter; squamous in some spots, in others tuberculo-crustaceous. On the entire surface there were some seventy or eighty of these sores. They pro- duced no itching; but gave rise to a most offensive exhalation. The patient had neglected to bathe for a long time. The sebaceous apparatus was in a state of atrophy for want of nutrition; the whole of the integument, not actually implicated in the complaint, was covered with dry, rough epidermis and other accumulated exuviae. At times, during inclement winter 27 314 GOi. RRHCEA AND SYPHILIS. weather, there had been sore throat to a moderate degree. The patient was extremely feeble and desponding, and was a spectacle of great wretchedness. He denied ever having had primary syphilis. His father remarked that he had consulted some of the most eminent surgeons and physicians in the United States, both at the North and the South, and that the subject had often been discussed; and that no medical man, who had examined his son, regarded his case as venereal; an idea which the father seemed to endorse. I obtained a private interview, on the following day, with the son. On this occa- sion he acknowledged, after a few evasions, that he contracted a gonorrhoea in New York, two years previous to the appear- ance of the cutaneous affection. The case was now relieved of the thin veil that overhung it. The chain of evidence was strong and complete, and my judgment and my course were unembarassed. The father, who was waiting in another apart- ment, was invited into the consulting-room. I communicated to the parties my opinion that the malady was constitutional syphilis; having its origin, probably, in urethral chancre. Great dissatisfaction was manifested by father and son; and the written opinion of the eminent surgeon above referred to, was presented, as antagonistic to mine. I replied that the case was to me as clear as the light of day, and that no names or documents would induce me to change my position. After wasting about two hours in fruitless debate, it was agreed that Dr. Dale and Dr. J. Mason Warren should be called in con- sultation ; and that if their diagnosis harmonized with mine, the decision should be considered correct and final, and that I should have the professional care of the patient. The first part of this arrangement was consummated in a few hours; and after a thorough examination of the young man, the two consulting gentlemen corroborated my opinion. Next morning the father and son took the cars for the purpose of again visiting the aforesaid eminent surgeon, and of reporting to him our views in regard to the case. In communicating our decision to this surgeon, the patient, in accordance with my advice, acknowledged that he had for- merly been exposed to the infection of primary syphilis, etc. The surgeon perceiving at once the whole merits of the ques- tion, exclaimed, " Primary syphilis ! primary syphilis ! you did SQUAMOUS SYPHILITIC ERUPTIONS. 315 not tell me that; the Boston doctors are right." The last re- mains of the cobweb were now swept from the father's mind. He returned to Boston and committed the son to my care, and a course of treatment was at once inaugurated. It embraced a period of two years, at the expiration of which it was brought to a happy termination. A brief resume of what was done is all that I propose to give. For a long time, tonics constituted the basis of nearly all the internal remedies; and prominent among these was the potassio-tartrate of iron, at the rate of six drachms per diem, in an infusion of quassia. The appetite was soon quickened, the digestion improved, and an increase of flesh became apparent in a few weeks. By care- ful attention to diet, particularly the free use of fruits, such as apples, pears, oranges, and grapes, the normal function of the bowels was gradually restored, and was easily maintained. By the use of the sponge and slightly chlorinated water, the faithful wife kept the poor victim in a cleanly condition, until he was able to endure warm water baths, which were some- times impregnated with sulphuret of potash, and sometimes unmedicated. As soon as he had gained a fair amount of strength, the pulse having acquired considerable volume, and the capillary circulation being well established, as shown by warmth of the extremities, the use of the bichloride of mercury, in pills, was added as auxiliary to the ferruginious solution. The daily quantity of the oxymuriate ranged from one-eighth to one-fourth of a grain, care being taken not to disturb the normal condition of the mucous membrane or salivary appara- tus. The time for the continuous employment of the last remedy varied from four to six weeks, generally followed by an intermission of two or three weeks. Given in this guarded manner, it appeared to act as a valuable therapeutic adjunct to the other constitutional means; and not the slightest incon- venience was experienced from it. From the moment the treatment was instituted to its close, no retrocession of symp- toms took place. The progress towards a cure was indeed slow; but it held the even tenor of its way, until all evidence of the syphilitic contamination disappeared, so far as relates to actual symptoms. The patient, who, from the beginning, carried out the prescribed course in its minutest details, has enjoyed comfortable health for several years. 316 GONORRHOEA AND SYPHILIS. Besides the remedies above mentioned, other suitable me- dicines were employed, such as dilute nitric acid, large liba- tions of the compound decoction of sarsaparilla, decoction of yellow dock-root, Congress Spring water at the fountain, the tincture of the muriate of iron, the citrate of iron and quinine, cod-liver oil, acetate of ammonia, and small quan- tities of the iodide of potassium, together with the use of various topical appliances, already sufficiently alluded to in previous pages. Nor was the benefit resulting from a salu- brious atmosphere and agreeable exercise forgotten. The patient took board a short distauce from the city, and as soon and as fast as his strength would permit, he was daily on the wing, making short excursions with his friends, visiting fashionable watering places and other notable localities. In many cases, the syphilodermata have their distinctive characters well marked ; and the eye that is familiar with them, can recognize their signification almost as readily as one can tell the hour of the day by looking at the face of a watch. On the contrary, there are other cases, in which the eye is not sufficient. The mind needs to consider the ensemble of the symptoms collectively, whether revealed to the organ of vision, or depending upon the general condition of the patient, or gathered from his past history. All the sources of informa- tion should be explored. The entire facts in the case are as essential to the practitioner as they are to a judge in deciding a matter of jurisprudence. When we are unable, with all the assistance we can com- mand, to arrive at a clear and satisfactory diagnosis, we can sometimes resort to mercury as a test. The ground on which this recommendation rests, is this : if the eruption be venereal, the medicine will be likely to relieve it; if not venereal, the patient will be liable to get worse. The medical attendant may be so situated with respect to the individual that he can- not exchange words upon the topic with safety or propriety. Such circumstances do now and then happen. Upon the sub- ject of syphilis the physician is bound to keep silence. In suspicious instances, the usual avenues to the truth being un- available, mercury may be properly summoned as a witness, provided the general health and the condition of the person SQUAMOUS SYPHILITIC ERUPTIONS. will warrant the experiment, and provided, also, that other means have been tried to no good purpose. On the other hand, it must be acknowledged that cases exist, in which the mineral in question, even if administered till the system be ab- solutely saturated with it, would afford no clue to the real character of the complaint. It is not every syphilitic subject who can tolerate the action of mercury in any form or quan- tity. The syphilitic pimple, which, in the elementary form, is a papule or tubercle, may terminate in a squamous disease, ex- hibiting repeated desquamation of the epiderma, in thin, flimsy scales. Sometimes the syphilitic spots are evolved in the form of squamae at the beginning of their appearance. They occasionally show a disposition to yield a very little purulent discharge ; but I am inclined to believe, that in a majority of instances, regarded as squamous, the lichenoid papule or the tubercle, precedes the squama, the latter condition being sim- ply the secondary stage of the eruption. The true squamous blotches belong either to psoriasis or lepra. They present themselves as circular discs, perceptibly elevated above the adjacent skin, are of different sizes, from the fourth of an inch to an inch in diameter, rarely accom- panied by any moisture from the morbid surface, and causing no inconvenience from pruritus, differing in this last particu- lar, from ordinary, non-specific eruptions of the same order, which are always a source of irritation and annoyance to the individual, even when only a very limited portion of skin is implicated. The terms syphilitic psoriasis and syphilitic lepra, as at present understood by dermatologists, are applied to one and the same disease. They differ, it is true, in the form of the patches which they exhibit, but not otherwise. The particu- lar portions most commonly occupied, are the scalp, the ante- rior surface of the body, the palms of the hands, and the soles of the feet. When the two last named are involved in these chronic, squamous inflammations of the derma, the scales are remarkably thick, corneous, dry, and brittle. The syphilitic squamae are to be regarded as of an inflammatory nature, al- though the inflammation is of a low, subacute type. The usual characters of inflammatory action, such as heat, pain, 27* 318 GONORRHOEA AND SYPHILIS. smarting, burning, throbbing, etc., are almost entirely absent. The same is substantially true of other syphilodermata. As we have already seen, one of the most remarkable peculiari- ties of them all is a deficient sensibility of the part involved in the disease, as if the cutaneous nervous substance were dead, or had nearly lost its functional energy. And perhaps this nervous defection gives rise to other singular features that appertain to venereal eruptions. Sometimes the squamous affection exists on the palms of the hands as the only manifestation of constitutional taint, and shows a disposition to extend in every direction from a cen- tral point, thus presenting an annulate figure. It is called psoriasis palmaris centrifuga, or erythema palmare annula- tum syphiliticum. Distinct and well-marked tubercles are often found associated with the squamae in different parts of the affected area. Occasionally, the disorder is developed on the back of the hands, and the central portion of the morbid surface presents a dark, livid hue for a long period, in conse- quence of enfeebled capillary action ; and the scales which are detached from time to time, are also of a very dark color, nearly black; but, as the process of cure advances towards completion, and the constitutional vigor waxes stronger, the integument resumes, by slow degrees, its natural properties, and the abnormal color fades away. The malady described as lepra nigricans, is probably nothing more than this lepra syph- ilitica, characterized by dark, fuliginous squamae. The blotches assume various tortuous appearances or forms, which are mod- ifications of a circle or segments of a circle. In some instances, the scaly eruption is accompanied by other consecutive symptoms. The mucous membrane of the nasal apertures and of the external auditory meatus, the eye- lids, and mouth, will exhibit marks of depraved action in the form of small pustules, excoriations, abrasions, or ulcers. Now and then, leprous squamae are seen on the face or on the supe- rior portion of the trunk, associated with tubercles on the arms, while ulcerations of various extent occupy the inferior extremities. These several co-existing phenomena indicate a serious impairment of the system, and are rarely present un- less the patient has struggled for a very long period against the venereal poison. When the squamae appear upon the SQUAMOUS SYPHILITIC ERUPTIONS. 319 scalp, the hair usually falls out, and it can seldom be restored to any great extent. In non-specific squamous eruptions, the pilous apparatus remains intact or nearly so. TREATMENT OP SQUAMOUS ERUPTIONS. The constitutional treatment with mercury, recommended where syphilitic lichen affects a chronic type, is equally appro- priate in squamous diseases of specific origin. As they are seldom accompanied by inflammatory action of any great amount, either local or constitutional, antiphlogistics are not required. These squamae cannot, in fact, be subdued by such energetic measures. Mercurials may be administered with a somewhat bolder hand than would be allowable in a lichenoid syphiloderma. The gums should be made, not absolutely sore, but quite tender; and the medicine be graduated in quantity so as to keep the gums in this condition, until the cutaneous disease shows a disposition to decline. If the system be prop- erly sustained by a full, nutritious diet, and the appetite encouraged by the administration of ferruginous tonics, or by quinine, or the infusion of quassia, the patient has nothing to fear from a somewhat protracted use of mercury. Its de- pressing influence can, in nearly all instances, be prevented, if the physician allow, in connection with it, a generous mode of living. To prescribe mercurial agents, and at the same time restrict the patient to a poor bill of fare, is, in my opin- ion, no way to cure him of constitutional syphilis. All the liberality which the digestive apparatus can bear, should be shown, in order that the system may be raised and preserved as near a healthy standard as possible. In my esti- mation, it is of little avail to maintain a ceaseless warfare against the disease by the employment of potent remedies, while the patient is kept on a meagre allowance of food. We might as well expect a ship to sail without wind, or a rush to grow without water, as to expect that syphilis can be subdued by such treatment. The squamous eruptions being, like the chronic venereal affections generally, of an asthenic character, there is a prevailing tendency to constitutional debility, which we are to guard against. To check this downward inclination most effectually, we must sustain the energies of the system 320 GONORRHOEA AND SYPHILIS. by food at once nutritious and easy of digestion, and thus confer upon the various organs, tissues, and fluids, ability to antagonize the inimical principle that is hidden within the physi- cal organization. Milk will usually agree with the patient. It comes already cooked, and contains such a combination of animal and vegetable qualities, that no improvement can be made upon it. The patient may, at the same time, require a diffusible stimulant with it; and the physician need not hesi- tate to allow the addition of half an ounce, or so, of the best brandy, or a still larger quantity of Sherry or Madeira wine, to half a pint of milk three or four times, in the course of the day and night. To endow the impoverished and infected blood with more opulent qualities, is also an end we accom- plish by the liberal administration of ferruginous medicines; for it is a point now well established, that by the exhibition of such remedies, the process of haematosis in the economy is facilitated; and that in the normal growth and development of the blood, its characteristic corpuscles are augmented nu- merically — and hence the therapeutic value of chalybeates, whether given in conjunction with mercurials or with the iodide of potassium. With a view, also, of restoring the lost tone of the consti- tution, the cod-liver oil may, in many cases, be advantageously prescribed in doses of two drachms three times a day, gradu- ally increasing the daily quantity to ten or twelve drachms, provided it be borne quietly. It is sometimes difficult to reconcile the stomach to the presence of the oil even in the smallest amount. But its salutary effects in sharpening the appetite and promoting nutrition, and overcoming, in a good degree, the cachectic state of the system, are well known; and its claims to our confidence, in the condition of things we are now considering, cannot be doubted. It is usually retained quite well, if administered in pale ale, or in the infusion of hops. Its disagreeable taste can also be disguised somewhat by the addition of a few grains of salt, by the aid of which it is more easily digested. Jellified Cod Liver Oil. — An article, bearing this title, is manufactured by Mr. E. Queru, a practical chemist of New York. It has already attained considerable notoriety and favor SQUAMOUS SYPHILITIC ERUPTIONS. 321 with practitioners, and in all probability is destined to become still more popular as a therapeutic agent, especially for delicate females, and other individuals, who have great repugnance to the oil. As a medicine, its value is equal to that of the latter substance, while it possesses the important advantage of being in a great degree deprived of its nauseous properties, and is tolerated by persons who cannot endure the oil. It contains eighty-five per cent of the latter. It can be swallowed, with- out masticating, in a little sweetened water. Used in this manner, the invalid perceives little or no taste, nor does it dis- turb the stomach like the crude oil. The jelly will be found most appropriate for those syphilitic patients, who exhibit a mal-assimilative diathesis and great emaciation. Cod-liver oil has also been converted into a dietetic form by Mr. Lebague, a chocolate manufacturer of London.* It is combined with chocolate in the proportion of four ounces to the pound. The cakes are divided into small tablets, each of which contains one drachm of the oil. This preparation is particularly convenient for children as a valuable dietetic medicine. The idea of prescribing the oil in this manner originated with Professor Wilson, who states that he has found it of great service. If mercurial preparations are taken in immediate connection with the food, a larger quantity can be borne without exciting irritation in the alimentary canal than could be on an empty stomach. Biett advises that the bichloride of mercury be taken in combination with opium, thus: — R. Hydrargyri Chloridi Corrosivi,.........................gr. xii. Pulveris Opii,........................................gr. xx. M. Ft. pil. No. xxxvi. Give one pill every morning, increasing the dose by degrees, and discontinuing the medicine from time to time, in case the bowels become too much affected. In his early practice, Biett * Of No. 10, Little Tichfield St., St. Marylebone. The chocolate can be ob- tained at Metcalf s, Tremont St., Roston. 322 GONORRHOEA AND SYPHILIS. gave the preference to the oxymuriate, over the other forms of mercury. Wilson is partial to the biniodide, as at first re- commended by Biett, although Biett soon relinquished the biniodide for the proto-iodide, which is more manageable, and is an eliminative agent of great power. The formula, as pre- ferred by Ricord, has already been mentioned. The quantity of this salt for ordinary use, is from one grain to four grains in the twenty-four hours. If opium be given in com- bination with the proto-iodide, the therapeutic qualities of the latter are completely neutralized, and therefore it should be prescribed in an uncombined form. Biett made this dis- covery. For the purpose of awakening the cutaneous excernent sys- tem to increased action, sudorifics are to be prescribed as im- portant adjuvants to mercurials. The kidneys are also to be brought into active play, and urination encouraged by the em- ployment of diuretics. Thus, by the most efficient, and at the same time, the most simple and harmless remedies, the skin and kidneys, with their immediate associate organs, can be used for any length of time as drains, in relieving the economy of the poison that pervades it. The question often arises, how long is the mercury to be continued? Sir Astley Cooper was wont to say, that the greatest secret in the treatment of syphilis, is knowing when to discontinue this remedy. So long as the patient gives evidence of improvement under its influence, so long it is to be employed; but circumstances sometimes unexpectedly occur, which render its further administration impracticable, and we are compelled to seek other remedial means as a sub- stitute. In such cases, the iodide of potassium will frequently prove a valuable article. In some instances, that have long been under mercurial treatment, the disease seems to remain uninfluenced by it, and the general condition of the patient is retrograde. His appetite, flesh, strength, sleep, and courage, perhaps, have failed him. In this condition of things, it will be ad- visable to suspend the administration of the mercurial, and to order the potassium, which may be given in doses of three or four grains, three times a day. SQUAMOUS SYPHILITIC ERUPTIONS. 323 It may be directed as follows: — B. Potassii Iodidi, .............................3 ij- Extracti Gentianae, ........................... Dossils of lint, saturated with this solution, are to be laid upon the diseased surface, and renewed thrice daily. MUCOUS TUBERCLES. Syphilitic patients do not all experience the same constitu- tional accidents; nor do these accidents uniformly exhibit themselves in the same undeviating succession; neither does it follow, as a matter of certainty, that a person who has tertiary syphilis, must previously have had secondary symp- toms. In some rare instances, the primary disease and the tertiary manifestations co-exist, although Ricord is entirely absolute that primary, consecutive, secondary, transitionary, and tertiary accidents follow each other with the most perfect regularity. This order in the series of morbid syphilitic phe- nomena, he believes, from clinical observation, to be uniform, unless interfered with by treatment. It is sometimes difficult to determine which of the consecu- tive constitutional affections should claim attention first; and again, it is not always easy to assign to every morbid devel- opment its most appropriate position in the natural history of the complaint. Mr. Wilson arranges mucous tubercles in the second group or period of syphilodermata, along with the tubercula ulcerantia, superficial and deep; lupus ulcerosus and tumores gummati, — that is, as belonging to tertiary syph- ilis. But mucous tubercles are frequently evolved in a few weeks after the existence of the primary chancrous sore, and are sometimes the earliest constitutional developments that 336 GONORRHOEA AND SYPHILIS. appear. I now happen to have under my care a young girl of sixteen, who contracted a chancre in the month of April. Eight weeks after exposure, mucous tubercles, in great profusion, sprung up around the anus, then appeared upon the perinaeum, then upon the right labium. Soon afterwards, a papular erup- tion spread itself extensively over the trunk and limbs, — and at a later period, secondary lesions showed themselves within the mouth. This is far from being a solitary or rare instance of constitutional syphilitic phenomena arising in the order above stated. Such cases induce me to regard mucous tuber- cles as belonging to secondary syphilis, rather than to tertiary. They are designated by several correlative terms, or syno- nyms, — as muco-cutaneous papules, condylomata, pustule plate, tubercule muqueux, papules muqueuses, etc. They are developed upon the moist surfaces of the genital and anal regions, upon the mammae, and in the axillae. They are occa- sionally seen sprouting from the umbilical depression, within the buccal cavity, within the nostrils, and just at the orifice of the external auditory canal. Occasionally, they are ob- served at the commissure of the lips, and about the roots of the nails. They are found in women much more frequently than in men. With the former, they mostly infest the inner surface of the labia majora. In the latter, they are usually seen forming a broad wall around the anus. A specific feature in regard to them is, that they rarely, if ever, proceed to normal ulceration, unless exposed to long continued irritation. They have a smooth or granular surface, and are of a deep, dull red or copper color. Where no measures have been taken to arrest their progress, they often spread over large portions of integument. A few days since, I saw in consultation, a young Englishman, on whom these mucous tubercles had been growing, unmolested, for several months. They occupied the whole perineal region, the scrotum, the root of the penis, the inguinal folds, and the upper part of the thighs. Upon the latter, and upon the scrotum and penis, they were mostly isolated, and projected very prominently; on the perinaeum and around the verge of the anus, they were closely crowded together, and presented a dirty, grayish coat on the surface, consisting of epithelium. They were moist and elastic to the touch, and sufficiently disgusting to the olfactories. They had TUBERCULAR SYPHILITIC ERUPTIONS. been subjected to no treatment, not even to that by cold water. At times, after much exercise, they occasioned a slight degree of pain, but no other inconvenience. The patient had other venereal maladies, derived from a chancre, which he caught two years previously. Mucous tubercles commence by increased vascularity in the spot, from which they are about to germinate. Sometimes they are developed with great rapidity, and are more or less ex- coriated. When they occur upon the mucous membrane of the labia, where they are always subject to gentle pressure, they do not ordinarily grow much above the adjacent surface. If they are evolved in groups, and become confluent, they may exhibit, in the aggregate, an extensive flat surface, while, if not subjected to pressure, the entire warty mass may be elevated two, three, or four lines above the surrounding integ- ument. When seated upon the dartos, they are generally solitary, and reach an extraordinary elevation and size, and are often traversed by fissures, from which a filthy, serous ex- udation oozes, charged with a most revolting smell. Many specimens present, in their superficial substance, a light yellow appearance, which is due to the presence of swollen, sebaceous follicles. Their soft, pultaceous consistence is caused by an infiltration of serous fluid into the minute, con- nective tissue-cells, which abound in the morbid growth. The condylomata are constituted of enlarged papillae, and have their origin in the corium. The accessory organs of the skin also become involved. The sebaceous glands and follicles in- crease in size, and subsequently a formation takes place of the epidermic-like cells; a process which does not occur in the normal condition of the sebaceous apparatus. In some cases, the morbid growths in question, will remain upon the parts for a long period without annoyance to the in- dividual ; in others, if neglected, they occasionally give rise to superficial ulcerations, and harass the patient not a little. In a case which I recently saw at one of our public institu- tions, the tubercles covered the clitoris and the entire raucous surface of the labia. In some places, they had the cauliflower or raspberry appearance. There was engorgement of the mucous surface as far as the examination could extend with- out the use of the speculum. The epithelium of the labia was 29 338 GONORRHOEA AND SYPHILIS. disorganized, and at several points, detached, thus showing ex- coriations, from which a trivial discharge was constantly ooz- ing. This, added to the natural exhalation from the parts, produced a nauseous effluvium, which it is unnecessary to describe particularly. The mouth and throat, likewise, ex- hibited consecutive lesions. The woman had been married about eight months, and dated her sickness from that event. For several weeks she suffered considerably from constitu- tional disturbance arising from her venereal symptoms. She was pregnant. Treatment of Mucous Tubercles. — The tincture of the muriate of iron, touched upon the morbid growths, morning and evening, by means of a bit of soft sponge, will frequently cause their immediate disappearance. A solution of the nitrate of silver applied daily in the proportion of one drachm to the ounce of rose water, will also act with great rapid- ity and efficacy in causing them to wither away in a short time. If the tubercles have become greatly hypertrophied and pre- sent an extensive vegetating surface, the concentrated nitric acid, or the acid nitrate of mercury will be found more bene- ficial and appropriate than any other topical remedy. Either of the two fluids last mentioned may be applied about every four days, until the condylomata are nearly annihilated, after which the solution of silver should be substituted to finish what remains to be done, locally, to these excrescences. When they are situated on the labia, or around the anal aper- ture, a piece of lint, moistened with a weak solution of chloride of soda, and placed between the opposing surfaces, will contribute to the comfort of the patient. As a daily dressing, the black wash sometimes proves efficacious. The submuriate of mercury, sprinkled upon these abnormal ap- pendages once in the twenty-four hours, will accomplish their destruction in a satisfactory manner; and where the disease exists in young children, and where the application can be made without inconvenience, it is to be preferred to all other local means. Before employing it, the tubercles should be thoroughly cleansed with chlorinated water, and wiped dry. Constitutional Treatment. — The bichloride of mercury, TUBERCULAR SYPHILITIC ERUPTIONS. 339 to the amount of one-eighth or one-tenth of a grain, twice a day, may be prescribed for an adult, affected with this variety of tubercles. The salt should be continued until its specific effects begin to display themselves; after which, it will be advisable to substitute the iodide of potassium. In conjunction with the mercurial treatment, a tonic course will, in most cases, be requisite. The tincture of the muriate of iron, or the potassio- tartrate of iron, and a generous diet will be appropriate. CHAPTER XXXI. SYPHILITIC PUSTULES. DO NOT YIELD PURE PUS — DIVIDED INTO TWO GROUPS BY WILLAN— RUPIA, TWO VARIETIES — TREATMENT OF PUSTULAR SYPHILIS. The pustulae may be considered as forming the third link in the metamorphic development of the syphilides. The papule is usually but the prelude of the tubercle. The pustule is en- grafted upon the tubercle, and the ulcer appears next after the pustule. Such is the order of succession in most cases, but not in all. The normal series may be broken by the course of treatment, and by other intercurrent circumstances; so that we are unable to say whether the vis medicatrix na- tural would pursue, in all cases, an undeviating method in this strange work of development, which is neither more nor less than the result of the various surgical experiments, which na- ture institutes in her own self defence. The syphilitic pustule is formed upon the summit of the • tubercle, which softens at this point, while the part that re- poses upon or within the derma, may remained unchanged. Thus the pustule will sometimes linger upon an indurated base for many weeks, and will yield but a small quantity of fluid ; and this will be very different in composition from that of ordinary impetigo, the pustules of which are always of a de- cidedly inflammatory character, and always furnish laudable pus; but it is seldom that true, yellow pus is elaborated from syphilitic pustules, although some of them belong to the im- petiginous form of eruption. (Plate VI.) These pustules are extremely sluggish in their formation ; and after occupying the derma for several weeks or even months, will heal; and thus, to one not familiar with their be- haviour, they give promise of future good to the patient; but anon, a new crop springs up on some distant portion of the integument, which shows that the disease is still persistent in 340 PI. VI. Pustular S^hilis. J.KBverardi Lith SYPHILITIC PUSTULES. 341 the economy. Sometimes the pustules degenerate into con- secutive ulcerations of greater or less depth, and secreting a foul, heterogeneous mixture of blood and serum, with perhaps the addition of a small quantity of pus globules, they refuse to improve under the most judicious management. They have been divided by Willan into two groups. First, those that ac- quire a large size, are seated on an inflamed and indurated base, terminate in a dense, brown scab, like the pustules of ecthyma, variola, and vaccinia, and are called phlyzacious pustules. The second variety is known among dermatologists as psydracious pustules. They are small, scattered, or in clus- ters ; and terminate in crusts of various irregular forms, as the pustules of impetigo, acne, and sycosis. Alibert gives to them all the title of crustaceous pustular syphilide. The fore- going distinctions, although they may be clear and important to the fastidious mind of the professed dermatologist, are, after all, a matter of secondary consideration; for the pustules require no special difference either in constitutional or local remedial measures. The eruptions are expressive of great debility and exhaustion of the system, which has now maintained a cease- less warfare for a long period against its relentless foe. The phlyzacious pustules, that arise from the syphilitic poison, and bear a general resemblance to ecthyma, are among the most remarkable and important we meet with. They are larger than those arising from the apices of tubercles. They are not numerous at any one time. They appear in successive crops, but at distant intervals. They are disseminated over various parts of the body and limbs, and also upon the face. They have a broad, ulcerated base, are flattened and frequently show a central depression like that of small pox when on the decline. The epidermis is pushed forward by the presence of a dark, thick, viscid, sanguinolent secretion, and the pustule and scab are encircled by a purplish-red, not copper-colored, ring of subacute inflammation. If the disease be not arrested at an early period, ulceration of a superficial kind takes place be- neath the scab, which is constantly pushed forward by new ac- cumulations of ichorous, semi-purulent matter; and this, in turn, hardens into an incrustation. The cuticle becomes de- tached around the border of this incrustation, which expands by increments of concentric zones, until the thin,brown, pointed, 29* 342 GONORRHOEA AND SYPHILIS. elevated, and rough crust of rupia prominens is produced. When this curious hollow cone is complete, the original stra- tum which formed its base, becomes its apex ; and of all the morphological transformations that occur in the history of syphilitic pathology, none present more hideous or extraord- inary features than the physiognomy of. rupia prominens. Judging from outward appearances alone, it would be impossi- ble to trace any affinity or relationship between this malady and its progenitor, the insignificant, harmless-looking pimple, the size of a pin's head, peering out from the integument of the penis in the form of chancre. Individuals, who are the subjects of this devastating form of syphilitic affection, are often reduced to the lowest degree of prostration. Life, indeed, may be spared, — it usually is, — and after years of suffering, debility, and self-loathing, the unfortunate victim may grad- ually emerge from his deplorable condition, and regain, in part, his original health. In a majority of cases, however, it is only in part, and he is under the imperious necessity of watching and guarding, at all times, and with unremitting solicitude, the shattered remains of what, perhaps, was once a splendid and vigorous frame. Professor Wilson, in the last edition of his work on diseases of the skin, takes occasion to modify the views he formerly expressed in regard to pustular eruptions developed under the influence of the venereal poison. For instance, he no longer considers it correct to speak of impetigo syphilitica, this pus- tular condition being nothing more than a syphilitic lichen passing into a state of ulceration. With the exception of rupia, it is probable that the different kinds of syphilitic pustules are in fact but a secondary stage of lichen or tubercle. A careful observation of the origin of the pustules, I think, will sustain this view, and we need have no difficulty or hesitation in adopting Wilson's theory, which is, that the only eruption coming strictly under the denomina- tion of pustular syphilis, is rupia, an affection depending es- pecially on a pyogenic condition of the constitution. But it would be a digression from the design of this work to pro- ceed more at length into discussion here, with a view to settle any unimportant differences, which the pustular, as well as other syphilodermata, present at different epochs of their history. SYPHILITIC PUSTULES. 343 Wherever the pustules are situated, they are very apt to terminate in small superficial ulcers. These latter do not, as a general thing, show a disposition to extend either in depth, or otherwise, but usually heal without difficulty; and herein they differ essentially from the deep and destructive ulcers that originate from the subcutaneous tubercula gummata, and which belong to the tertiary group of symptoms, and require a con- stitutional and local management different from that which is applicable to the secondary ulcers. Bupia makes its first appearance in purulent bullae, which are always isolated. The eruption is more frequently developed on the lower extremities than elsewhere. No portion of integ- ument, however, is exempt from its invasion. There are two perfectly distinct varieties of the complaint, according to the thickness and form of the crust, which is evolved by the gradual concretion and drying up of the fluid contents of the bullae, so that we have rupia simplex, and rupia prominens. The disease is extremely chronic and slow in its progress, and is one of the most loathsome affections that come upon the human skin. It indicates the very lowest degree of impoverishment of the system, and is sometimes accompanied by purpura upon the extremities, and by serous effusion into the several cavities of the body. I have at the present time, a young married man under my care, for this pustular syphilitic malady. His constitution is shattered through the joint influence of intem- perance, syphilis, and quack medicines. Six weeks ago, nu- merous dots and small patches of purpura, appeared suddenly, first about the ankles, and shortly afterwards over nearly the whole extent of the legs and thighs. I have seen one other in- stance of purpura co-existing with rupia. In both persons the former disappeared in about three weeks. Rupia often shows itself in its various stages at the same time, thus giv- ing to the patient a most extraordinary appearance. In some spots, small, livid pimples will be seen; in others, those of a larger growth, and filled with sanguineo-purulent fluid; others, still farther advanced, will be surmounted by thin, yellowish- brown scabs. In some individuals, the incrustations present a greenish appearance, and look like vegetable fungi sprouting up from the integument. They acquire different degrees of 344 GONORRHOEA AND SYPHILIS. altitude and circumference. In shape and general aspect, these crusts are somewhat irregular; hence the epithets " limpet- shell," and " oyster-shell," to which they have been compared. Case. —Mrs. B. aged thirty-six years, residing in a neighbor- ing city. Four years previous to my seeing her, she received the venereal poison from her husband, one week before his death, which took place suddenly from an injury. The woman had never been under the care of any regular practitioner ex- cept at odd intervals. The tampering of quacks constituted the principal medical attentions she had received, and the dis- ease may be said to have pursued very much its own course. It was in the month of July that I saw the patient for the first time. I found her sitting in a chair. She had been confined to her room for about six months, was able to sit up in bed or in her chair nearly all day and could walk across the room. She was emaciated and anaemic, and as filthy as she was thin. The catamenial function had been suspended for ten months. The face was covered with some eighteen or twenty rupial crusts, from the fourth to the half of an inch in diameter, and in length some of them had grown to nearly an inch. They were distributed nearly symmetrically on parts corresponding with each other, not only on the face, but elsewhere. Upon the back of the hands, and upon the dorsal surface of the thumbs and fingers, especially on the integument covering the joints, they were particularly numerous. On the upper por- tion of the back, the scapulae, about the shoulder-joints, along each clavicle and arm, they had also formed in great numbers, and had, in some instances, reached the size of an inch in dia- meter and as much in length. On the thighs and legs they were likewise thickly developed. About the knee-joints they had acquired the greatest dimensions. A few had a circum- ference equal to a half dollar. Numerous cicatrices were seen, where former rupial sores had healed, and several ulcerated patches existed, from which the crusts had fallen off. These atonic ulcers were all superficial. The woman had no relish for food; the bowels were costive, the tongue slightly coated and having upon its edges the impressions of the teeth, very deep; the pulse was quick and feeble. [Vide Frontispiece, Plate I.] Quinine, chalybeates, the iodide of potassium, cleanliness, SYPHILITIC PUSTULES. 345 and a generous diet, were prescribed. In four months the patient recovered health and strength sufficient to take short rides in the cars, and to visit friends in her immediate neigh- borhood. I saw her but a few times, and was unable to keep an unbroken thread of her history as she had no permanent abiding place; and whether a perfect cure took place is more than I know; although I do know that the rupia did entirely disappear. Both forms of the eruption, now in review, are occasionally seen on the same individual, as once happened to be the fact with a female patient of mine, whose case I will here briefly submit. In October, 1855,1 was requested to visit a woman who had been married seven years, was the mother of two healthy children, one five, the other three years old. She was very tall, slender and thin in flesh. She reported that for eighteen months different portions of her skin had been the seat of numerous ulcerations. At the time of my visit, the principal ulcerated patch occupied the right elbow-joint, and a large portion of integument, covering the inferior extremity of the humerus to the distance of three or four inches. The ulcer was superficial and irregular in outline — serpiginous. Some twelve or fifteen small sores were scattered elsewhere over the extremities, and the cicatrices of former ulcers were suf- ficiently abundant. The syphilitic character of all these ex- ternal manifestations was well marked. During a period of eight months before I saw the patient, she had lupus exedens, or in other words, syphilitic ulceration of the soft parts of the nose. The alae and cartilaginous septum were destroyed, and the disease was still active ; in fact it ceased its ravages only with the loss of the entire organ. In April, 1856, three or four bullae made their appearance upon the dorsal aspect of the left fore-arm. Soon after this, one bulla was developed just above the superciliary prominence, near its commence- ment at the root of the nose, and another came upon the in- tegument of the left side of the lower jaw, one inch from the symphysis. The latter specimen became an object of special interest as it was the only one that furnished the crust of rupia prominens. Several weeks were consumed in the 346 GONORRHOEA AND SYPHILIS. development and decline of this rupial sore. The woman, according to request, was careful not to disturb it by picking or rubbing. The crust was produced very gradually, each layer being preceded by an erythematous band, which widened from time to time ; the cuticle subsequently became distended with a thick opaline, semi-purulent fluid. In six weeks, the crust completed its growth. It had a slight downward curve near its apex ; projected about an inch from the jaw, and was an inch in diameter at its base, which was in form a com- pressed circle. None of the other crusts assumed this pecu- liar prominent aspect. They became considerably thicker in the central portion than at the circumference, presented a large circular base, were for a long time very adherent, and on being cast off spontaneously, an ill-looking ulcer, having no disposition or power to furnish healthy pus, or granulations, was brought into view. One or two points in connection with the foregoing narra- tive, I must presume to submit to the reader for consideration. The most careful inquiries failed to bring out the whole truth touching the history of this case. The husband denied all ex- perimental knowledge of syphilis in his own person; and I be- lieved him. The woman ignored all primary symptoms as developed in the usual localities or any other place; and I did not believe her. I was confident that she was the transgressor. The parties were in health at the time of marriage. Now the query is, when did the woman contract the disease, before marriage or after the birth of the second child? She never suffered abortion, and both children were healthy. The hus- band believed the infection took place anterior4to matrimony. Treatment of Pustular Syphilis. — For this I must refer, to a considerable extent, to the principles already adduced. If I were to offer any further considerations or suggestions, they would be in reference to the importance of attending now, more than ever, if possible, to the employment of all the hygienic means that can be summoned, with a view to rescue the patieut from impending danger; for he is often so sadly reduced that medicines seem to be nearly inert, or perhaps ab- solutely injurious. When such a case occurs, we may inter- pret the failure of the system to respond in the usual manner SYPHILITIC PUSTULES. 347 to the action of remedies, to a loss of tone, which nothing can restore but a judicious plan of diet, regimen, etc. If the individual has been accustomed to the habitual use of wine or to other alcoholic stimulation, his nervous organiza- tion may not quietly bear their entire prohibition, unless a substitute be provided. The carbonate of ammonia julep to the amount of §iv. during the day will appease the cravings of this appetite more satisfactorily to the patient than any thing else, which it would be expedient to give. The julep may be administered in a weak infusion of hops. It will not be advisable to interrupt the previous habits of the man in the particular here alluded to, and leave him nothing to fall back upon. In pustular syphilis, the practitioner meets with so many de- grees of severity in the symptoms, with so many complications, with such a diversity of constitutions, and other circumstances appertaining to the general health, that he cannot follow any absolute rules of practice that shall be applicable to all per- sons. Although some authorities tell us of lentigo, of miliary pus- tules, of impetiginous pustules, of two forms of ecthymatous pustules, etc., it seems hardly -worth while to stray away into a wilderness of words, and confuse the mind by descanting upon the existence and treatment of these fancied varieties, of syphilitic pustules. I have already signified my disposition to adopt, with slight variation, the views and the nomenclature of Prof. Wilson; that is, to consider these pustules as only a secondary stage of the papular or tubercular affection. The only exception that need be allowed is in reference to ecthyma. It would be difficult to point out any very characteristic fea- tures, by which to distinguish many specimens of this eruption from rupia. In external characters, the two are sometimes closely allied, and are developed under similar conditions of the economy. They are often met with side by side in the same individual, and appear to be only different degrees of the same inflammatory process; and no variation whatever is required in our efforts to cure them. As the practical surgeon, who is qualified to take charge of patients requiring the operation of lithotomy, is usually com- petent for any emergency that may demand his professional 348 GONORRHOEA AND SYPHILIS. skill, so, it may be presumed, the medical practitioner, who can conduct cases of rupia to a successful termination, may regard himself as able to manage the lesser pustular forms that arise in syphilitic patients. The iodide of potassium often exerts a salutary action over the class of accidents now before us, and in a majority of in- stances, no one remedy is more influential in promoting recov- ery. The rupial affection quickly gives evidence of amend- ment, and the general condition of the patient improves very rapidly. The salt just named may be advantageously em- ployed conjointly with the compound decoction of sarsaparilla, and can be administered for several successive weeks or months, if need be. In lichenoid and tubercular eruptions, which are purely secondary manifestions, the iodide fails to be useful; but when these have become pustular, and have reached that transition state, which, so to speak, is midway between secondary and tertiary syphilis, or when tertiary accidents have actually occurred, then it is, that it displays its sanative powers to the best advantage. But, notwithstand- ing the symptoms yield so readily to its influence, and the patient continues to improve, and even, perhaps, may remain to all appearance cured for a while, the disease is liable to return. The same remedy can again be employed as one of the elements in the treatment; but it will not be advisable to rely upon it as during its previous exhibition. The vene- real poison still reigns in the system; and whatever theoretical views we entertain* of the action of the potassium, we have the clinical fact now before us, that it will not, alone, eradicate the virus. Where small doses fail, some surgeons advise a great increase in the quantity — even to the amount of two or three drachms per diem. I have seen this experiment work advantageously; and, on the contrary, I have known large doses to be used in rupial pustules and ulcerations, with- out producing the desired improvement. Failing of success by such a procedure, I have sometimes witnessed the best effects, where the tartrate of iron and potash has constituted, a supplementary article to other remedies. If the patient has been subjected to somewhat heroic experiments for a long time, with no special benefit to his malady, his system is very liable to become irritable and greatly debilitated; and he SYPHILITIC PUSTULES. 349 seems suddenly to lose all power to tolerate medicines of any description. The iodic, or what is still worse, perhaps, the mercurial intoxication may be upon him. In such circum- stances, favorable results will probably be realized by allowing him to rest for a short period from the use of all potent reme- dies. Let him drink Congress Spring water, — let him have a liberal dietetic range, — let him seek the salubrious country air, if possible, and afterwards medical treatment may be re- sumed with better success. Mr. Wilson relates an extraordinary instance of rupia existing in connection with primary disease. The treatment, in this case, consisted in blue pill and opium internally, and black wash, locally, for the primary symptoms. For the secondary symptoms, the patient had sarsaparilla and nitric acid at first, and opium to relieve nocturnal pains. Afterwards, he took the iodide of potassium with sarsaparilla. His regimen con- sisted of eggs and wine ; then a mutton chop with four glasses of port-wine ; and as he grew stronger, a pint of stout, with two glasses of port-wine daily. If numerous ulcerations exist in connection with a copious pustular eruption, the patient gen- erally suffers extremely, especially during the night; and he will require the tranquilizing influence of large doses of opium. It is highly important for him to get his accustomed sleep. For this purpose, half a grain of sulphate of morphia in a drachm of camphor-mixture, should be administered at bedtime, and if necessary, let the dose be repeated in two or three hours. In pustular syphilitic affections, the use of mercury is to most patients decidedly prejudicial. It is liable to cause sloughing and phagedaenic ulceration of the skin, and thus impose upon the individual great additional misery. The rupial crusts may be removed to advantage, provided this can be done without employing much force; but if they are quite adherent, they should not be disturbed. Alkaline baths, and sometimes warm poultices, will promote their de- tachment; and the indolent ulcers thus brought to view, should be touched with the nitrate of silver, or some other less stimulating substance. Dossils of lint, soaked in a weak solution of nitric acid, or in the potassio-tartrate of iron solu- tion, constitute an appropriate dressing to the sores during 30 350 GONORRHOEA AND SYPHILIS. the day; and for the night they will need the protection of some mild, gently stimulating ointment, as that of the nitric oxide of mercury very much diluted. The small pustular and ulcerative affections that appear between the toes and at the roots of the nails, do well when dressed with aromatic wine and opium, balsam of Peru, com- pound tincture of Benzoin, or the weak nitric acid lotion. A solution of the aqueous extract of opium, with the addition of a small quantity of the solution of chloride of soda, makes an excellent anodyne and stimulating application: R. Extracti Opii Aquosi,...............................gr. xxv. Aquae Ferventis,.....................................J viii. Cola, et adde,........................................ Solutionis Sodae Chloridi,............................3 vi. M. Let the above solution be frequently applied to the sores by means of pledgets of lint. The position of the foot, while these ulcers are upon it, is a matter of no small importance. It should rest upon a cushion, in a chair or on a sofa. CHAPTER XXXII. ALOPECIA. —BALDNESS. The loss of the hair is not a very frequent accompaniment of constitutional syphilis, although it is sometimes the only evident symptom of the presence of the venereal poison in the system. Thinning of the hair, however, when it does occur in syphilitic patients, is always a source of anxiety and mortifi- cation ; and, unless the surgeon prescribe for it, the individual will go to some one who will. The affection is not always confined to the scalp. It sometimes attacks the eyebrows, the eyelashes, the beard, and the pubes; and in rare instances, where the syphilitic diathesis has existed for a long period, the alopecia becomes complete over every part of the body and limbs. In some cases, the falling out of the hair from the scalp is accompanied by a light furfuraceous desquamation of the epidermis.' The accident has been attributed to the pe- culiar effect of mercury on the matrix that supplies the hair. The charge is doubtless unjust. The process of decadence can usually be arrested, if suita- ble measures are adopted early. The long-eontinued use of the iodide of potassium will frequently accomplish the desired object. It should be taken to the amount of five or six grains three times a day. The internal administration of mercurial agents will not be called for. There are several local appli- cations that have proved serviceable. The following lotion is worthy of trial: — R. Tincturae Cantharidis,.. Olei Amygdalae Dulcis, Liquoris Ammoniae, aa, Aquas Mellis,.......... Spiritus Rosmarini,..., MP Lotion. Two or three drachms are to be rubbed upon the scalp at night. This lotion bears the reputation of bringing out a new 351 3 iij. Si- Sij- Siv. 352 GONORRHOEA AND SYPHILIS. crop of hair, unless the hair follicles with their productive base or matrix, are destroyed, which is not often the case with young syphilitic subjects, although it is the fact in senile bald- ness. The following lotion is an agreeable, and oftentimes an effi- cacious remedy: — R. Aquae Colognae,....................................... Spiritus Rectificati, aa,.................................3 i- Tincturae Cantharidis,.................................3 iij- Aquae Fontanae,......................................3vm- M- A drachm or two may be rubbed into the scalp morning and night. Another topical remedy may be prepared according to the annexed formula: — R. Olei Lavandulae,....................................gtt. xv. Essentise Jasmini,...................................3 i- Tincturae Cantharidis,...............................3 ij- Unguenti Rosae, ....................................5 i. M. A small quantity of this ointment is to be rubbed into the scalp with brisk friction. The use of an ointment containing creosote, has occasion- ally been followed by a reproduction of the hair: — R. Creosoti,...........................................gtt. x. Olei Limonis, ......................................" iv. Unguenti Rosae,.....................................3 i- M. The whole scalp should be thoroughly cleansed night and morning, with the best White Windsor Soap and warm water, and afterwards a small quantity of the ointment must be rub- bed into the bald patches with the finger. Meantime, the io- dide of potassium is to be administered internally. The iodide of mercury will sometimes arrest the thinning of the hair, when occasioned by syphilitic causes, and the sub- joined preparation can be prescribed: — R. Pulveris Camphorae,..................................... Hydrargyri Proto-Iodidi, aa,..............................5)ss. Unguenti Rosarum,.....................................5 i- M. A small quantity of this is to be thoroughly rubbed into the ALOPECIA— BALDNESS. 353 hair at night. It is quite stimulating to the integument; and, after a few applications, perhaps every other night will be as often as the patient can bear it comfortably. The following is a particular favorite with some of the French surgeons. It goes by the name of Dupuytren's pom- made, although it is by no means certain that the preparation can rightfully claim such paternity : — R. Olei Caryophylli,...... " Canellae, aa,...... Plumbi Acetatis,...... Ealsami Peruviani, .... Spiritus Rectiricati, .... Medullae Ossium Rovis, Another: — R. Unguenti Hydrargyri Nitratis,...........................3 ij- Olei Olivae,"...........................................§i. M. The last prescription will often do the patient essential ser- vice in obstinate cases of alopecia. If the scalp has been the seat of syphilitic lepra, or of any tubercular or pustular affection, leaving a scaly condition of the integument, this compound may be usefully employed. I have also frequently ordered it, with satisfactory results, in cases of non-specific alopecia, ac- companied with a slight pityriasis. I know of no better topi- cal remedy, whatever may have been the original cause of the complaint. It may be perfumed with a few drops of ber- gamot or lavender if the patient choose. The hair should be thoroughly brushed before using it. The hair must be kept very short either with the scissors or the razor. The latter should be used every ten or fifteen days unless the scalp be too tender to endure the shaving process. If the baldness be of very long standing, and occupy extensive portions of the skin, and if the latter present a polished, ebur- nated appearance, it will be exceedingly difficult to relieve the deformity. In some instances, it is associated with other con- stitutional manifestations, such as pains in the bones, superfi- cial ulcerations, or syphilitic lepra, fissures about the angles of the mouth, partial loss of the nails (syphilitic ungueal alo- 30* gtt. xvi. 3i- 3ij- 3i- 5 viii. M. 354 GONORRHOEA AND SYPHILIS. pecia), or inflammation and hypertrophy of the mucous lining of the mouth and throat. In all such cases, while any of the above named topical remedies are applied to the calvana, the general treatment indicated by these concomitant symptoms, should be employed. CHAPTER XXXIII. ULCERS ON THE TONGUE—FISSURES OR CRACKS — TREATMENT — SLOUGHING ULCERATIONS OF THE THROAT -- LOCAL TREATMENT --NITRIC ACID--COM- POUND TINCTURE OF BENZOIN--CONSTITUTIONAL REMEDIES. Among the most frequent situations, for the appearance of secondary symptoms, are the parts within the mouth. The lips, more especially at the angles of the oral aperture, are often excoriated, or are the seat of ulcers; the tongue is affected more or less with excoriations, with fissures, with ulceration, and induration of its substance;—the gums, the uvula, the tonsils, the soft and hard palate, and the posterior walls of the pharynx, are all liable to suffer from the violent local action of the syphilitic poison. The vascularity of the mucous membrane within the buccal cavity, and its intimate sympathetic and anatomical relations with the external integu- ment, seem to predispose it to participate in many of the forms of disease that are developed upon the latter tissue. This tendency is not manifest in the syphilodermata alone; — it is seen in scarlatina, in measles, in severe eczematous in- flammation, etc. The fauces are generally inflamed or even ulcerated, at an early period in the train of secondary venereal phenomena, that are manifested upon the mucous membrane. In certain patients of a scrofulous diathesis, and of frail constitution, or who have been scantily supplied with food, or have lived on that of an inferior quality for a long period, and thus have induced an impoverished state of the blood, we occasionally meet with eruptions and ulcers so nearly resem- bling those resulting from the venereal virus, that we can hardly say wherein the difference consists; and yet nothing can be more unfortunate for the physician in private practice, than to commit a mistake in this matter; for he may thus charge the patient with crime he never committed, and, by this false accusation, provoke a displeasure which may never have an end. Sailors, who make long voyages, and who are 355 356 GONORRHOEA AND SYPHILIS. reduced to short rations, and those perhaps consisting of poor articles of diet, are subject, from these causes, to eruptions and ulcers on the skin, and to corresponding appearances on the mucous lining of the mouth, which closely resemble sec- ondary symptoms. In examining seamen at the Marine Hos- pital in Chelsea, I have occasionally met with such anomalous cases ; and the question has often presented itself, — whether an eruption or ulcer upon any part of the skin or of the mu- cous surface, can be pronounced, ^>er se, to be syphilitic, unless accompanied by other corroborative testimony ? I answer in the negative. The opinion here expressed, however, is not applicable to infantile syphilis. In new-born children, it is ex- tremely rare to find any cutaneous eruption, or any affection of the mucous membrane, as of the nose or mouth, except those of a venereal character. This fact will receive further consideration under the head of Infantile Syphilis, in the con- cluding chapter of this work. Tubercles, ulcerations, and other consecutive lesions, that attack the mouth and throat, furnish the strongest evidence of the contamination of the blood. They are, for the most part, more easily managed, than analogous affections, that appear upon the cutaneous tissue. In some instances, how- ever, they prove the most obstinate morbid conditions we at- tempt to remedy. In still other cases, when we think the parts are nearly well, and we are anticipating the time as at hand, when the treatment can be discontinued, the diseased action will be kindled up anew, and we are driven to straits as to what can be done next. The Tongue. — The true syphilitic ulcers, that attack the tongue, generally penetrate quite deeply into its substance. Their edges are sharply defined, excavated and hard to the touch. Their occurrence is much less frequent than the more superficial ulcerations of the tonsils and pharynx. They are sometimes mistaken for cancer, even by experienced surgeons. Several cases are mentioned in Guy's Hospital Reports;* one in particular, where a venereal ulcer of the tongue wa3 pro- nounced by several eminent surgeons to be cancer. It was * Vol. VII., p. 345. ULCERS ON THE TONGUE. 357 touched with caustic, and the iodide of potassium administered internally for six months, by which time the ulcer was healed perfectly. The patient finally acknowledged that he had the syphilitic taint; and the presence of coppery stains detected upon the legs, confirmed the truth of his confession. In some patients of peculiar idiosyncrasy, the use of the io- dide of potassium, for a few days only, has been known to create swelling, soreness and lumps upon the tongue, closely resem- bling true syphilitic tubercles. These conditions of the organ will generally subside immediately, on the withdrawal of the medicine. I have known the presence of artificial teeth give rise to injuries of the tongue, which, judging from appearances presented by the member, apart from all other considerations, could not be distinguished from venereal accidents. I have seen two such instances within a year, and have met with others in the course of my practice. The individuals have usually been pale, delicate, dyspeptic females. In the two last cases, to which I have alluded, the edges of the tongue were ulcerated in several places. Both patients were married women. Both knew that their husbands had suffered from syphilis in former days, and both entertained an abiding fear that their lingual difficulty was due to the ancient delinquency of their recreant lords. The sides of the tongue are sometimes affected with small ulcers, having well-marked indurated edges, as a consequence of long-continued attrition against the sharp fragment of a de- cayed tooth. These sores bear a close resemblance to syphil- itic ulcers occupying the same localities. Their occurrence demonstrates and enforces the importance of always ascertain- ing, by careful examination, the state of the teeth, before we decide upon the character of the lesion thus situated. The internal use of mercury will sometimes occasion super- ficial ulcerations upon the tongue, or even severe glossitis, while the gums and salivary glands remain undisturbed by the medicine. A knowledge of the entire history of the case and its treatment, will enable the surgeon to judge of the precise nature of these abnormal conditions, and to determine whether they are mercurial or syphilitic. The most frequent syphilitic affections of the tongue con- sist in superficial abrasions, of various extent and shape, and 358 GONORRHOEA AND SYPHILIS. situated on the dorsum, among the circumvallate papillae. They do not appear to extend much, if any, deeper than the base of these papillae. The diseased surface is of a fiery red color, if the epithelium has been removed; but sometimes this delicate covering is only partially detached, and may be seen rolled up into minute, loosened granules, and resting on the excoriated organ, giving it a mixed color of white and red, or perhaps yellowish white. Another lingual trouble of venereal origin, is occasionally met with. I refer to sinuous fissures, which form on the mar- gin or dorsum. They are of various depths. Sometimes they are mere superficial cracks; sometimes they penetrate two or three lines, and exhibit irregular, ulcerated edges. In other instances, no ulceration can be detected. The parts have very much the appearance of a small incised wound, made by a sharp cutting instrument. This breach of continuity is fre- quently associated with tubercles in some portion of the buccal cavity ; but it may be the only specific symptom com- plained of. It is in most cases a source of no little annoyance to the individual, who can neither eat nor converse with com- fort or freedom. I have at this time under treatment, a young man, who had a year or two since, constitutional syphilis, and has now several rhagades or clefts running parallel with each other across the tongue on both sides, opposite the molar teeth. They have existed for more than ten months. The patient has no other venereal manifestation. The chlorate of potash has proved particularly beneficial in this case. When my attention was first directed to these sulci, I could scarcely persuade myself that they were syphilitic, but sus- pected they were caused by friction of the tongue against the teeth in some patients, and in others, who used tobacco, I at- tributed them to its influence. The affection is occasionally attended with a slight oozing of blood from the diseased sur- faces. Treatment. — These fissures are often difficult to cure. The ulcerative process extends farther than might appear from slight inspection, and I have known this complaint to resist every remedial appliance for several months. The solid nitrate of silver used daily, or every other day, will sometimes ULCERS ON THE TONGUE. 359 cause the ulcerated walls to close up and heal kindly, in a very short time. In other instances, its employment is productive of no benefit. The chlorate of potash, both as a gargle and internally, is generally useful; so also is the compound tinc- ture of iodine, brushed over the parts two or three times each day. Sometimes the patient complains of a constant, dull pain in the part. In such cases, the following lotion may be employed several times during the day, by means of a small camel-hair pencil: — R. Extracti Opii Aquosi,.................................gr. vi. Aquae Ferventis,.....................................3 iij. M. Cola, — et adde, Mellis Communis,....................................3 ij- Tincturae Myrrhae,....................................3 vi. The undiluted tincture of myrrh, the compound tincture of lavender, the aromatic wine with tannin and opium, a weak solution of the potassio-tartrate of iron, may all be em- ployed. If the complaint show no disposition to progress towards a cure under the influence of one of these topical remedies, another and another must be experimented with, until a favorable effect is realized. Allusion has been made to the fact, that nearly all the syph- ilitic lesions of the skin, have their analogies in the mucous membranes; and accordingly, in addition to the phenomena already specified, as invading the mouth, we find the deep, ex- cavated ulcer, the inflammatory ulcer, the sloughing ulcer, the ragged ulcer, the chronic ulcer, the creeping serpiginous and superficial ulcer; all which may attack any part within the buccal cavity, as the uvula, the fauces, the tonsils, and the pharynx. The ulcers that appear upon the palatine vault, or on the fauces or pharynx, do not ordinarily penetrate these parts to any great extent; those that come upon the tonsils, eat their way through these glands in a very irregular manner, and cut out excavations of all depths and sizes. Sloughing Ulcerations — are among the most formidable accidents that seize upon the mucous membrane of the mouth and throat, especially when seated upon the posterior walls of 360 gonorrhoea and syphilis. the pharynx. These ulcerations may form either in the secondary or tertiary period of syphilis. Their disposition is, invariably, to extend in all directions. Downwards, they pro- ceed towards the oesophagus and rima glottidis, always inter- fering with the act of swallowing, and, in some instances, exciting the most agonizing dyspnoea. Backwards, the ulcera- tive process may attack the bodies of the cervical vertebrae, and induce caries; and in its upward course, it will advance toward the nares, involving the fauces, tonsils, and the soft palate. In some cases, the morbid action, which has its origin in the mouth or throat, produces closure of the Eustachian tube, and extending along its whole course, reaches the lining membrane of the tympanum, which becomes inflamed, and the result is irremediable loss of hearing. I have, while writing this, a patient under treatment for tertiary syphilis; and among the hydra-headed symptoms, that every now and then arise in the case, is ulceration, which commenced at the back of the pharynx, and subsequently spread to the adjacent parts. For about a year past, the primary seat of the ulceration has remained sound; but the disease still lingers in the parts above. The left Eustachian tube is implicated; and loss of hearing in the corresponding ear has existed for more than six months. It is a well-marked case of syphilitic deafness. The patient is a young female, and has suffered from specific symptoms of one kind and another, for more than six years, with an occasional truce of a few weeks. Secondary sloughing ulceration of the pharynx sometimes gives rise to a catenation and severity of symptoms, which it is not in the power of human language to describe. In these extraordinary cases, the patient is doomed to suffer intensely from constitutional irritation. The pulse sinks to an extreme degree of feebleness, the skin becomes hot and dry, there is unceasing pain in the throat and chest, with a sensation of im- pending suffocation, which any attempt at deglutition exasper- ates, and renders still more alarming. The morbid process, as already stated, extends in every direction, involving the tissues in one continuous, ulcerating surface. Among the important structures thus engaged, are the epiglottis and the larynx; and the patient is then tormented with fits of coughing, accom- panied by a constant secretion of thick, viscid saliva, which ad- ulcers on the tongue. 361 heres firmly to the throat; expectoration becomes difficult; so tomch so, that he thrusts his fingers into his mouth to pull away ihe ropy mass, and thus save himself from suffocation. By day, there is a ceaseless inclination, but without the ability, to vtomit; and during the night, the throat is clogged every few minutes by the incessant discharge, and he is, consequently, not\ only deprived of sleep, but thrown into great distress. Thel power of speech becomes more and more feeble, until, at lengfth, complete aphonia supervenes. Day after day, the symptoms assume a more desperate character, until the suffer- ings ot the miserable victim finally become terrific. He can neitheneat,drink,nor sleep; and he falls into a condition from which l\o human skill can rescue him. I have seen a few instance^ of this description; the last of which occurred about tw\o years since in this city. The agony, bodily and mental, ini the case, was so unremitting and dreadful, that the patient oftven begged for chloroform to put an end to his exist- ence. Red\uced nearly to a skeleton, he sank at last under the weight oof his accumulated miseries. Those of timy readers, who have had an opportunity to ob- serve, from dmy to day, the symptoms of an individual strug- gling with theVyariety of pharyngeal ulceration, the prominent effects produced^ by which, are here given, will bear witness that the description is not couched in the language of hyper- bole. Thirty or fortfy years ago, such cases were far more common among venereal patients, than they have been since a more simple and rationa\treatment has characterized medical practice. N^ Treatment. — This resolves itser^Jnto local and general, as is the fact in nearly all venereal affections. In the diversified syphilitic ulcerations aiN^ other morbid conditions of the mouth and throat, topical remedies, although for the most part of secondary importance, are nevertheless of great value; and the patient will not be content without, recourse to them, nor should the surgeon. In the selection of the most appropriate local means, by which to establish and keep up healthy action in the affection now before us, the pro- fessional attendant will often find his highest skill put to a severe test. 362 GONORRHOEA AND SYPHILIS. Nitric Acid. — For sloughing idcers, the concentrated nitric acid is justly regarded as an excellent topical remedy,/ It is suited to a majority of such sores. If the surgeon def- sire to touch it upon the tonsils, fauces or any part nearer t/o the oral aperture, a small bit of sponge, secured to whalebor/e, and slightly wet with the acid, should be used. The utmost care must be observed not to have any dripping of the flihid. After moistening the sponge, it will be well to squeeze it against the cup or gallipot,-so that there shall be no danger of a particle of the caustic falling where it is not wanted./ The medicated sponge is to be carried forward directly against the ulcer, and withdrawn as quickly as possible. A tumjoler-full of warm water should be at hand, that the patient ma/y use it as a gargle, at once. The surface touched with the acid, will now present a white aspect, which is evidence that it has done proper execution. After one or two trials, the young surgeon will feel at ease in performing this not unimportant^ operation, which he should always take a pride in doing w/ell. If the posterior surface of the pharynx be the seat of/the disease, and if the application of the escharotic be made there, the operation is not so simple as when performed oil the parts just spoken of. This is true, at least, so far as relate^to the patient. In spite of all precaution, it will sometime^ happen that the dense vapor generated while the acid is be/mg applied, will ex- cite exceedingly unpleasant symptoms. / While the surgeon depresses and confines the tongue with/a spatula or spoon, for the purpose of gaining free access to the distant walls of the pharynx, the patient cannot always have perfect control of the respiratory apparatus. Th/fe head is inclined backward, and the epiglottis and its immediate dependencies are not in a nor- mal position. The heavy fumes of the acid may gravitate upon these parts,, which may be instantly stimulated to a most violent spasmodic action, threatening the life of the patient. Some- writers give us the caution to wait until the fumes of tiie acid pass off from the sponge before applying it; but if it be merely damp, there is still a liability to serious mischief from particles of vapor lodging where they ought not. I speak from experience. I once had under my care a young medical gentleman with extensive ulceration upon the pharynx, to which I applied the acid with a probang, the sponge being ULCERS ON THE TONGUE. 363 not as large as a common chestnut. This was done every second or third day, for two or three weeks, care being al- ways taken to have the sponge acidulated in the slightest manner possible. The fumes, at length, occasioned a good deal of irritation, coughing, and distress in breathing. At each successive trial, these unpleasant effects increased, until it became impracticable to use this topical remedy, although it exerted a favorable influence upon the ulceration. The last application was made with great prudence and gentleness, but it instantly produced intense agony and alarm. For a mo- ment it almost seemed that the patient must expire. I am sure these untoward effects were caused by the vapor, and not by any excess of the acid. The compound tincture of Benzoin was substituted, and the fruits of its good service in maintain- ing healthy granulations upon the ulcerated parts, were soon manifest. It was applied thrice daily, for three or four days; subsequently, only twice a day, and by the patient himself. Where it is proposed to touch the nitric acid to the posterior surface of the pharynx, I think it should be diluted with two or three times its quantity of water. The numerous trials, how- ever, which I have now made with the Benzoin tincture, and the prompt and beneficial results that have uniformly been ob- tained, have weaned me from the acid as a topical remedy in the disease under consideration. The unmitigated harshness of the latter substance, and the danger invariably attending its most cautious employment, will deter me from using it upon the pharynx. The Benzoin is about as safe as so much cold water, and, as a curative agent in such cases, I know not where to look for its superior. The compound tincture of Benzoin has lost none of its ancient prestige. It was formerly known as Traumatic Balsam, Wade's Balsam, Friar's Balsam, etc. In its immediate local effect, it is moderately stimulating, and as a reparative to ordinary sloughing ulcers, wherever situated, I regard it as possessing great merit. It was once a popular ap- plication for recent wounds, to which, it is scarcely necessary to say, it is injurious, as it would excite too much inflamma- tion, and thus prevent union by the first intention. As a local application to the pharynx, it can be entrusted to the patient's management with safety. If a few drops happen to be swal- lowed, no harm can result. 364 GONORRHOEA AND SYPHILIS. Case. — Sloughing ulcer of the pharynx — compound tinc- ture of Benzoin employed — cure. April 7, 1856. The patient was a married lady of educa- tion and high social position, aged 28 years. She was ex- tremely pallid, thin in flesh, and dejected in spirits. Four years ago she received the primary inoculation from her hus- band, who lived everywhere. She had secondary eruptions and ulcerations more or less upon the skin for three years before I saw her. When she first consulted me, there was in- flammation and hypertrophy of the fauces, and a few vegeta- tions of the size of kernels of wheat had sprouted upon them. The posterior surface of the pharynx had been the seat of similar growths, except, as she reported, that the latter had a larger base than those on the fauces. They were, doubtless, broad, flattened, mucous tubercles. A few slender excres- cences were also hanging from the velum. At the date above specified, an extensive ulcer occupied the pharynx, giving much discomfort and pain, and occasioning serious impedi- ment in deglutition, especially when she attempted to swallow solid food. The skin was free from disease, although numer- ous cicatrices, occasioned by former ulcerations, were imprinted upon the extremities. Mercury had been administered at different times; but there was no evidence that ptyalism had ever been induced. As a local appliance to the pharynx, the compound tincture of Benzoin was selected. At first it was used twice daily, by means of a bit of sponge secured to a stick. In two days the ulcer acquired a decided reparative action. In ten days, the patient, who resided some thirty miles from the city, was allowed to return home, with instructions to use the tincture two or three times each day, — which she did. She com- plained of very little inconvenience from the immediate im- pression of the tincture. In a few weeks the ulcer was healed. For the removal of the abnormal growths upon the fauces, a few touches with the concentrated nitric acid proved sufficient. The administration of the potassio-tartrate of iron in the infusion of gentian, associated or alternated with the iodide of potassium,— opium to quiet any occasional pain and irri- ULCERS ON THE TONGUE. 365 tability of the system, and to secure refreshing sleep by night, — quinine, decoction of sarsaparilla, decoction of yellow dock root, generous diet, wine, porter, warm bathing, and the pure air of the country, constituted the general therapeutics in the above case. No mercury was employed either locally or otherwise, while the patient was under my care. She im- proved gradually and without experiencing any relapse, until she acquired a tolerable measure of health, although by no means equal to that of former days. A few months after the date given in the preceding instance, another of similar character came under my charge, altliough the ulceration did not occupy the pharynx. September 7,1856. — Patient Mrs. B., aged 32 years. Twice married. Infected with primary disease six years ago by her first husband; knows she had chancre. Reports that she never had any cutaneous eruption nor other abnormal condition of the skin, except what was then apparent. Large, dirty yellow blotches covered most of the integument of both thighs. The discoloration gave no inconvenience, and never had. It had existed, according to the patient, nearly four years. No marks of papules, pustules, or ulcers to be discovered on any portion of the skin. The complexion, originally fair, had now a mot- tled appearance; integument, generally, felt harsh and dry; and a furfuraceous exfoliation of the epiderma of the upper extremities, between the shoulders, upon the chest, and face, presented itself, although daily ablution was practised. The patient was a short, stout built woman, but complained of great lassitude, pains in the limbs and head, loss of appetite, and extreme difficulty of deglutition. She was unable to swallow a particle of solid food, and had lost 18 pounds of flesh in six months. The vocal apparatus was so mutilated, that she could scarcely enunciate her words so as to be understood. She stated that she had taken large quantities of mercury at different times under the direction of physicians, and had suf- fered from salivation. Upon examination of the mouth, a large portion of the fauces, the tonsils, and soft palate, was found to have been destroyed; and the buccal cavity pre- sented a hideous look. How much of this extensive destruc- tion was due to mercurial action and how much to the syphil- 31 366 GONORRHOEA AND SYPHILIS. itic poison, could not be determined; but the fact that the skin had never been disturbed by any papular, tubercular, or other morbid condition of a serious character, led me to doubt whether all the mischief, which had happened within ihe mouth, was chargeable to the latter cause. The constitutional treatment, in this case, was almost precisely like that adopted in the preceding. The only topical remedy to the ulcerated remains of the palate and the fauces, was the compound tincture of Benzoin. The employment of gargles was impracticable. They could not be retained in the mouth. The moment the head was raised, all fluids would descend into the oesophagus. The patient resided about an hour's ride from Boston. She reported herself from time to time. From the 7th of September to the 1st of the following January, she gained in weight twenty-five pounds, and at this latter period, the diseased surfaces were healed. An ingenious artisan con- structed a metallic palate, which the patient has worn nearly the whole time without inconvenience. She remains well, and eats, drinks, and converses without difficulty. The sponge or rag-swab employed for applying the tincture of Benzoin, very soon becomes hard and unfit for use ; but the patient can easily keep himself supplied with a fresh stock. My experience with the Benzoin is limited to old, atonic ul- cers, and to secondary phagedaenic or sloughing ulcers. In the treatment of primary phagedaenic, chancrous sores, I should question its utility. For these, the concentrated nitric acid or the saturated solution of potassio-tartrate of iron, is to be preferred. Gargles. — In cases where the compound tincture of Benzoin is employed repeatedly during the day, it is seldom necessary to resort to gargles. In some instances, however, the latter are required; and there are several formulae that prove beneficial in various kinds of ulcerations within the mouth. A solution of the chlorate of potash of different de- grees of strength, has already been sufficiently noticed. A decoction of the sophora tinctoria (wild indigo or indigo- weed), makes an effective gargle for aphthous and other ulcers the mouth, whether syphilitic or mercurial. The bark of root is the part to be steeped, in the proportion of one ULCERS ON THE TONGUE. 367 ounce to the pint of water. The oxymel of subacetate of cop- per, diluted with water, is another preparation that will be found excellent. The following is the strength generally to be employed: — R. Oxymellis Cupri Subacetatis,............................5 'J- Aquae Fontanae,........................................5 vi. MP ft. gargarisma. To be used repeatedly during the day. Another: — R. Decocti Cinchonae Corticis,.............................§ x. Acidi Hydrochlorici Diluti,.............................3 ij- M. ft. gargarisma. To be used two or three times a day. The mouth should be rinsed with warm water immediately afterwards. A mixture of cinchona and opium furnishes a valuable wash and gargle in all cases of sloughing ulcers within the mouth; also where there is a disposition in the part to degenerate into a gangrenous condition, as is sometimes seen in the side of the cheek, the gums, etc. R. Corticis Cinchonae Rubra;,..............................3ij- Aquas,...............................................3 xn- M. Boil down to eight ounces, and add one scruple of the wa- tery extract of opium. Filter. To be used ad libitum. If the under surface of the tongue be ulcerated, a small piece of English lint, soaked in weak chlorinated water, should be kept in contact with it. Constitutional Remedies. — The brief epitome of the gen- eral treatment pursued in the two last cases reported, to- gether with what has been advanced elsewhere in preceding pages, will, I trust, sufficiently indicate the views I entertain relative to the constitutional measures, when sloughing ulcers exist in the mouth. The use of mercury, while the patient has the misfortune to be struggling with such an affection, seems wholly uncalled for, and in a majority of cases, would be sadly disastrous. He is sufficiently miserable without the hazard of becoming still more so by its action ; and in such a juncture the practitioner should study to spare the poor vic- tim any exposure to causes that might provoke a serious aggravation of symptoms. Mercury, therefore, should be 368 GONORRHOEA AND SYPHILIS. withholden. But when the patient comes to us with other venereal symptoms, which have been mentioned as appearing within the mouth and throat, and we are sure they are such, our inquiry should be, when we are about to prescribe, whether mercurials have been administered and have had a fair trial. If they have not, and if the constitution of the patient appears to be in a favorable condition, so that he can bear the remedy with safety, then the bichloride, to the amount of one-eighth or one-tenth of a grain, morning and evening, may be pre- scribed in combination with tonics, sudorifics, and a generous diet. The effect of the mercury, even when administered in small quantities, must be carefully watched, otherwise a sore, which is not of a sloughing nature, may become so, especially if it be located on the soft palate, or the inside of the cheek. If mercury in any form has been given, the iodide of potash should be our chief reliance; for it will probably turn out that the case is either far advanced in the secondary period, or is what syphilographers style, in the transition-stage between secondary and tertiary syphilis. At any rate, if mercury has been tried, and has failed to cure, the potassium will be well adapted to the case. It can be alternated, if the physician choose, with large quantities of the potassio-tartrate of iron ; that is, one of these preparations may be given for two or three weeks, and then the other. Nitric acid, quinine, and sarsapa- rilla are to be administered in some cases as auxiliaries. In regard to local measures, which may claim confidence, the formulae inserted under the head of sloughing ulcers, will furnish the mind of the judicious medical attendant with am- ple resources, from which to make appropriate selections, according to the different varieties and phases, which"the ul- cerations may present. If the consecutive phenomena, now under consideration, are seen at an early period, they can usu- ally be subdued without difficulty, and the probability of their re-appearance in their original severity, is not very great, even -f they return at all. For the two-fold purpose, however, of guarding the system, as far as possible, against a recurrence of these symptoms, and of protecting it against any tertiary phenomena, the potassium and potassio-tartrate of iron should be continued for four or five months in moderate quantities, and with occasional intermissions of one or two weeks. ULCERS ON THE TONGUE. 369 If a long period has intervened since the advent of these sec- ondary lesions, and if the constitution has become, as it were, saturated with the syphilitic poison, which may be known by the concomitant symptoms on the skin, by nocturnal rheu- matic pains in the bones or joints, by the falling out of the hair, by the pale, emaciated, and shriveled features, by the soft, adynamic state of the muscles, and by the serious deteriora- tion of the general health, all which are indications that ter- tiary affections are about to appear, then our anticipations in the case will be any thing but favorable. However judicious the line of treatment, and however successful for the time being, the disease will manifest a viability not inherent in any other malady ; and the chances are, that before many months have elapsed, the patient will again present himself, with the necessity upon him, of once more testing our skill; or, what is quite as probable, some professional neighbor may be called upon to occupy our post. CHAPTER XXXIY. SYPHILITIC DISEASES OF THE NOSTRILS AND NASAL FOSSAE. MAY BE SECONDARY OR TERTIARY — SUPERFICIAL OR PROFOUND — INSIDIOUS IN THEIR APPROACH — TREATMENT. These accidents require but a brief special notice. They usually appear subsequently to the affections which implicate the tongue and buccal mucous lining. In some instances, they can be properly reckoned among the more tardy secondary symptoms, at other times they are to be included in the ter- tiary group. The ulcers that form within the nose under the influence of the syphilitic diathesis, present two varieties ; the first being superficial, and confined to the mucous surface ; the other pen- etrating more profoundly, and destroying, not only more or less of the soft parts, but also attacking and demolishing the cartilaginous and osseous structures, and producing conse- quent irreparable deformity of the features, impairment of speech, and abolition of the sense of smell. These effects are not unfrequently witnessed in patients, who, either from neg- lect or necessity, have failed to receive proper medical atten- tion. The symptoms of morbid action are usually developed in a very gradual manner, and, in many instances, exist for several months before they excite alarm or even suspicion. At first, the patient discovers a little tenderness of the Schneiderian membrane, with a sensation of soreness within the nasal passages, and a slight impediment to the free transit of air in the process of respiration. At this early stage there is no fixed pain in the parts, and the individual merely has occasion to employ the handkerchief, and make a little extra effort to dislodge any accumulations which he thinks may have been se- creted in consequence of a cold. Sometimes no abnormal ex- 370 NOSTRILS and nasal FOSS2B. 371 udation occurs until several weeks have passed, when ulcera- tion takes place in some portion of the mucous tissue. The discharge is small in quantity, and consists in a heterogeneous compound of blood, pus, epithelium, and debris of the parts that have been destroyed. It exhales a most offensive odor. Sometimes it concretes upon the ulcer, and is dislodged in the form of a dark, dry, thick scab. The natural tones of the voice become altered as the morbid process extends, and the patient, perceiving that what he regarded as a cold has taken a singular turn, at length applies for advice. This is the sim- plest and most superficial form of ulceration which occurs within the nasal apparatus. It belongs to the secondary acci- dents, and is sometimes co-existent with cutaneous affections of the same chronological epoch in the history of the syphilitic disease. A favorable prognosis may usually be entertained. With or- dinary skill on the part of the practitioner, and prudence and care on the part of the patient, the affection above described may be healed in a short time. But when ulceration within any portion of the nasal organ appears as a tertiary symptom, our anticipations will be of a different complexion. The patient will probably survive this local affection; but the chances are, that the cartilages and bones of the nose will be destroyed to an extent that will result in a most repulsive deformity, and render him utterly wretched for life. The abnormal action is remarkable for the exceedingly slow rate of its progress. The soft parts may remain in a merely hypertrophied state for weeks and months, without yielding any morbid exudation, and the complaint may appear to be nearly stationary. In time, a slight, but foetid discharge is noticed, containing, perhaps, small osseous fragments detached at distant intervals, from one of the turbinated bones, from the ethmoid or vomer. These facts will show, with sufficient plainness, that ostitis exists, with ulceration of the soft cover- ings of the bones. The two lesions often accompany each other; and the medical practitioner, who has had much expe- rience, will regard such a condition of things with profound apprehension. The disorder, as thus developed upon these parts, may continue its ravages for two, three, or four years, notwithstanding his unremitting and most judicious efforts, 372 GONORRHOEA AND SYPHILIS. and terminate only with a total loss of the whole interior of the nose. The complaint seems to die out in such cases, be- cause it has nothing to feed upon. Treatment. — If the ulceration be superficial, and appertain to the earlier period of constitutional disease, local remedies may be resorted to with a fair prospect of immediate and per- manent relief. Injections claim our first attention. A solution of chloride of soda, variously diluted with soft, warm water, will be likely to afford more benefit than any other local measure. At whatever point of the nasal mucous lining the ulceration is situated, the solution may be used with safety many times in the day. To be more definite as to the strength that should be employed, I will submit the following formula as suited to the generality of cases. R. Solutionis Sodae Chloridi,...........................3iv. Aquae Fontanae,.....................................3 vi. M. To be used as an injection. The black wash is excellent and is preferred by some sur- geons to all others. It should be thrown up the nostrils every two or three hours. The chloride of zinc, in the proportion of four or six grains to the ounce of rain-water, is" likewise very beneficial as an injection. If the nasal affection belong to the tertiary period, involving the delicate osseous frame-work of the organ, the injections that have been mentioned will be required, — and I prefer them in the order given; especially if the patient be troubled with ozaena. Should the diseased action be concealed high up the fossae, or in the region of the posterior nares, injec- tions, even here, will be of great utility, and the patient should be encouraged to employ them with persevering assiduity. Constitutional Treatment. — If the mucous membrane, alone, be the seat of chronic inflammation, and there be as yet no ulceration or other obvious phenomena connected with the nostrils, the bichloride of mercury, to the amount of one-eighth of a grain each day, and as an auxiliary agent, may be prescribed, provided the individual is otherwise in fair health, and has never been affected by the specific influence of any mercurial nostrils and nasal fossjs. 373 preparation. Chalybeates in some form, the iodide of potas- sium, and other tonics, will be appropriate for most patients who complain of this local trouble, which, in very many in- stances, is but the sure harbinger of a more profound mischief that awaits the ill-fated organ. If the periosteum and bones are involved, the constitutional treatment will form a difficult problem for the consideration of the wisest practitioner. The symptoms, in these cases, are so remote from the original specific lesion, which gave them birth, that mercurials must be excluded from the calendar of therapeutics; for they would only augment existing evils. Indeed, there is reason to believe that caries and exfoliation of the nasal bones are not always produced by the exclusive agency of the syphilitic poison, even in venereal patients. In many instances, these shocking results have been induced, in part, if not wholly, by the previous injudicious administration of mercury. Of tertiary syphilitic affections of the nose, I have met with a goodly number of cases. I have seen them most frequently in the foul wards of our public charitable hospitals, the final refuge of so many victims of both sexes, who are reduced to the last extremity of wretchedness. The facts I have gleaned in connection with this form of disease, have almost brought the conviction to my mind, that, in very many in- stances, it is but little benefited by any medicinal remedies. All the tissues, that constitute the organ, may continue for years to be the abode and the prey of the venereal element, while no other portion of the physical system is absolutely im- plicated. The external integument of the nose, the mucous membrane, and the periosteum, yield up their substance, little by little, to the morbid encroachments; and the fragile bones become denuded, perforated, and eroded by the same destruc- tive process, which, whether any attempts are made to arrest it or not, seems to advance at about an equal pace. The work of demolition progresses without pain and with almost incon- ceivable sluggishness, showing itself at distant intervals in de- crements of a solitary granule of bone, or in a microscopic relic of soft tissue, dislodged from the diseased locality together with other effete matters. The exhibition of the iodide of potassium alternately with 32 374 GONORRHOEA AND SYPHILIS. the potassio-tartrate of iron; a nutritious diet, residence in a wholesome atmosphere, and the inculcation of regular habits, constitute a code of treatment, which should be recommended in this deplorable condition of the syphilitic patient. The mucous membrane of the ear, the eye, the genital ap- paratus, the anal region, etc., is obnoxious to secondary lesions ; it would, however, be but a needless repetition to go into a separate consideration of these several varieties of local mani- festations. They all have a general similitude of type and development, and require no important modification of the constitutional or topical measures already enumerated. CHAPTER XXXV. SYPHILITIC IRITIS. SOMETIMES A SECONDARY, SOMETIMES A TERTIARY AFFECTION — SYMPTOMS — DIAGNOSIS — TREATMENT — MERCURY — MR. CARMICHAEL'S SUBSTITUTE — DR. H. W. WILLIAMS* PLAN OF TREATMENT. This affection was formerly attributed to the physiological action of mercury, but is now known to be one of the mani- festations arising in consequence of the venereal contamina- tion, and to exist, in many instances, where mercury has con- stituted no part of the treatment for the cure of the original disease. The German oculists were the first to discover this fact. The disorder frequently arises in conjunction with second- ary phenomena on the skin or mucous membranes, and must of itself, in such cases, be reckoned as a secondary accident. It sometimes, however, makes its appearance at a very late period, while the patient is afflicted with periosteal and other well marked tertiary affections; and when thus associated, it is proper to regard it as a tertiary lesion. The distinction here given is somewhat important, especially in relation to treatment. The therapeutics adapted to the former group of symptoms, may not be suited to the latter. For instance, cases of iritis occuring while the skin is more or less covered with syphilitic papules or tubercles, may do well under the influence of mercurials; whereas the same ophthalmic symp- tom, developed at a more advanced period of the specific dis- ease, and as a sort of tertiary vestige, would do better under the use of iodide of potassium and other tonics. The complaint may exhibit an acute or a chronic type from its earliest stage, or the chronic form may supervene upon the acute. The term " iritis " as signifying a distinct malady, has been objected to by some eminent surgeons, because other struc- tures besides the iris are implicated in the morbid processes. They regard the attack as a profound ophthalmia. 376 GONORRHOEA AND SYPHILIS. Iridal inflammation may attack one eye or both at the same time. One of the earliest appreciable effects consequent upon this morbid action, is an impairment or even total loss of sight. This result is, in-some instances, manifest within twenty-four hours from its commencement. A great change is wrought in the natural appearance of the eye, in consequence of the effu- sion of lymph into the anterior chamber and into the sub- stance of the iris. As the disease advances, this membrane is more or less concealed by a fibrinous deposit occuring in nod- ules or tubercles of a brownish tint, and collecting in greatest abundance near the pupillary margin, which is thickened and more or less corrugated or scalloped. In some instances, these tubercular excrescences become quite organized with ves- sels and degenerate into minute yellow abscesses. The latter frequently burst, and the matter settles at the bottom of the anterior chamber, constituting what is termed hypopyon. The inflammatory process involves the whole parenchyma of the iris, the surface of which may sometimes be seen dotted with particles of extravasated blood. Adhesions are very liable to form at different points between the ciliary border of the iris and the capsule of the lens. They often acquire considerable firmness, and the liberation of the iris by the employment of belladonna, is a work of no little difficulty. There is distor- tion of the normal figure of the eye, and a corresponding ir- regularity in the shape of the pupil, in consequence of some portions of the iris being confined to the capsule, while other portions remain free. Occasionally, adhesions are formed between the whole cir- cular edge of the iris and the capsule, and what is called cap- sular cataract is the result. In April, 1854,1 saw a case of this kind in a woman who had been under the care of a quack for secondary syphilis. The right eye had been attacked with iritis about one year before I saw it. The complaint lasted but a short time. The cornea was not injured. The pupil was contracted, and the iris apparently cemented to the cap- sule, which was covered with a dense fibrous membrane, and the function of the organ was totally destroyed. In some severe cases, all the textures are involved, until finally, the entire visual organ is converted into a mass of irre- parable disease. When the attack occasions such phenomena, SYPHILITIC IRITIS. 377 one may well question the propriety of regarding it simply as an iritis. Where the morbid action pursues its career rapidly, it is at- tended with pain, which occurs in paroxysms usually marked by their greatest severity during the hours of night. But if it be chronic from the commencement, it is rarely attended with much suffering. In some instances, it is so insidious and gentle in its approach and development, that the individual may lose the use of the eye unconsciously, and before he is aware of any abnormal condition of the organ ; especially is this true, if the patient be engaged in some employment re- quiring no special exercise of accurate vision. Now and then the complaint will disappear spontaneously, without the use of remedial means from the surgeon. Although iritis may be subdued, and the organ restored to its natural appearance and functions, there is for a long time, great liability to relapse. In the month of December, a few years since, a patient under my care for consecutive papular eruption, had an attack of iritis, in consequence of an exposure of several hours, which he spent in riding in an open vehicle, on a cold after- noon. The ride was one of pleasure, and was taken contrary to advice. The patient was a stalwart, daring man, of great natural powers of endurance, and his general health was tol- erably good at the time. But as a result of his imprudence on this occasion, a severe inflammation of the right eye com- menced on the following day. For some weeks he had been taking the bichloride of mercury. This was now laid aside. A saline cathartic was prescribed ; after the operation of which, the patient was put upon the use of Ricord's pill of the proto-iodide of mercury, and the gums kept tender. For more than two weeks, the ophthalmia was acute and painful. For the relief of the latter symptom, fomentations of poppy-water were directed, and proved entirely adequate. The malady be- came chronic and intermittent. Vision was nearly lost and re- stored several times during a period of six months. The eye finally regained its natural state. Diagnosis. — The differences between the syphilitic variety of ophthalmia and the arthritic or strumous form, are not suf- 32* 378 GONORRHOEA AND SYPHILIS. ficiently marked to constitute a rational basis for diagnosis. The medical attendant can rely with safety only on a true his- tory of the antecedents and the concomitants of this local trouble. Slight cases of corneitis may be mistaken for iritis. In se- vere and aggravated instances of the former, the opacity and vascular excitement, conspicuous in the superficial struc- ture, almost exclude the possibility of mistake ; but where the inflammation of the cornea is mild, a mere dulness of this mem- brane takes place, closely resembling, on slight inspection, dulness of the iris. But on a more careful and exact ex- amination, the medical observer will perceive, from every available point of view, that in iritis the loss of brilliancy seems to be deep-seated and uniform. In inflammation of the cornea, the haziness is seen to be superficial; and in most instances, some portion of the corneal texture remains transparent, and through this the iris may be examined. If the pupillary mo- tions are found to be active, — dilatation and contraction being rapid, — there is satisfactory proof that the iris is sound. Ricord considers that the great peculiarity, that separates this form of iritis from arthritic inflammation of the same part, is the eruption, which, in the syphilitic variety, takes place upon the iris, and which, he believes, bears as great an anal- ogy to the cutaneous eruption, as the anatomical differences of the two regions permit; that is, if papules exist on the skin, they will be found on the iris; and if a vesicular eruption be present on the former, true vesicles will be detected on the latter, and so on. That these analogies usually.prevail, I will not take it upon me to doubt; but will add that I have re- cently met with two instances in which there was no venereal eruption, although there had been, only a few months pre- viously. In one of these, the mucous membrane of the mouth was affected with secondary lesions simultaneously with the iritis. The other was accompanied by tertiary manifestations in the joints, the periosteum, etc., and the iritis was of a sub- acute type, and of which the patient suffered several relapses. At my request, Dr. H. W. Williams of this city, saw the case in consultation. A tonic course of treatment, without mer- cury was pursued, and the organ was finally restored to a healthy state. The patient had never taken any mercurial with a view to cure the ocular disease. SYPHILITIC IRITIS. 379 Treatment. — For the removal of this local complaint, the mercurial treatment has for many years been regarded as " the sheet anchor," by the great mass of practitioners. The sub- muriate is the form usually preferred. The subjoined formula is perhaps as appropriate as any that can be selected in cases where the medical attendant has decided upon its employ- ment. But no fixed rule can be laid down: — R. Pulveris Opii,........................................ gr. xv. Hydrargyri Chloridi Mitis,..............................3iss. M. Ft. pil. No. lx. Dose. — One pill thrice daily. As the disease yields, the pills may be taken less frequently. As soon as the mouth or breath indicates that ptyalism is about to set in, the quantity of mercury should be diminished, and every caution taken not to induce salivation. The remedy should be continued in quantities just sufficient to maintain a preternatural redness of the gums, and no more. In some cases, where the individual is in tolerable health, and the local inflammation is very severe, the application of a few leeches, and the employment of a brisk purgative, before commencing with any mercurial, will be advisable. But ordinarily, such preparatory measures will not be demanded. The calomel may be prescribed at once. Some surgeons prefer to combine it with the extract of hyoscyamus for the reason that the opium may have a tendency to favor the con- traction of the pupil. The utmost vigilance will be requisite to keep the pupil dilated, otherwise, permanent adhesion of the iris to the cap- sule of the lens may take place. The extract of belladonna should be smeared freely over the eyebrow and forehead two or three times in the twenty-four hours, throughout every stage of the complaint. Or-, what is perhaps still better, the extract may be dissolved in the proportion of one drachm to eight ounces of rain-water, and applied over the eye by means of a fold of English lint. Atropia will exert the same favorable influence on the structures, and will likewise assuage any orbitar or frontal pains. It acts more rapidly, and is more convenient and cleanly for external use than the extract, and is now employed by many surgeons as a substitute for it. A 380 GONORRHOEA AND SYPHILIS. single drop of a solution, made by dissolving one grain of the atropia in four ounces of distilled water by means of three or four drops of acetic acid, is to be applied to the inner sur- face of the lower lid. Ricord's formula for iritis is the following: — R. Extracti Opii,......................................gr- xv- Hydrargyri Proto-Iodidi,............................. Extracti Cicutae, aa,..................................gr. xlv. M. Ft. pil. No. lx. One to be taken every night, and in four or five days, two per diem, until the mouth becomes tender; at the same time, frictions to the base of the orbit with equal parts of strong mercurial ointment and extract of belladonna are to be used. The therapeutic operation of the mercurial, in suddenly arresting the abnormal exudation or tissue, is generally mani- fest at the moment it begins to display its disturbing, physi- ological properties upon the salivary apparatus. The circulat- ing current is the medium, through which the salutary agency is exerted. Mr. Addison, in his able work on Scrofula and Consumption, offers the following explanation relative to the beneficial action of mercury: " The principle, upon which, in cases of internal disease, this is effected, before materially disturbing healthy functions, appears to be, that the diseased growth has the embryonic type, is the youngest, or last formed, the tenderest or most succulent, and being abnormal, is the farthest removed from the accumulated conservative powers of the whole organism, so that it is the first to fade and sink away upon the presence of unsuitable conditions, of alterative agents taken for the express purpose of its re- moval."— These are ingenious thoughts; but the fact that iritis can be cured without the administration of mercury, would seem to cast a doubt upen the solution offered by the learned author as to the methodus curandi of the potent min- eral. And I cannot but regard the therapeutic problem as still remaining unsolved. After iritis is subdued, the iodide of potassium should be ad- ministered as an adjunct to the mercurial treatment, and also as a prophylactic measure against tertiary symptoms. The potassium may likewise be advantageously prescribed at the SYPHILITIC IRITIS. 381 same time with the mercury, in cases of iritis accompanied with severe neuralgic pains. Such are occasionally met with, where the ophthalmia comes on at a great remove from the primary lesion. The application to the affected organ, of vapor-baths, will be attended with favorable results, not only in subduing pain, but likewise in disgorging the vessels of the sclerotica and the palpebral conjunctiva, which, very often, are highly inflamed. While the efficiency of mercury in promoting the absorption of lymph, and preventing its further deposition, is admitted, — its power in controlling different forms and different stages of iritis, has probably been overrated; and it has, without question, been administered too exclusively and too indis- criminately. If, in any given instance, there be a good share of constitu- tional vigor, and if the exudation retain the form of plastic lymph or fibrine, the employment of mercury, as the chief curative agent, will afford more favorable results than any other. Should the patient be of a scrofulous diathesis, and his con- stitution feeble and broken down by a long and debilitating disease,— if the effusion of lymph be very abundant, and pos- sess but few traces of organization, mercury will tend to in- crease the exudation instead of arresting it. It will act rather as a poison to the system, than as an antidote to the complaint, and thus will aggravate the very condition of things, which it was intended to remove, and which, in a less debilitated frame, it would have cured.* So also, if the malady be developed in conjunction with distinct tertiary symptoms, the individual will be in no condition to justify a resort to mercurial prepar- ations. In all the exceptional cases and conditions here sup- posed, far better effects may be anticipated from the iodide of potassium, ferruginous tonics, nitric acid, and generous living. If, from the constitutional circumstances of the patient, the physician cannot with prudence appeal to the well-known in- fluence of mercury, the oil of turpentine, as first recommended by Mr. Carmichael of Dublin, will be found a valuable substi- tute. The salutary and prompt action of this medicine in * Vide London Lancet, March 1855.— Mr. Critchett's Lecture. 382 GONORRHOEA AND SYPHILIS. iritis, has been attested by the most reliable authorities ; and I cannot take leave of the subject, without inserting the for- mula relied upon by the distinguished Irish surgeon, even when the inflammation and pain and other symptoms, are very severe. R. Olei terebinthina; rectificati,...........................5i- Vitellum unius ovi tere simul, et adde gradatim,......... Emulsionis amygdalarum,.............................§ iv. Syrupi corticis aurantii,...............................5 U- Spiritus lavandulas compositae,.........................3 iv. Olei cinnamomi, guttas................................ij. vel. iv. Dose. — %i. three or four times daily. Some of the most eminent and practical ophthalmic sur- geons now consider that mercury may, as a general rule, be safely dispensed with in the management of iritis, whether it exist in connection with syphilitic cachexia or not. Dr. Wil- liams has reported a large number of cases successfully treated with the use of tonics, mydriatics, and the iodide of potas- sium, and without the administration of mercury in any form. In all instances, and especially those that assume a chronic type, great attention should be directed to the improvement of the general health. CHAPTER XXXVI. TERTIARY SYPHILIS. ORGANS AND TISSUES INVOLVED — SYPHILIS AND SCROFULA—RICORD, LUGOL, AND PHILLIPS — TUBERCULA GUMMATA — RARELY MET WITH — DIAGNOSIS — CASES—SYPHILITIC GUMMATA IN THE MUSCLES — LUNGS —LIVER—BRAIN — BONES, ETC. — TREATMENT — IODIDE OF POTASSIUM. Chiefly to the scientific and important investigations of Ricord are we indebted for the present classification of vene- real symptoms into three separate divisions, and for intima- tions that even a fourth group, the quaternary, may at some future day, be defined and established in conformity with the laws, which, if undisturbed, control the movements of the syphilitic poison in its mysterious wanderings through the hu- man organization. The arrangement of these consecutive phenomena into distinct periods, renders their study highly interesting and satisfactory to the student, while the practi- tioner is enabled to conduct the treatment on principles that lead to far greater success than that obtained in former times. The tertiary symptoms consist in certain changes that take place in the subcutaneous or submucous cellular tissue, in the testicles, in the fibrous and osseous textures, and in the deep- seated organs, as the lungs, the liver, the heart, the brain, the kidneys, etc. The serous membranes have seldom exhibited any syphilitic lesions. The affections, included under the name of gummy tubercles or deep-seated tubercles, nodes, in- flammation of the periosteum, exostosis, and caries of the bones, belong to the division upon which we have now en- tered. By most writers on syphilis, the fact is regarded as estab- lished, that the tertiary manifestations are not transmissible by hereditary taint under their peculiar type, although, in conse- quence of a kind of degeneration or modification of the syph- ilitic virus, they are one of the most fruitful sources of scrofula. 383 384 GONORRHOEA AND SYFHILIS. I am unable to perceive the propriety of applying the term scrof- ula to symptoms that have their origin in syphilis. It seems no more than fair and honest that syphilis should be permitted to retain undisturbed and full relationship to the multitudinous progeny which it begets. The relation is by blood, and what the law's of nature have thus joined together, should not, and indeed cannot in truth, be sundered by mere hypothetical speculations. Scrofula, also, has quite an amplitude of range among its own legitimate connections, and has no occasion to borrow of such a neighbor. To suppose that the matter of syphilis can be transformed into that of scrofula, would be, to believe that the wolf can be changed into a lamb. The wolf may mutilate or devour the lamb. In like manner syphilis may serve its victim; but neither wolf nor syphilis can lose its identity. Ricord speaks of a kind of degeneration or modifi- cation of the venereal virus, in consequence of which, it is not transmissible as a syphilitic element; but is changed into an element for the genesis of scrofula. But this virus is subject to constant degenerations or changes. It is modified in its transit from the chancrous focus on the penis to its develop- ment on the fauces. The conditions or manifestations here, are secondary, but they are syphilitic still, and not scrofulous. From the fauces, the malady passes, we will suppose, to the nasal or other bones. Here is another modification, the tertiary ; but the manifestations or phenomena, are still regarded as vene- real and not as those of scrofula. Thus far all writers agree. Now suppose a child be born of a parent, in whom the syph- ilitic virus is lodged, whether in the skin or the bones, or whether it shows itself in the form of deep-seated tubercles, and the child inherits the parental taint, why call call it syph- ilis in the first case, and scrofula in the others ? Some years since, M. Lugol broached the doctrine that ter- tiary syphilis engendered scrofula. The idea is a specious one; but facts to support it, have not as yet been adduced to the satisfaction of the medical profession generally. Mr. Phil- lips, in his able treatise on scrofula, iu commenting upon the question, "Does a syphilitic taint in the parent tend to pro- duce scrofula in the child?" remarks: " I do not deny but that a scrofulous child may proceed from a syphilitic parent, yet that is no proof that the child becomes scrofulous, because TERTIARY SYPHILIS. 385 the parent was syphilitic. And we have abundant proof that it is not scrofula, but syphilis, which under those circumstances is entailed upon the child. ... I know no well-proved fact, which can be received as evidence that a syphilitic taint in the father or the mother, can, exclusive of other causes, pro- duce scrofula in the child. . . . From all these circum- stances, I arrive at the conclusion that scrofula and syphilis are independent one of the other; that each has a character proper to itself, and that the same treatment is inapplicable to both diseases. For example, if scrofula be rife where syphilis is rare ; if syphilis affects all periods of life, while scrofula is more confined to a particular period; if hereditary syphilis be manifested at, or soon after birth, while scrofula unfrequently appears before the second or third year; if syphilis, whether inherited or acquired, be rarely cured spontaneously, and if, as every one knows is the case, scrofula often disappears at the approach of puberty; if syphilis usually yields to mercurial treatment, while scrofula does not, should we not conclude that the one has no dependence on the other?" Among the most remarkable and interesting phenomena developed within or beneath the cutaneous membrane are the Tubercula Gummata. — These tumors usually appear at a very late period in the train of consecutive symptoms orig- inating in a chancrous sore, and by common consent they occupy a position in the tertiary group of venereal affections. Occasionally they are formed in the substance of the skin, but for the most part they lie below the true corium, and have the subcutaneous cellular tissue for their nidus. Here they may remain for an indefinite period in an indolent state, without infringing upon the healthy condition of the adjacent parts. In rare instances, they have been known to show themselves within a few months from the primary disease, but ordinarily they do not form until the lapse of several years after the introduction of the syphilitic ferment into the system; and comparatively, but few individuals, who have had chancres, are ever afflicted with this variety of tubercles. These curious abnormal bodies are hard and slightly elastic to the touch, and when lodged where the cellular tissue is quite deep and abundant, they are movable in almost any 33 386 GONORRHOEA AND SYPHILIS. direction; if gently felt with the thumb and finger, they seem to float, as it were, or to be suspended in the cellular sub- stance in a loose manner. They sometimes attain the size of a hen's egg. They are called by different names, as gummata, tubercles in the cellular tissue, tubercula gummata, turn ores gummati, tumeurs gommeuses. In process of time, perhaps many months or years, an inflammatory action may be excited; they lose their mobility, and form adhesions to the skin, which by slow degrees becomes disorganized, and an ulcer of peculiar character is the result. The morbid process eats its way through the integument at different points, and complete per- forations are made through it and extend to the interior of the tumor, which is sooner or later converted into a decomposed, sloughy pulp. The bridles of skin between these artificial apertures, undergo a gradual absorption, and a large, open, deep ulcer is ultimately established. Sometimes several of these tumors are seen side by side, and suppurate successively ; and the ulcers, which follow, are extremely difficult to heal. They are usually associated with other venereal accidents, and their occurrence denotes that the economy is profoundly affected by the syphilitic cachexia. Generally, not more than three or four specimens are present at any one time, unless they appear in groups, which is rarely the case. They occupy localities remote from each other; for instance, one will be found upon the neck, one or two on the fore-arm, and one in the popliteal space; and perhaps one or more within the mouth, subjacent to the mucous membrane. If they happen to be dispersed as they often are when attended to seasonably, another crop will very likely arise in their stead in the course of a few months, and thus a succession may be continued for several years. Diagnosis. — It is seldom a difficult matter to distinguish these singular formations from all other morbid developments. If they are unaccompanied by other specific manifestations, a truthful history of the patient will bring to light all that the surgeon needs to know. But if the antecedents are studiously concealed, and a solitary subcutaneous tumor should advance to suppuration and slow phagedaenic ulceration, the case might be mistaken for a scrofulous or cancerous affection. TERTIARY SYPHILIS. 387 Cases of Tubercula Gummata. — June, 1858. — For about three years I have had under my care a young Scotchman, who had primary syphilis ten years ago. Secondary symptoms came on four years afterwards. The patient has at times had sore throat with pretty exten- sive ulcerations, — the tonsils are destroyed; and cutaneous affections have existed in almost every variety of type and severity. During the past year, the skin has remained sound, and the mouth and throat are now nearly so. For two or three years past, periosteal pains have prevailed at times, but have not been of an obstinate character. Ten months since, a subcutaneous, elastic, movable tumor was developed close under the base of the left nipple, and soon afterwards a similar product came on the right side of the neck, one inch below the mastoid process. The nodule on the breast increased more rapidly than the other, until it became as large as a common walnut. The one on the neck was smaller. Both were some- what painful and more elastic as they enlarged, and in all respects corresponded with the descriptions given of syphilitic tubercles in the cellular tissue, and which, when they suppu- rate, give rise to the horse-shoe or serpiginous ulcer, having a phagedaenic tendency. The iodide of potassium is the principal remedy which this patient has taken during the last six months. The daily amount has ranged from fifteen to thirty grains, having been wholly omitted on several occasions for five or six days. The tumors have disappeared. Case II. — In October, 1854, a young married woman, whom, four years previously, I had attended for severe sec- ondary affections, presented herself, having two gummy tuber- cles, one on each side just below the angle of the jaw. They were not enlarged lymphatic glands. They had existed for four months. The one on the right side was of the size of a marble, the other a little less. They caused but slight incon- venience, although occasionally they were somewhat tender and painful. They seemed to be loosely suspended in the cellular membrane, and would slip from between the thumb and finger, unless secured by a careful grasp. In this case, the iodide of potassium was prescribed to the 388 GONORRHOEA AND SYPHILIS. amount of a scruple per diem, and in less than three weeks both tumors vanished. A few months afterwards, similar growths sprung up in the same neighborhood, and the potas- sium was again resorted to with like beneficial results. Co- etaneously with these gummata, the patient had caries and exfoliation of the nasal bones; and in consequence of this ostitis, the lachrymal apparatus became involved. The sac inflamed, a tumor formed at the inner canthus of the left eye, and suppuration ensued. The abscess was punctured at sev- eral different times for the purpose of liberating the purulent collection. It finally became necessary to introduce a canula into the lachrymal canal, where it was allowed to remain for a few weeks. I am aware that the use of the canula, under such circumstances, is regarded by some ophthalmic surgeons as a measure of doubtful propriety, as it is supposed in some cases to favor the process of necrosis. The loss of bony substance, in this instance, took place chiefly before the inser- tion of the stilette. This destruction of bone was sufficient to cause a depression and consequent deformity of the organ; there was also obstructed respiration and impaired phonation. The patient was under my care and that of other medical men for about five years. She took mercury at various times, but never to a point beyond producing a slightly disagreeable taste. She was naturally of a scrofulous diathesis, had a frail constitution, and was too feeble to warrant the free employ- ment of any mercurial preparations, which were always ad- ministered as supplementary or subsidiary to tonics, iodide of potassium, chalybeates, and diaphoretics. Dr. Egan, who is generally good authority, expresses his assurance, that caries of the nasal bones never results solely from the absorption of the syphilitic poison; but is occasioned by the injudicious and repeated use of mercury. In the case here related, however, I do not hesitate to attribute the nasal lesions to the agency of the venereal disease alone. Case III. — I am reminded of another instance of the for- mation of subcutaneous tumors in a sea captain, who had suf- fered severely from the ravages of constitutional syphilis for several years. He had, originally, an iron frame, which bravely resisted the encroachments of the malady for a long period, be- TERTIARY SYPHILIS. 389 fore tertiary lesions manifested themselves. But these finally came on, and caused dreadful mutilation and destruction within the mouth and nose, and upon the face. A gummy tubercle formed in the cellular substance of the left cheek, and in a few months became so large as to interfere with the mastication of the food, and with other functions requiring motion of the parts. This tumor was carefully removed by a surgeon, and no ill consequences supervened. A similar mass showed itself in front of the tragus of the right ear. It ulcerated while the patient was far at sea, remained open for many months, and finally healed without spreading much in any direction. It never yielded a large discharge of any kind. Isolated deposits of the same description were developed near the angles of the lower jaw, and in other situations about the neck, and on the arms. The iodide of potassium was efficacious in accom- plishing their absorption. Syphilitic gummata are occasionally met with in the muscles. Ricord states that as soon as this venereal condition com- mences, the muscular tissue, which seems to undergo a sort of degeneration, contracts, but this contraction is hardly no- ticeable as long as the muscle gets passively shorter. There is at first a plastic transformation, which may, by proper treat- ment, entirely disappear without any deformity being left be- hind ; but if the disease be allowed to reach a more advanced stage, the consequence may be either a complete atrophy, through resorption, or a fibro-cartilaginous or osseous forma- tion. In the latter case, there is shortening of the affected muscle. This degeneration usually attacks the flexor mus- cles, as, for instance, the biceps, the gastrocnemii, etc. Ricord relates the case of a celebrated singer who consulted him for such a syphilitic contraction of the biceps, which interfered with the proper action of the arms on the stage. He was put on the iodide of potassium, and progressed very nicely; so much so that resolution gradually ensued, and while the public were applauding his splendid vocal powers, Ricord used to join them enthusiastically, enraptured as he was with the vig- orous action of the arms and the triumph of the iodide. Acton states that he has witnessed several cases of these tumors in the muscles, particularly in the biceps. He relates the history of one which he saw in Paris. It was as follows: 33* 390 GONORRHOEA AND SYPHILIS. " Eight years ago, a man contracted chancre, which did not be- come indurated. Two years later, that is, six years since, he had a second infection ; induration came on ; he remained free from disease until two months ago, when a tubercle formed in the masseter, and another in the substance of the gastrocne- mius. The limb became enormously enlarged, but had en- tirely subsided under the use of the iodide of potassium, with plasters of ammoniacum and mercury." At the autopsy of a venereal subject, Ricord found in the walls of the ventricles of the heart, several points of tu- berculiform alteration, consisting of a yellow substance of scirrhous hardness at some points, at others, analogous to that of tubercular matter in process of softening. These deposits he regarded as possessing the characters of tertiary syphilitic nodes or tubercles, which are observed in the subcutaneous or sub-mucous cellular tissue. In the case here cited, the cardiac muscular fibres were involved. These circumscribed syphilitic gummata or nodes are fre- quently developed among the tendons of the muscles. They spring either from the surface of the tendon or from its in- terior. They present different characters at different times, according to the various transformations which they are known to undergo. Accordingly, when examined, they are found to be fibrous, elastic, semi-fluid, fluctuating or perfectly solid. Sometimes inflammation is set up, and they terminate in a sort of furuncular suppuration; at other times, ossification occurs. In some instances, extensive portions, or even the entire length of a tendon, may be involved in the affection. In some cases, even where these tubercula acquire a very large size, they are productive of very little pain, and about the only inconvenience which the patient experiences from their presence, arises from an impediment in performing the several motions of the limbs. In other cases, they interfere with the normal action of the nervous centres or ganglia, or some portion of the cerebro-spinal system, causing great irri- tation, pain, and partial paralysis. They have been found in the epididymis, testicle, liver, lungs, brain, bones, etc.* * " A special kind of exudation is seen in what is termed gummata. Lobstein de- scribes it under the name of " gumma periostitis," and compares the contents of these nodular swellings, as respects their consistence, with a semi-fluid mucilage of TERTIARY SYPHILIS. 391 TREATMENT OF TUBERCULA GUMMATA. Experience has at last demonstrated to the satisfaction of every practitioner who has much to do with the management of syphilitic patients, that the specific powers of mercury to control venereal affections, become more and more feeble in proportion as these phenomena recede from the original in- fection ; and we have seen that the lesions now under notice, are among the most tardy constitutional affections entailed upon the system. While I wish to be included among the advocates for the cautious administration of mercury in primary syphilis, and in many secondary lesions, I should be chargeable with being under the dominion of a blind and illiberal prejudice, and of being behind the improvements of the day, did I not admit the superiority of the iodide of potassium over all other med- icines, in the treatment of tertiary phenomena. This convic- tion has not been brought about solely by the statements of others, but is also the result of my own observation of its ex- traordinary sanative power. These tertiary evils, in their se- verer forms, at least, would probably appear less frequently, if their predecessors in the chain of abnormal actions were resisted by suitable ferro-mercurial treatment, combined with the observance of proper hygienic principles. But such a re- medial course is not, and cannot always be pursued. The medical man must therefore be prepared to encounter the class of symptoms now before us with all the skill he is master of. Iodide of Potassium. —In a recent paragraph I have partly anticipated what I must here repeat, that in the treatment of gum arabic, and of the color of currant jelly. The seat of these gummata he places in the tissue of the periosteum itself, or more often, between that membrane and the bone." — Wedl's Pathological Histology, p. 235. Mr. Rusk in a note, remarks : " In syphilitic gummata, such, for instance, as are frequently observed on the frontal and breast bones, the contents are a glairy fluid, containing but few morphological elements. The latter consist chiefly of ir- regular molecules and colorless granule cells, and granular masses, often consisting apparently of oil spherules, surrounding a transparent mass; but, notwithstanding the apparently complete separation of the periosteum from the bone, by this hetero- geneous product, it rarely happens, if the case be properly treated, and the opening of the tumor be avoided, that any exfoliation takes place." 392 GONORRHOEA AND SYPHILIS. the tubercula gummata our chief reliance must be upon the iodide of potassium, so far as our dependence can be placed on medicinal agents; and yet there may be occasion to employ others at the same time, or even before the potassium is pre- scribed. The physician should, at any rate, diligently inquire whether any local inflammation or irritation exists in any organ, and which demands, perhaps, a brief employment of some gentle antiphlogistic or anodyne. The condition of the stomach and bowels, or of the biliary apparatus, may require to be rectified; or the use of tonics and a pretty full diet may be requisite to elevate the depressed state of the system, before the potassium can be resorted to wTith the best ad- vantage. If the patient have a capricious appetite and im- paired digestion, if he be troubled with constipation, with restless nights, or with any abnormal sensations of a serious character, and referable to any of the vital organs or func- tions, it will be important to relieve him of these annoy- ances before attempting the removal of any specific venereal symptoms. But as soon as the constitution has been suita- bly prepared for the reception of the salt in question, its beneficial influence will be realized in all cases of gummata, that are amenable to any therapeutic agent. We have the ex- perience and testimony of the most distinguished men now active in the medical and surgical ranks, all over the civilized world, to justify us in the belief that this remedial substance is entitled to hold the same position in the management of these and other tertiary symptoms, that has been accorded to mercury in primary and secondary affections; and this is say- ing all that need be offered in praise of any ingredient in the materia medica. Not a few medical practitioners have expressed disappoint- ment at the results, which have followed the use of the potas- sium as prescribed by them for venereal affections that appear at a late period. I am of opinion that the article has been employed somewhat indiscriminately for secondary and ter- tiary lesions, and hence the frequent failures. In presuming to submit this remark, I am willing to include myself among those who have erred in thus prescribing it. The high en- comiums, which, a few years since, came over from European hospitals to this country, respecting the healing virtues of the TERTIARY SYPHILIS. 393 potassium in certain syphilitic symptoms of long standing, naturally excited the hopes of medical men in advance of any practical experience they had acquired of its merits; and in this country at least, its popularity preceded its employment; and the hasty and hap-hazard administration of the salt has in many instances brought disappointment. Even in tertiary syphilis I have known patients to be put upon its use, under circumstances unfavorable for the realization of any beneficial results. I could cite instances, where the parties have been so situated, that no advantage could be derived from salubrious air, bathing, generous diet, and other hygienic measures, the influence of which it is always so desirable and important to weave in as auxiliary in the treatment of all venereal symp- toms. In such cases the medical attendant, as well as the patient, is truly unfortunate; but no maledictions should fall upon the remedy under consideration, although it fail to do good, when administered under such adverse circumstances. It has a Herculean task to perform, to subdue the monster that has so long held possession of the ground; but it cannot work miracles. In syphilitic gummata, as well as in all other tertiary acci- dents, the daily quantity of the salt may be from fifteen to twenty grains for the first three or four days, after which it will be safe to increase the dose, if the patient experience no unpleasant effects. It has been frequently prescribed to the amount of one and two drachms per diem, according to its therapeutic energy, and the peculiar condition of the person taking it. A favorable change usually takes place in the symptoms, in a short period, and as soon as this improvement declares itself, it will be judicious practice to keep the amount given at the point, which appeared to cause the amendment. It is better for the physician to allow himself this latitude as to the quantity he recommends, rather than be governed by any mere mathematical rule. A diminution in the size of the tubercles is in some instances perceptible within forty-eight hours from the time the individual begins to take the salt; and I have known specimens of the bigness of a common marble to be obliterated within ten days through its agency. It is not very unusual to find old tertiary ulcerations and long- standing nocturnal pains, of syphilitic origin, in the bones, 394 GONORRHOEA AND SYPHILIS. coincident with the gummata. Such cases afford the most gratifying proof of the excellent powers of the iodide ; for while the gummata subside under its action, the ulcers rapidly amend or heal, and the osseous affection ceases to torment. Instances have been authentically reported, in which syphilitic tumors as large as an orange, and situated among the muscles, have been carried away by absorption in the course of six weeks, the potassium being the chief constitutional means resorted to. If the situation of the tumors will allow of the employment of pressure, mercurial plasters may be applied as useful auxiliaries. The iodide of lead ointment, one drachm to the ounce, has the reputation of acting beneficially as a discutient. So has the tincture of iodine. While the patient is taking the potassium, he should be allowed a good, regenerating diet; and for drinks, wine, por- ter, and ale in generous quantities. The above course may be continued for weeks or months without danger of inducing any unfavorable consequences. Even after the particular morbid symptoms, for which the potassium was given, have disappeared, it will be judicious to continue its use, in small doses, for several weeks, for the pur- pose of preventing relapses as well as with a view of recruit- ing the condition of the system. When the subcutaneous gummata yield a slight fluctuation on pressure, and the integument is not discolored, it will be proper to attack them with energetic local means. The skin may be covered with a blister, and as soon as the cuticle is detached, the raw surface may be dressed with strong mercu- rial ointment for the purpose of encouraging absorption of the purulent collection. If fluctuation should increase, the con- tents of the tumor should be set free with the lancet, as all further attempts to induce absorption will not only prove abortive, but the pus, if not evacuated, will undermine the in- tegument in every direction, and great ravages among the different tissues will be likely to occur. If the tumor be situ- ated on the scrotum, it will be especially important to open it at the earliest moment after the softening and fluctuation are detected. The suppurating surface will require a subsequent local treatment of a somewhat stimulating character. The chloride of soda makes one of the most useful topical dress- TERTIARY SYPHILIS. 395 ings for these unhealthy sores. The black wash, the yellow wash, the Peruvian balsam, and a solution of the potassio-tar- trate of iron will all likewise act favorably. If there be much redness and inflammation in the surround- ing parts, a soothing application will be demanded, in prefer- ence to one of a stimulating nature. A saturated solution of the extract of opium should be applied to the ulcerated surface for a short period, and afterwards one of the preceding reme- dies. In most cases, the abnormal local action is of a sub- acute type, and the ulcerations, that are almost certain to supervene upon the opening of the gummata, present a slough- ing tendency, to arrest which, stimulants applied directly to them will be most appropriate. In addition to those above named, for daily use, the nitric oxide of mercury ointment will be found an excellent preparation for nocturnal use. The occasional employment of the undiluted nitric acid will be requisite if the ulceration extend into the soft parts. In such cases, the malady is wont to assume a formidable aspect, and it is not only necessary to resort to topical meas- ures with the intention of destroying the phagedaenic action; but our main reliance must be on constitutional treatment, which, in addition to the iodide of potassium, should consist of the free administration of the potassio-tartrate of iron, quinine, opium, wine, etc. In the treatment of primary sores, the potassium is of no value. The same is true as regards the early stage of sec- ondary eruptions. Cases are recorded, in which this salt has been taken for many months for the cure of pustular and tu- bercular affections of the skin without any permanent advan- tage. Sometimes it will suspend or keep under such eruptions for a while, but, as soon as it is omitted, these phenomena will return as severely as ever; and from the numerous trials that have been made with it, it appears to be a well-established fact that its therapeutic qualities are in direct ratio with the long continuance of the specific symptoms. Experience has now sup- plied ample proof that under its action, tertiary or very late sec- ondary ulcerations of the soft tissues heal rapidly, that pains in the bones are relieved or annihilated, that exostoses are to- tally destroyed, that extensive periostoses are arrested in their progress, that old sequestra are promptly eliminated in very 396 GONORRHOEA AND SYPHILIS. many instances, and that tedious and distressing caries will dry up and cicatrize in a permanent and healthy manner. What may be termed the more extraordinary degrees of tertiary accidents, such as are mentioned in the preceding par- agraph, are seldom met with in private practice. Although I am constantly dealing with this class of accidents in all their forms, my experience is quite limited in regard to in- stances of peculiar severity. Painful swellings and plastic infiltrations about the joints, and periosteal and osteal inflam- mations accompanied with nodes, are the most frequent ter- tiary lesions I am called upon to treat. For the removal of these, my reliance is on the iodide of potassium as the great constitutional antidote. I have often witnessed with sur- prise the rapidity of its therapeutic action. Within three days from the commencement of its use to the amount of thirty or forty grains, per diem, I have known articular en- largements of several months' duration, begin to decline, and to be entirely reduced in a few weeks. In one instance lately under my care, and in which Dr. S. D. Townsend was called in consultation, the enlargement of the knee-joint was over two inches, and in three weeks it almost wholly disappeared under the influence of the iodide, which was prescribed at the rate of one drachm daily. Equally favorable results are realized when it is employed for subduing other local affec- tions appertaining to the tertiary group; and as the remedy displays its power over these, the general condition of the system undergoes great improvement also. The tongue be- comes clean, the appetite returns, the digestion is good, and the patient is very sure to increase in flesh. The data, upon which these statements are predicated, are derived from my own observation of the potassium in numerous cases of ter- tiary syphilis, in which the effects of this medicine have almost uniformly been such as to remind me of the expression of Ricord, that it is " all-powerful." And when I hear of failures and disappointments connected with its administration, I al- ways suspect that it has been prescribed in cases not belong- ing to the tertiary, nor yet the late secondary period, or that it has been given in a manner or under circumstances that would render any medicinal agent nugatory. CHAPTER XXXVII. SYPHILITIC SARCOCELE, OR ORCHITIS. BELONGS TO NO PARTICULAR PERIOD OF SYPHILIS--COMMENCES IN THE TUN- ICA ALBUGINEA--SUPPURATION RARELY TAKES PLACE IN THE TESTICLE -- ATROPHY OF THE GLAND—THE DISEASE APT TO RECUR — DIAGNOSIS — TREATMENT. This is a chronic affection. Some writers consider it a sec- ondary venereal malady; others class it among the tertiary symptoms. I have met with it in persons, who have had secondary papular and pustular eruptions at the same time, but no tertiary complaint; and I have seen it where the other concomitant affections were strictly tertiary. In one instance, a man was troubled with sarcocele during secondary consecu- tive manifestations, and also after tertiary lesions had existed for a long time. Thus, abstractly considered, this glandular difficulty belongs to no one period of syphilis exclusively. Nor is it strictly accurate to regard it as occupying a transi- tion state between the secondary and tertiary epochs. The disease has been known to appear at the same time with primary chancre, and in connection with the profound abnor- mal phenomena that attack the periosteum and bones; and it may occur at any moment intermediate between the extremes here mentioned. This irregularity as to the times of its de- velopment, has created doubts in the minds of some surgeons as to the propriety of separating venereal manifestations into three distinct divisions. As a general rule, it may be stated that orchitis is one of the latest exhibitions of the syphilitic disease. It commences in the tunica albuginea, or the fibro-cellular tissue of the body of the testicle, and not in the tubular portions of the organ. In its incipient stage, the epididymis is not involved. The numerous researches of Sir Astley Cooper have placed these facts beyond doubt. In a majority of cases, both testicles are involved in the morbid action simultaneously; in others, only 34 397 398 GONORRHOEA AND SYPHILIS. one testis is implicated. The enlargement proceeds very gradually, is attended with only a moderate degree of pain, and the individual will allow the part to be handled without complaining. For some time, the gland preserves its smooth- ness and its natural pyriform or ovoidal figure ; but as the dis- ease advances, it becomes globular, and assumes a fleshy feel, from which circumstance is derived the term sarcocele. * Af- ter a considerable period has elapsed, the smoothness of the surface is slightly interfered with by prominences occasioned by the presence of tubercles or zones, as they are sometimes called. These, however, eventually coalesce into one mass. In certain instances, where there is great hardness of the gland, it presents a somewhat irregular, lobulated appearance. As the disorder becomes still more chronic, the epididymis participates in the inflammation, and is merged in the general enlargement, so that it cannot be felt. In the'generality of cases, the trouble terminates in resolution, and the testicle is restored to its natural size. Now and then, a slow process of foul, unhealthy suppuration is set up. f In such cases, the patient suffers intense pain; but otherwise, there is merely a dull, achiug sensation, accompanied by a feeling of weight in the organ, as in non-specific orchitis. Instances are occasionally reported of the disease terminat- ing in atrophy of the gland. This condition has been erro- neously attributed to the physiological influence of the iodide of potassium. The wasting away of the testicle may some- times be the result of the specific affection; or, it may arise from neglect or from improper management, or it may be due still more frequently to some peculiar diathesis inherent in the constitution. There is one feature appertaining to this variety of sarco- cele, which it possesses in common with nearly all the other constitutional venereal affections, and that is a disposition to recur. Even if the treatment have been entirely successful *From aap£, flesh, and icnln, a tumor. t Mr. Acton is of opinion that syphilitic sarcocele never brings on suppuration ; and the late Mr. Colles remarks that he could not recollect any case of what he con- sidered purely venereal swelled testicle, which went on to suppuration, although he had seen this occurrence take place in some persons where the debilitated and de- ranged state of the health appeared to be the exciting cause. SYPHILITIC SARCOCELE, OR ORCHITIS. 399 in removing the engorgement, the probability is, that after an interval of a few months, the same difficulty will return, al- though perhaps in a mitigated form. In former times, the complaint under consideration, not so well understood as at the present day, was often looked upon as cancerous; and surgeons who were fond of using the knife, were frequently too ready to relieve the patient of his testicle by castration. In ordinary cases of orchitis, virility remains unimpaired; but if both testicles are diseased, and the morbid condition continue for a very long time, producing disorganization in the seminal tubes, then their normal function may be destroyed, a circumstance, however, which rarely happens. Diagnosis. — The testicular engorgement generally takes place amid circumstances calculated to shield the judgment of the practitioner from any mistake as to the precise nature of the swelling. Other constitutional symptoms of a specific type will be present. Upon an examination of the patient, if such a ceremony should be necessary, tubercles, cutaneous, sub- cutaneous, or submucous, chronic and unhealthy ulcerations, phagedaenic sore throat, nodes, iritis, scaly eruptions, or articular pains, will probably be found to exist. But if these venereal symptoms should all happen to be absent, the history of the individual for the few previous years, will develop facts, a careful analysis of which, will point with sufficient distinctness and emphasis in the right direction; so that the diagnosis will be rendered easy. Pathological Appearances. — On dissection, the general appearance furnished by the syphilitic testicle exactly corres- ponds with that of the common chronic inflammation of this body. The glandular structure of the organ exhibits a quan- tity of 3-ellow, unorganized matter, collected in small masses or deposits, possessing more or less solidity. * treatment of sarcocele. Local. — If the case be presented for treatment at an early period, and before any material structural change has * Cooper, Brodie, Hamilton, Curling. 400 gonorrhoea and syphilis. taken place in the part, it can usually be restored to a healthy condition without difficulty. Should it be very painful and tender, five or six leeches must be applied to the scrotum, which should be supported by a suspensory bandage. The frequent use of hot vapor or of soft warm poultices, will exert a soothing influence, and likewise materially assist in reducing the enlargement of the gland. The fomentations or poultices should contain a solution of the extract of belladonna, which will add to their efficacy. The iodide of lead ointment will sometimes prove beneficial in promot- ing the absorption of the plastic infiltration. It will be good practice, also, to paint the scrotum with the compound tinct- ure of iodine every day, so as to maintain a lively counter- irritation. Blisters are serviceable where the sarcocele has become chronic. Many surgeons have great faith in the resolvent qualities of mercurial ointment. I have no objec- tions to offer to its employment; nor do I entertain any special confidence in it, as being superior to the other local appliances that have been mentioned. Its use is attended with no little trouble on the score of uncleanliness, which overbalances any specific advantages that can be urged in favor of it, while we have at command an abundance of other resources of equal curative value. If there be a high tone of inflammatory action, refrigerating lotions will be demanded for the time being; and the patient will likewise derive advantage from a general warm water bath, morning and evening. Constitutional Treatment. — The iodide of potassium will prove the most beneficial medicine that can be addressed to the constitution. This salt will be especially appropriate if the orchitis be developed in patients, in whom tertiary phe- nomena are more predominant than secondary. In regard to the necessity or desirableness of prescribing mercury in any form or quantity, I am inclined to the belief that the general condition of things will seldom warrant such a procedure, except in the most cautious manner. Nine-tenths of the persons, who present themselves to the medical man for the treatment of swelled testicles, are just the ones, who cannot be put upon a mercurial course, without incurring a SYPHILITIC SARCOCELE, OR ORCHITIS. 401 risk, which the exigencies of the case do not justify. It is far safer and better to rely upon the action of the potassium and the other remedial measures recommended in connection with this subject. If there be considerable effusion into the tunica vaginalis, it will be advisable to puncture it with a small trocar. This operation will greatly promote the success of the subsequent treatment. 34* CHAPTER XXXVIII. DISEASES OF THE PERIOSTEUM AND BONES. SYPHILITIC OSTEOCOPES--NODES — CRANIAL EXOSTOSES — TUMORS ON THE DURA MATER -- CASES OF INTRA-CRANIAL AFFECTIONS RELATED BY MR. TODD OF LONDON--BY DR. REID OF IRELAND--CASE RELATED BY MR. REEVE — CASE IN THE AUTHOR'S PRACTICE -- CASE AT RAINSFORD ISLAND HOSPITAL--DIAGNOSIS --TREATMENT OF TERTIARY PAINS--OF NODES-- MERCURY — LOCAL TREATMENT. Syphilitic diseases of the bones and of their investing membrane, the periosteum, are less frequently met with at the present day than formerly. One, and perhaps it might be said, the chief reason of this difference, is to be found in the mild treatment, which the members of our profession have, of late years, chosen to employ for the cure of secondary symptoms. To the exhausting effects of the immense quantities of mer- cury, which it was once the custom to crowd into the stomach, while the system was struggling against the malign influence of the venereal poison, is doubtless to be attributed a large share of those violent and destructive morbid processes, which preyed upon the bones of its subjects. Syphilitic accidents appear most frequently in those bones that are thinly covered with muscles and consequently exposed to varieties of temperature. Of all the bones, the tibia suffers most from tertiary affections. The cranium, the clavicle, the radius, the ulna, the inferior maxilla, the sternum, and ribs, are also obnoxious to specific pains, inflammation, nodes, tumors, necroses, and caries. It is scarcely probable, indeed, that any portion of the osseous system enjoys immunity from the effects of the disease. Osteocopic symptoms are ushered in without any apparent exciting cause. A dull, circumscribed pain is seated, for in- stance, at a fixed point, upon the shaft of the tibia. It does not shift from place to place, as in ordinary rheumatism ; — is not accompanied by redness, swelling, or increased tempera- 402 DISEASES OF THE PERIOSTEUM AND BONES. 403 ture; is intermittent, and for a long period, is almost wholly nocturnal. If, however, no attempt be made to annihilate it, the individual ultimately suffers by day as well as by night. Sometimes, when pressure is made upon the part, the distress is increased, — thus proving that the affection is deep-seated. In the latter class of cases, the syphilitic inflammation may attack either the medullary membranes or the cancellated structure of the long bones. Where the disease is deep- seated in the bones of the extremities, a morbid deposit takes place, accompanied with intense suffering in consequence of the unyielding nature of the surrounding tissues, — and the operation of trephining can alone give relief. Surgical expe- rience has demonstrated this fact. Syphilitic osteocopes are regarded by some eminent author- ities as only a symptom of an affection of the bones, and not as a distinct malady. In reply to this, it may be stated that persons are occasionally met with, who suffer tertiary pains for many months before any organic lesion is manifested, although, in most cases, these osteocopes do not continue but a few weeks before some serious derangement takes place, either in the periosteum or bone. Generally, a slight tenderness on pressure is perceptible at the spot where the disease is located, and, in a short time, irregularities and periosteal en- largements, termed nodes, reveal themselves. These abnormal deposits are more frequently developed in persons, who have been subjected to the protracted use of mercury, than in those who have not been thus treated. They are seen, how- ever, as purely venereal accidents, where no mercurial prep- arations have been administered. They do not exhibit precise uniformity in their appearance or character, and have been sep- arated by Ricord into three different varieties ; viz., the elas- tic, the phlegmonous, and the plastic. Several nodes are fre- quently noticed on the same bone at the same time. When they thus appear, they are generally of smaller size than when a solitary specimen exists. Their outlines are not always well defined. The central part is usually more promi- nent than the other portions of the swelling, and as the finger follows the morbid growth from the summit towards the basal periphery, it is often difficult to trace it distinctly. Some- 404 GONORRHOEA AND SYPHILIS. times the nodes form without being preceded by a painful condition in the place from which they spring; but in most instances, as already stated, they are ushered in by pretty severe and constant pain. Nodes may remain indolent for a long period, — may undergo little or no alteration, —and occa- sion but very little inconvenience; on the contrary, they sometimes prove extremely troublesome, and are premonitory of still more serious and profound lesions, that are sooner or later to follow. In some instances, the lymph or serum, which they contain, can be carried away by absorption, — in others, a slow process of suppuration is excited, abscesses form between the periosteum and the bone, and exfoliation of the latter, to a greater or less extent, ensues. This is particularly liable to be the case, where the periostitis is situated upon some portion of the cranium. Instead of remaining soft, doughy, and painful, as in their incipient stage, they some- times change their character after they have existed a few weeks. They acquire solidity and cease to be painful. This solidity or hardness does not, of itself, indicate the composi- tion of the nodular deposits. Mr. Stanley states that he has found what was supposed to be osseous matter, to prove mere indurated periosteum. The pericranium differs from the fibrous investment of the other bones in never becoming ossified. Instances have been known in which the inner table of the bones of the skull and dura mater have been diseased for a long time, while the external osseous surface has remained perfectly sound. Exostoses or nodes may arise from the inner surface of the cranium, produce compression of the brain, and more or less cerebral distress, together with partial paralysis, and other se- rious consequences, the cause of all which would not be sus- pected, perhaps, unless a most careful and accurate history of the patient were taken into consideration. Sometimes, there are no other venereal manifestations, and the individual may have been exempt from any specific symptoms for several years. Nevertheless, if particular inquiry into his past life reveal the fact of a former constitutional syphilitic affection, it may furnish to the investigating mind of the intelligent DISEASES OF THE PERIOSTEUM AND BONES. 405 practitioner, a clue to the true nature of the case before him, and he will form his diagnosis and regulate his line of thera- peutics accordingly. In tertiary or chronic syphilis, where cerebral symptoms have been prominent, tumors have been developed upon the dura mater; sometimes this membrane has been found three or four times its natural thickness, the morbid action, in such instances, being like that which attacks the periosteum. In some cases, arachnitis takes place. In one patient, in whom the dura mater and the arachnoid were found to be united, Mr. Todd, of London, discovered two large masses of matter of a yellow color, like concrete pus, opposite which, were cor- responding depressions or concavities on the surface of the cerebral hemispheres. And, at those points, the substance of the brain was somewhat softened, and also of a redder tint than natural. In a second case, Mr. Todd had an opportunity to verify his diagnosis, which was founded chiefly on the history of the individual and the general symptoms. Besides other appearances, the bone of the right temporal region was ascer- tained to be much thickened, and a small osseous spiculum was seen projecting from the inner surface of the left tem- poral bone.* We are also indebted to Dr. Reid of Belfast, Ireland, for a paper detailing the symptoms of intra-cranial syphilitic disease, and the triumphant success of the means adopted for their re- moval. In this contribution, three cases are related, from which we learn that at a remote period or stage of syphilis, paralytic symptoms, with defective intelligence and memory, impaired vision, difficulty of articulation, and epileptic seiz- ures, may set in, and ultimately disappear under proper treat- ment. The means principally relied upon by Dr. Reid, con- sisted in shaving the head, extensive blistering of that part, and mercury. In one of his cases, venesection, active purga- tives and tartar-emetic were had recourse to.f Mr. Reeve, author of a work on" Syphilitic Meningitis," re- ports a case in which there was every reason to believe that the patient labored under compression of the brain, occasioned by syphilitic tumors, developed upon the dura mater. He had * London Medical Gazette, New Series, Vol. xii, p. 1. fLabatt on Venereal Diseases, 1858, p. 196. 406 GONORRHOEA AND SYPHILIS. a paralytic affection with other cerebral disturbances of an alarming character. He could not stand upon his feet; his ar- ticulation was imperfect; his memory and ideas generally im- paired ; vision in both eyes was disturbed. He was known to have had constitutional syphilis a few years previously. The scalp was shaved, and covered with a blister, to the surface of which mercurial ointment was freely applied for a few days. Recovery took place rapidly. Some of Mr. Todd's cases were treated successfully with the iodide of potassium. In my own practice, I have met with one unequivocal exam- ple presenting the leading features appertaining to the cases above cited. The iodide of potassium was given largely for a long period without permanent benefit. The patient did well for a time, but afterwards suffered a relapse from which he did not recover. He lingered several months in an imbe cile frame of mind before death took place. Softening of the brain was the principal lesion discovered at the autopsy. The following case, which occurred at Rainsford Island Hos- pital, has been furnished me by Dr. David W. Cheever, of Bos- ton, who was connected with that Institution in 1857. " Mary R. entered the hospital June 3. She had no chancre nor tubercles. Denies a primary sore, but has inflammation of cervix uteri with discharge, and an enlarged gland, not ten- der, in the left groin. An eruption of coppery blotches in the skin, and also alopecia and hoarseness. She looks pale and cachectic. Ordered to have good diet and small doses of io- dide of potassium, that is, twelve grains per diem, in syrup of iodide of iron. " The eruption was fading, and she seemed going on favora- bly, until June 15th, when she was found in the morning hem- iplegic on the right side. Great difficulty in protruding the tongue and in articulating ; the mouth drawn to left; the right leg quite powerless and the right arm less so. The other functions not affected. '• Twelve grains of the submuriate of mercury (given grs. iij. per diem) sufficed to render her mouth quite sore. She at once began to recover power, and at the end of a fortnight could move very comfortably. She had no other symptoms; had a good convalescence and restoration of muscular power. " Mr. Solly speaks of the venereal poison often ' putting its DISEASES OF THE PERIOSTEUM AND BONES. 407 paw upon the dura mater.' It would seem most reasonable to charge this paralysis to one of the freaks of constitutional syphilis." * Diagnosis.—These tertiary affections, in common with nearly all the others appertaining to syphilis, are generally charac- terized by peculiar symptoms, which proclaim their specific nature. If the surgeon have any doubt whether the inflam- mation of the periosteum and bones arises from the venereal element, or in consequence of a rheumatic diathesis, all such doubts can be put to rest, and an accurate diagnostic conclu- sion be formed, by obtaining from the patient his syphilitic history. It must be admitted, however, notwithstanding the contrary is asserted, that in some cases simple rheumatic affec- tions and tertiary venereal pains have many symptoms in com- mon. It would be strange if they had not. Sometimes both diseases, rheumatism and tertiary syphilis, co-exist. Mr. Stan- ley makes the just and important distinction, that while a rheumatic affection occasions general inflammation of the shafts of bone, syphilitic inflammation in the periosteum, gives rise to circumscribed swelling of the bones. If the diagnosis relate to the character of nodes, we should never trust to our own skill or self-conceit, nor assume that we can distinguish a venereal affection of this description from all other local conditions, having a similar aspect, but which are non-specific in origin. The real nature of a node, inde- pendent of its history, and of any antecedent or concomitant symptoms, cannot be determined with certainty by any man. Treatment of Tertiary Pains. — When the syphilitic virus takes refuge in the deeper organs, as its last hiding-place, it is more difficult of control, through the instrumentality of mer- cury than when its manifestations are situated in the superfi- cial tissues. Indeed, in proportion as the venereal element penetrates the interior, and becomes les3 accessible, the med- * The reader is referred for further information on this subject, to valuable papers written by Dr. John Watson, " On some of the Remote Effects of Syphilis," which were published in the New York Journal of Medicine and Collateral Sciences, for 1843 and 1845. In these contributions Dr. W. has reported several cases of hemi- plegia and epilepsy arising from syphilitic affections of the cranial bones and their envelopes, and tubercular deposits in the brain. 408 GONORRHOEA AND SYPHILIS. icine in question seems to be shorn of its ability to do good ; whereas the therapeutic action of the iodide of potassium fol- lows the opposite rule; that is, its curative energy is most remarkable in those very accidents, over which mercurial pro- parations exert no beneficial influence. Hence for tertiary pains, and all other morbid phenomena that follow m their train,'the constitutional management must consist in the em- ployment of the iodide as the principal remedy. But, not- withstanding the frequent announcement of these facts, there are to be found in the profession a few practitioners, whose faith in the power of mercury to banish tertiary syphilis from the system wanes not, and they still prescribe it, where the iodide would be vastly more appropriate and efficacious. Experience has now abundantly taught us that tertiary pains are to be expelled, and their recurrence prevented, by pretty liberal doses of the potassium. At first, eight or ten grains, three times a day, in the compound syrup of sarsapa- rilla, will ordinarily be a suitable quantity. This, however, may be increased if the physician choose, in the course of four or five days, to twice the original amount. The topical use of the compound tincture of iodine will be attended with benefit. It should be painted on until the skin is made nearly black with the coating of iodine, and the pro- cess should be repeated every other day. The measures above suggested will usually bring the symp- toms speedily to a termination. The constitutional remedy should, nevertheless, be continued for five or six weeks, in small doses, even after the individual is rid of them. I advise that carbonate of ammonia enter into the prescription, so that the patient shall take twenty or thirty grains a day of this salt or even more. If these measures fail to bring the desired relief, there is but little hope of benefit from any mere medical treat- ment. Aconite internally, and also as a topical appliance, colchicum, and copious draughts of the sarsaparilla decoction, can be tried ; but the results will, in all probability, be unsatis- factory. In such cases, which, fortunately, are very rare, the seat of distress is in the interior of the bones, that is, if the bones of the extremities are implicated; and the operation of trephining becomes a matter for consideration. This surgical measure has been resorted to in repeated instances with entire DISEASES OF THE PERIOSTEUM AND BONES. 409 success. A few years since, Mr. Lee, of London, published a paper, in which he shows that long-continued pain in a bone may depend, among other causes, upon the deposition of solid material arising from the venereal poison. He recommends trephining for this affection. He operated on a woman, in whom the pain and swelling were confined to the neighbor- hood of the knee-joint. As the epiphysis of the bone ap- peared to be the original seat of the complaint, he trephined at that part. As soon as the outer shell of bone was per- forated, the cancellous structure was felt to give way under the pressure of the instrument, and some minute and separate flakes of white matter escaped with the blood. The patient recovered.* Mr. Langston Parker mentions the case of a woman, in which the medullary membrane became inflamed during the secondary stage of syphilis. The shaft of the left tibia was the part affected. This bone was trephined, and the medullary canal opened. The medullary membrane, turbid with black blood, which ran from it in a stream, protruded through the opening; the perforation was filled with a piece of soft lint dipped in oil. The patient was soon relieved of a most agonizing distress. The opening closed with new bone. In about three months, Mr. Parker removed with the trephine a second piece of bone, which was carious, and again pene- trated the medullary canal. No constitutional disturbance followed either operation. The woman recovered. Treatment of Venereal Nodes.—Patients who are suffering from syphilitic periosteal nodes usually manifest progressive failure of the general health. Under these circumstances, a course of treatment should be adopted, that will tend to recruit the vital powers. The utility of mercury was once believed to surpass that of all other drugs, in the various stages of periostitis; but of late years, the attention of medical men has been favorably attracted towards the iodide of potassium, and now the voice of the profession is, with here and there an exception, in favor of this article, as the most reliable agent we can employ, with a view not only of subduing tertiary pains, but also for the more important pur- * London Journal of Medicine, October, 1852. Also Vidal. 410 GONORRHOEA AND SYPHILIS. pose of causing the absorption of the morbid deposit, and thus greatly to diminish the chances of active inflammation and its direst ulterior consequences, exfoliation of the sub- jacent bone. All these indications, as regards the local dis- ease, can be accomplished, and no permanent traces of its visi- tation remain, and in the mean time the constitutional state of the individual will be improved by the same measures. Per- sons, who have long been troubled with periostitis, become exceedingly pale and chlorotic, a circumstance indicative of serious impairment of the composition of the blood. The most important deterioration consists in the diminution of the red corpuscles. The process of reduction in the relative proportion of globules, commences early in the venereal history of the patient, and continues during the progress of his malady, until, at length, it terminates in the exsanguine condition alluded to. These facts furnish the practitioner with an important principle in a therapeutic sense. They make known to him the reason why the preparations of iron are so beneficial, and so eminently entitled to confidence in chronic venereal disorders. For the purpose, therefore, of restoring the equilibrium of the elemental constituents of the vital fluid, and of enabling the system more speedily to regain its wonted tone, the class of remedies now referred to may be advantageously united with the iodide of potassium. Of all ferruginous compounds, the potassio-tartrate is the most valuable. It exerts a prompt influence in enriching the im- poverished sanguineous fluid, and restores it nearly to its healthy physiological standard; it works in perfect harmony with the potassium, and in most cases, which fail to derive the anticipated benefit from the latter substance, the tartrate can be brought into service as an important tributary. In case of recurrence of ancient periosteal affections, — and this is not very uncommon, — the iodide is again to be pre- scribed, until the symptoms once more yield. A full, generous diet, pure air, and frequent bathing, will likewise essentially inure to the benefit of the patient. While it is a well-established fact, that the potassium exerts almost a specific influence on the hard periosteal nodes, it is equally certain that when suppuration has commenced, this salt possesses little or no virtue, so far as relates to the local DISEASES OF THE PERIOSTEUM AND BONES. 411 disease. If there be a marked syphilitic cachexia, with en- feebled nutrition, emaciation, and depreciation of the whole organism, and the surgeon see fit to continue its use in small doses as a general tonic, there is no objection to the treat- ment ; although in such a juncture the iron will be found more efficacious. Whether a solution of the potassium or the iron be ordered, it should be taken in a large quantity of the com- pound decoction of sarsaparilla. Mercury. — Notwithstanding our repugnance to the use of mercury in this complaint, and our confidence in the iodide of potassium, instances will present themselves, for the cure of which, the former medicine will be required as a small fractional part of the treatment. For instance, if there be a goodly share of constitutional vigor,' and if the antecedent symptoms have been treated entirely by what is termed the " simple method," the practitioner will do well to institute a short mercurial course, and especially will this plan be ju- dicious, if there be much local inflammation. But as soon as this has been subdued, the potassium, together with some chalybeate, should be substituted. LOCAL TREATMENT OF NODES. If much inflammation exist in the integument, a few leeches near the nodular tumefaction will be proper. Afterwards, blisters, and the compound tincture of iodine, repeated suffi- ciently often to keep the skin perfectly raw, will constitute the most suitable topical means we can put in force. Or, the denuded surface may be dressed with the Emplastrum ammo- niaci c. hydrargyro, or with the strong mercurial ointment. If, notwithstanding a judicious employment of the measures here recommended, the node continue to increase, and seem tending towards suppuration, or if that event have already taken place, the surgeon need not wholly despair of accom- plishing the absorption of the fluid, which is sometimes effected under very unpromising circumstances. However strongly he may be inclined to set free the purulent collection, he should delay the operation until all rational hope of absorption is abandoned. The opening of a node is very liable to be 412 GONORRHOEA AND SYPHILIS. followed by most unpleasant consequences. Should the prac- titioner decide to puncture the abscess, as a last resource, a very fine trocar, rather than a lancet, should be the instru- ment ; and every precaution should be observed to prevent the entrance of air into the wound. The danger of caries and exfoliation of the subjacent bone, will thus be essentially lessened. A case now and then transpires, in which the morbid growth has been of long duration, and after undergoing a certain degree of diminution, remains nearly stationary, is of bony hardness, and is attended with no pain or other inconvenience. It is an instance of real osseous deposit — an exostosis, which will be uninfluenced by any medicinal agents. It is the result of the previous inflammatory action in the bone and perios- teum, and unless it should interfere with the normal functions of the related organs, it may be allowed to remain on the part as a mere excrescence and harmless deformity. In whatever portion of the osseous system exfoliation, caries, or necrosis takes place, under the influence of the syphilitic virus, the surgical and medical treatment is to be the same as under circumstances wholly independent of such a cause; and any suggestions from me, relative to the man- agement of these conditions, seem uncalled for. CHAPTER XXXIX. INFANTILE SYPHILIS. NOT ALWAYS SECONDARY — PROCREATIVE ELEMENT THE MEDIUM OF CONTAM- INATING THE FCETUS — BLIGHT OF OVUM AND ABORTION — THE CIRCULATION THE MOST COMMON MODE OF INFECTING THE FCETUS--INFECTION RARELY COMMUNICATED TO THE CHILD BY THE PARTURIENT MOTHER--THE MILK OF A SYPHILITIC NURSE POISONOUS--AN INFANT BORN WTTH SYPHILIS CAN- NOT INFECT ITS MOTHER, BUT MAY A STRANGE WET NURSE, ETC. The transmission of the syphilitic materies morbi from pa- rent to child, has long since ceased to be a subject of doubt. But it does not follow that the offspring of venereal parents, will, as an absolute matter of course, exhibit specific symp- toms during the infantile period of its existence. The devel- opment of such phenomena may be postponed for several years, even until the child reaches adult age. Such cases are known as hereditary syphilis. In some rare instances, the taint never shows itself. Immunity, however, is but the ex- ception to the rule. In April, 1855, a young woman, whom I was attending for constitutional syphilis, gave birth to a plump, healthy child, which is now more than four years old, and has thus far been free from all specific affections. During gestation, the mother suffered greatly from general debility, and was sadly afflicted with tubercles, pustules, and cutaneous ulcers. The primary disease in this woman wTas derived from the father of the child, and happened as early as 1850. Both parents had secondary symptoms ; the mother for more than four years, when ter- tiary lesions were also developed. For a short time she nursed her infant; but the natural fountains failing to yield the needful supply, it was placed in charge of a healthy wet- nurse. What destiny awaits this child in regard to the syph- ilitic taint, time must show; but that the offspring of such parentage should have remained so long exempt from its man- ifestations, is not a little extraordinary. In infantile syphilis the symptoms belong almost exclusively 35* 413 414 GONORRHOEA AND SYPHILIS. to the secondary group. The tertiary affections, involving the bones and their immediate investments, are very rarely met with. A few years since, Dr. Van Buren of New York had a case of this sort; and M. Bertin has given an instance that occurred at la MaternitS nearly half a century ago, and in a child thirty-five days old. There was periostitis on the superior and posterior surface of the ulna; tubercular pustules sprang up on various parts of the surface; and a^ tumor, as large as a pigeon's egg, formed over the left great trochanter. Small doses of corrosive sublimate were administered, and in three or four months all the symptoms disappeared. The bones of the nose in the new-born infant are occasion- ally destroyed by the disease; and a falling in of the organ takes place, which imparts to the features a most hideous de- formity ; and Dr. West records the case of an infant of a few months old, whose bony palate was destroyed. If the father have at any period been afflicted with primary disorder, but is free from consecutive lesion when the ovum is impregnated, the product of such impregnation may, never- theless, be tainted with constitutional syphilis. Here, the pro- creative element is the medium of transmission. Results of this description are extremely rare; but the bare fact of their occurrence is established beyond all possibility of doubt. Within a twelvemonth I have met with one example perfectly well authenticated. The child began to show evidence of the venereal taint when three weeks old. But its true condition was not understood by the parents, and no apprehension for its safety was entertained until the surface of the body and limbs, and a portion of its face and head, were thickly covered with scaly blotches of undoubted specific eruption. The father, a well-educated legal gentleman, took alarm, and made known to me his history, stating that several years before mar- riage, he contracted chancre, but never had constitutional symptoms. I saw the child but once. It was a living mass of corruption, and died before it reached its tenth week. The mother escaped contamination and had no suspicion of the real malady that destroyed her first-born child. She did not nurse it. Where one instance occurs like that of the child above men- tioned, there are hundreds, probably thousands, where no taint infantile syphilis. 415 is communicated by the spermatic secretion of the father, who, at a former period, may have had chancre, but in whom no constitutional complaint exists at the time the ovum is impreg- nated. The explanation of these facts must, in the present state of our knowledge, be purely hypothetical. In the in- stance I have adduced, the father, as he stated to me, was subjected to the simple method of treatment for his chancre. Had mercury constituted the chief remedy, would the child have escaped the infection ? Whatever may be the true an- swer to this inquiry, I deemed it expedient to put this father upon a moderate mercurial course, combined with diapho- retics, the use of which was prolonged for several months, with a view to eliminate the latent poison, and thus prevent its transmission, in the event of any future pregnancies through his instrumentality. The result of this treatment has not yet transpired. My confidence in it is not very great. The blight of the ovum and abortion are often produced by the presence of the syphilitic virus derived from the vitiated spermatozoa of the father, who, as well as the mother, may be in good health at the time of conception. By some writers it has been supposed that in these cases, the mother must be in- fected first, and the foetus afterwards ; but facts are every now and then brought to light disproving this theory, and establish- ing exactly its opposite, namely: that the mother, who escapes the infection at the time of copulation with an individual labor- ing under the venereal diathesis, may become infected from the foetus, the germ of which has been poisoned by the semen of this same individual. This proposition may be considered as established by indubitable facts which have been announced by the most reliable observers. I must here cite an instance related by Mr. Langston Parker in a recent lecture at Queen's College, London. A man married a healthy lady, having had no symptoms of syphilis of any kind for a year previous to his marriage. Shortly after marriage, his wife became pregnant, and the husband again suffered from copper colored blotches on the skin ; and he had ulcers in the throat, and lost his hair and eyebrows. The wife was prematurely delivered, in the fifth month of her pregnancy, of a dead child. She had about this time, copper-colored blotches like her husband, a sore throat, and lost her hair and eyebrows. In this case, and I dwell espec- 41G GONORRHOEA AND SYPHILIS. ially on the fact, says Mr. Parker, no sexual mischief existed. The wife was carefully examined ; she had never had a vagi- nal discharge of any kind ; the vagina, and the mouth and neck of the uterus appeared totally free from disease.* In considering the facts connected with the etiology of in- fantile syphilis, there is no difficulty in comprehending the influence of a syphilitic mother in transmitting the same mal- ady to the new being that germinates in her womb. The mystery is, rather, how the bud or branch that springs from such a trunk, can possibly escape. During the intra-uterine existence of the child, it derives its pabulum, its life-blood, from the same vivifying current that supplies the maternal organism, and it would be strange indeed, if, during this imprisonment, and this condition of utter dependence, it did not imbibe into its tissues the same morbid element that preys upon the mother. Probably the circulation constitutes the most common me- dium or channel, through which the venereal poison is con- veyed to the foetus in utero, although Hunter entertained the hypothesis that the blood could not infect, and, therefore, he could not comprehend how the foetus was contaminated. The infection can be communicated during parturition by the infant passing through the vagina affected with primary ve- nereal ulcers. Inoculation, in this way, however, is probably very infrequent. The smegma or sebaceous matter that covers the whole surface of the child, operates as an admirable safe- guard. Vidal questions whether primary chancre has been observed in the new-born infant, produced by disease in the genital passages of the parturient mother. There is also reason to believe that the milk of a syphilitic nurse is sometimes the medium of infecting the nursling, whether the breast is the seat of any local disease or not! This opinion is entertained by Mr. Whitehead, Mr. Wilson, and other writers of note ; but is denied by other high authori- ties. I imagine that no practitioner would, if called upon for advice, recommend a suckling child to the custody of a syph- ilitic wet nurse, knowing her to be such. Such counsel, if given by a physician in this country, would be suicidal to the professional reputation and standing of its author, and that * Lancet, May 29, 1858. INFANTILE SYPHILIS. 417 justly. He might as well countenance the deadly administra- tion of arsenic dissolved in the contents of the milk-bottle, as to allow a child to draw poison from the human breast. An infant, having secondary symptoms at birth, cannot infect its mother's breasts, even if its mouth be ulcerated, although such a child can, and often does, inoculate a strange wet nurse. The late Mr. Colles, of Dublin, was the first to discover and furnish to the profession this curious fact. His statement has been corroborated by others who have had ample oppor- tunities for observation. Mr. Hutchinson, surgeon to the Metropolitan Free Hospital, London, gives full countenance to the views of Mr. Colles, and suggests, in explanation, that in such cases, the mother of the diseased child has already re- ceived from it, whilst in utero, all the contagion it is capable of conveying. Hence her exemption or immunity. Prognosis. — If the child be seen early, and can be placed under favorable hygienic and remedial influences, the prognosis in many cases is quite favorable. It is a fact, however, in a majority of instances, where the disease is congenital, that is, where the infant comes into the world with the syphilitic leaven pervading its organization, that it is endowed with a low vitality, and that its existence is very seriously com- promised. Although for a few days or a few weeks, all may seem fair and promising, death will very probably overtake the poor victim before it arrives at the period of dentition. The most fatal epoch is before the child reaches the third month of extra-uterine life. If contamination take place after birth, the case is one of acquired syphilis, in distinction from congenital or hereditary disease, and the prognosis is more favorable than it can be, where the taint is coeval with conception, or with any portion of foetal existence. The symptoms are usually of a mild type, and yield to good nursing, cleanliness, pure air, and gentle medicinal treatment. If inoculation with chancrous matter have taken place, which, as previously stated, is an exceed- ingly rare occurrence, the resulting sore is more apt to assume a phagedaenic character, than in the adult. Symptoms. — Infants born with the venereal taint within 418 GONORRHOEA AND SYPHILIS. them, exhibit, for the most part, great uniformity of symp- toms; and yet there is not, in every instance, an entire assemblage of all the morbid phenomena, which the virus is known to engender. In some cases, where the constitutional infection is contracted during embryonic life, the manifestation of all specific accidents or lesions is delayed for several months; the infant, meantime, being to all appearance in per- fect health, until some incidental circumstance, such as denti- tion or the process of weaning, seems to operate as an imme- diate exciting cause in bringing to light the latent diathesis. Generally, however, it may be remarked, that the effects of the poison are well pronounced at an earlier period.* If you look at a child three or four weeks old, that has the virus within it as a transmitted inheritance, the first thought that suggests itself, is, that you have before you a miniature em- blem of old age. The integument of the face and of the whole frame is wrinkled in consequence of defective nu- trition ; it hangs in little folds about the jaws, neck, and different parts of the limbs, and is of a dirty yellow tint. This peculiar color of the skin, Trousseau considers of great value in forming a diagnosis. He attaches more importance to it than to the copper color of eruptions. Within the past ten years I have had opportunity to examine great numbers of foundlings and other young infants, in whom the venereal impregnation manifested itself by the presence of this unique, cutaneous pigment, as one of the earliest, most constant and significant abnormal conditions visible. It is frequently pres- ent before any actual eruption appears upon the external sur- face, and before the mucous membranes exhibit any marked signs of specific disease. Remarkable and characteristic blotches, having the well-defined, coppery hue, are especially frequent about the buttocks, thighs, genitals, legs and ab- domen. The integument of the hands and feet presents an erythe- matous congestion, with numerous traces of exfoliation of the cuticle; and fissures of various depth, and ulcerations, mostly superficial, are formed in the natural flexures of the fingers * The data, obtained by Diday from various sources, show that out of one hundred and fifty-eight cases, eighty-six presented symptoms before the first month, forty-five before the second month, and fifteen before the third month. I.GI, Syphilitic THButteri-i l.itk3i~3W:VlSi Boston INFANTILE SYPHILIS. 419 and toes, at the roots of the nails and elsewhere on these parts. A similar appearance of the skin will generally be noticed on examination of the nates, the perineal and anal regions, the scrotum, and labia. The surface often has a mottled aspect, not unlike that of rubeola. It is, however, of a darker hue than that of ordinary measles; it comes at first in small circular discs on the fore- head and cheeks, or about the chin, or below the ears, and resembles mere flea-bites in appearance. In four or five days, nearly the whole of the face, the neck, the chest, and abdomen, will be occupied by them. These blotches of eruption are quite persistent, and are frequently accompanied by a general anasarcous state, which imparts to the skin a smooth polished aspect. This morbid condition has been called rubeola syph- ilitica. Syphilitic maculce frequently arise upon various districts. They are of different dimensions and assume an oval or round figure, and the well-known coppery color. They subside par- tially under the pressure of the finger. In some cases, a slight desquamation, as in chloasma, is perceptible in con- nection with these yellow stains, and in others not. [Plate VII.] If the morbid patches become decidedly squamous, it will be found on examination, that this condition is preceded by a crop of minute papules, which spring up on the inflamed spots/ and pultaceous scales are afterwards evolved on the apices of the papules. The portions of skin thus implicated, usually increase in size by new accessions of papules appearing on their borders, which are elevated above the adjacent surface. They assume and maintain a pretty uniform orbicular figure. [Plate VIII.] In some instances, the eruption is confined to the hands and feet, in the form of well-defined, copper-colored squamae while all the other portions of the integument are free from blemish. Sometimes the eruption manifests a marked pustulo-papular tendency. The amount of exudation, however, is small, and produces irregular, thin, dark-colored incrustations, which are very adherent to the subjacent derma. Superficial sores often break out also about the knees, the ankles, shoulders, and other parts, that are exposed to pressure or friction. Fissures 420 GONORRHOEA AND SYPHILIS. are likewise very generally seen at the angles of the mouth in such children, and a sort of psoriasis of the lips, which are dry and parched; and the little sufferer seems to keep the mouth compressed instinctively, as if for the purpose of avoid- ing constant distress in the parts. Isolated mucous patches are often observed in the same localities as in the adult; so also the lining membrane of the mouth, the throat, and nasal passages, participates in the specific lesions ordinarily entailed upon older persons. In certain cases, the morbid affections of the mucous mem- branes exist some little time before any abnormal condition of the cutaneous structure is noticed; in others, the mucous tissue apparently receives nearly the whole force of the dis- ease, while the skin remains intact, or nearly so. The con- gestion and inflammation of the pituitary membrane always interferes with respiration, especially when the child is at the breast. The peculiar breathing, on these occasions, attracts the notice of the mother or nurse, who reports that the child has " the snuffles," — an expression familiarly known and very suggestive to the medical attendant. As the morbid action progresses, the breathing becomes more laborious and ob- structed, and the patient has no little difficulty in swallowing its nourishment. It chokes and struggles, and fitfully quits the nipple for the moment. The disease penetrates down- wards ; the larynx soon becomes implicated, and the voice has a singular, but characteristic, stridulous tone, when the child attempts to cry. Sometimes the cry is hardly audible, or if heard, amounts to a mere hoarse,squeaking sound, that is scarcely human. There is a discharge from the nose of an offensive, sanio- purulont secretion, intermingled with mucus. This irritates the integument, and concretes into scabs about the nasal aper- tures, thus materially increasing the discomfort of the child. The mouth is dotted over with white aphthae and superficial ulcerations; and if nothing be done by way of treatment, the whole lining-membrane becomes involved, and secretes a thick, acrid, heterogeneous fluid, which has been known to occasion excoriations, or still more serious disease on the nipples of the wet-nurse. After the morbid processes have existed in the mouth for a short period, a relaxed state of the bowels is apt PI Vlll. 3lm-:■':..: >. iiS,.r'/-.\Jh'. Psoriasis Drbiciilaris SypMitic. JKUvTtoi-iii Midi INFANTILE SYPHILIS. 421 to supervene. This, of course, augments the general disturb- ance of the child's constitution, and it soon fails to take the requisite nourishment, sinks rapidly into a pitiable condition, and dies greatly emaciated. Such are the symptoms, and such is the result, where the malady is allowed to pursue its own course, as is often the case among the lower ranks of society. Some children, that come into the world imbued with the syphilitic poison, perish before any specific symptoms show themselves on the skin or mucous membranes. They have been badly nourished in utero, are feeble, squalid, and wasted in flesh to the last degree. They take the breast with indif- ference, or perhaps scarcely at all; they survive but a few hours or days, and then die of starvation, and without exhib- iting any evidence of suffering. In some instances, the syphilitic infant will remain quite thrifty, until it arrives at the age of eighteen or twenty months, when a specific eruption will break out here and there upon the body and limbs. Where the appearance of the cutaneous affection is deferred until the period here mentioned, it is likely to come in the shape of well-defined tubercles or papules; whereas, in the child of only a few weeks, the abnormal con- dition of the surface usually presents a squamous type only. The tubercular or papular masses are most commonly abundant about the folds of the neck, the inguinal region, the labia, the scrotum, perinaeum, and anus. Specimens of the true mucous tubercle, occupying the same localities as in the adult, are occasionally met with in these young subjects. The external eruption is accompanied with extensive lesions within the mouth. If the child be so fortunate as to be well fed, its gen- eral health will frequently continue good for three or four months after the advent of the phenomena above described, even if no treatment be instituted. Diagnosis. — By studying the specific accidents, the physi- cian will soon be convinced that the child has upon it symp- toms and appearances not belonging to any non-venereal mal- ady. The child may be born at the normal period of gestation. It may, possibly, be plump and hearty, and no signs of dis- 36 422 GONORRHOEA AND SYPHILIS. ease be manifest for several weeks after it comes into the world ; when, suddenly, it will furnish indubitable proof that it is the offspring of syphilitic parents. The salient points, which, for the most part, present themselves for examination and study, have already sufficiently engaged our attention. Infants a few weeks or months old, are subject to eczema on the face, the scalp, and extremities. But however severe this troublesome affection may be, it is very seldom indeed that the general health of such young children is impaired. They have restless nights, because of the ceaseless pruritus that characterizes the affection, but they feed and thrive as well as if no cutaneous eruption were upon them ; nor have they any corresponding abnormal state of the buccal and nasal mucous membrane. They can cry with a clear and strong voice, and are generally extremely fractious ; whereas syphilitic infants are usually just the reverse, and to a remarkable degree, for the rea- son that they do not suffer from cutaneous irritation, however extensively the skin may be covered with specific eruption. Strophulus confertus is quite a common eruption among in- fants during early dentition. It appears upon the cheeks, upon the dorsal aspect of the extremities and trunk. Although the elementary form of the rash is a papule, the general ap- pearance of the skin and of the patient has nothing in com- mon with the features observed in a syphilitic papular erup- tion at this age. Besides, strophulus, like simple eczema, oc- casions a good deal of itching, and prevents the quiet sleep of the child, which, however, usually enjoys high health, and the pimples disappear in a few months as well without medical as- sistance as with it. It has been sufficiently shown that a venereal complaint de- veloped upon the skin of an infant is almost without excep- tion, associated with disease within the mouth, and with con- stitutional derangement of a very grave character. Let this important fact always be fresh in the mind in all cases that present themselves for our decision as to whether they are syphilitic or otherwise, and we shall rarely misjudge the nature of the disease. Another important general fact or circumstance, due to the venereal poison, when pervading the foetal economy, is the de- fective performance of the function of nutrition; and it is to INFANTILE SYPHILIS. 423 this imperfect developmental action continually operating upon the embryonic organization, that we are to attribute the withered, senile condition of the majority of children born under the evil star of syphilis. Mr. Hutchinson is of opinion that in those instances, where the infant is born apparently well, but showing signs of syphilis soon after birth, the taint is derived solely from the father. The mother, being free from disease, furnishes a supply of healthy nutriment to the foetus, which lives and thrives, having no need for the exertion of its own organs of assimilation. But after birth, it loses this privilege ; and, with a constitution enfeebled by its taint, is compelled to digest its food, and aerate and elaborate its blood for itself; hence its speedy exhibition of the hitherto latent disease. The squamous form of eruption is one of the most frequent and decisive external manifestations of the specific virus, that are observed in the young child; whereas, squamous affec- tions of a non-specific origin, are rarely ever met with in the infant. If, therefore, circular patches of psoriasis are seen on a child within a few months from its birth, there is substantial ground for suspicion that the complaint is venereal. There is a peculiarity in the anatomical character of the squamae. They are thicker, and in many places, as on the head, the face, the buttocks, and about the roots of the nails, are more like thin, laminated crusts than like the dry, white, furfuraceous, branny scales of simple psoriasis or lepra. Other lesions pointing to the same morbific source, will also be present. Nevertheless, if it be possible for the physician to obtain a truthful medical history of the parents, he should bring that to his aid before determining upon the case. All the circumstances relating to any previous illness of the father or mother, whether before or after marriage, should be ascertained and analyzed. They will, in all probability, constitute very essential links in the pathological chain that connects the parental malady with that of the offspring, as cause and effect. Notwithstanding the utmost diligence to gather the ele- ments, on which a just diagnosis can be established, a case will sometimes present itself, that will • greatly embarrass the shrewdest practitioner. The mother, for instance, nfay never have had any venereal trouble. The husband may be able to say 424 GONORRHOEA AND SYPHILIS. the same for himself; or he may have had the primary disor- der ten or fifteen years antecedent to the birth of the child, and may never have had constitutional symptoms. Or, instead of the husband, an alien may unlawfully have stepped in and contributed to the conception of the child. Other circumstances relating to the parties, and calculated to involve the question of diagnosis in obscurity, are liable to transpire; and the medical man cannot too strongly fortify himself against the many stratagems and other sources of er- ror that may beset his path, when he is called upon to give his opinion either in private, or in the halls of justice. Treatment.—The administration of mercury directly to the infant constitutes the most efficacious treatment for the removal of all venereal symptoms, which it may exhibit. The idea of making the mother or the wet-nurse the medium, through which to reach the manifestations inherent in the child, has become obsolete, and is justly discountenanced everywhere. It matters but little whether the mineral be conveyed into the child's system through the cutaneous surface or through the stomach; whether a powder, a liquid, or an ointment be used; the ultimate effect on the constitution and on the mal- ady will be substantially the same. I have tried all these methods with equally favorable results. Either plan and either preparation, as may be most convenient, may be prescribed. It is well known that children are rarely affected with that factitious disease, salivation, so readily induced in the adult. I have never known a child of four or six months to be dis- turbed by ptyalism, as the result of mercurial action on the system. The remarkable power of this class of patients to tolerate the presence of mercury, without suffering from its physiological influence, as usually displayed in the adult, has been differently explained. By some writers, the immunity of the young infant has been attributed to the fact that in the latter, mercury exerts its force on the skin and intestinal canal, and avoids, as it were, the salivary glands. Others consider that there is an imperfect development of the organs as re- gards their function in the infant; and I confess that I am inclined to accept this theory. So long as the mother's milk INFANTILE SYPHILIS. 425 constitutes the nourishment of the infant, the secretion from its salivary glands is not needed. An analogous fact no less curious and interesting, and which I cannot forbear to men- tion in this connection is, that the function of the maternal mammary glands is postponed until the time and occasion ar- rive when this function can be turned to useful account. The lachrymal glands furnish still another example of tardy func- tional activity or development. The infant will cry right heartily from the moment of its birth, but sheds no tears until it is several months old. The use of the strong mercurial ointment has been in vogue for more than half a century for the cure of infantile syphilis, and it is the form of medication that has been adopted by a large portion of medical practitioners up to the present time. Ten or fifteen grains of the ointment should be rubbed upon the feet or about the ankles or knees, morning and night, until the symptoms begin to yield. It may then be applied with less freedom. This is a mild and safe way of introducing the mineral into the system. It is no small recommendation to state that inunction is preferred by. Sir Benjamin C. Brodie to any other mode of treatment. His method is this: A drachm of the ointment is to be spread on one end of a flannel roller, which is to be applied round the knee for a period of twenty- four or forty-eight hours. If the application create too much irritation before the expiration of either of these periods, it must be removed for a day or two, and then be resumed. Or, it may be put first on one knee, and then on the other. Mr. Brodie is opposed to any other mode of administering mercury to the infant. The liquor of Van Swieten, in the dose of fifteen drops, which is equivalent to one sixty-sixth of a grain of deuto- chloruret of mercury, is prescribed by Trousseau for infantile syphilitic patients. A solution of the bichloride of mercury can be given, to the amount of one sixty-fourth of a grainier diem (one grain to eight ounces of water) and be continued for ten or twelve weeks, with intermissions of four or five days every two or three weeks. If relapse take place, the use of the iodide of potassium will be indicated, to the amount of two or three grains each day. 426 GONORRHOEA AND SYPHILIS. The hydrargyrum cum cretd is a suitable preparation also. It should be given in simple syrup. The dose of the powder is from half to a whole grain daily. It must be contin- ued for five or six weeks after the symptoms have disap- peared. Should it act too freely on the bowels, the child will need a few drops of the camphorated tincture of opium or a grain or two of Dover's powder at night. If any ulcers exist on the surface, they will do well under a dressing consisting of equal parts of simple ointment and the nitric oxide of mercury ointment. Whatever mercurial preparation be selected, its effect on the child should be carefully watched; and the moment any constitutional disturbance is displayed, the treatment with mercury should be suspended, and the cautious use of the iodide of potassium be substituted, for two or three weeks; after which the mercurial should again be administered. Country air and good nourishment will materially aid in the restoration and welfare of the child, which should be brought up by hand. Syphilis and Pregnancy. — The method of treatment to be adopted for a female, whether more or less advanced in pregnancy, requires no modification, whatever, of the reme- dial course that would be appropriate under other circum- stances. This proposition or statement is fully sustained by the experience of the best and most reliable observers, with scarcely a dissenting voice. The opinion was formerly ex- tensively diffused among the members of the profession, that the administration of mercurials was injurious to women dur- ing utero-gestation ; and also that the class of medicines here referred to, had a tendency to cause abortus or the death of the foetus. Now, however, such prejudices exist only to a very limited extent. They have been replaced by views of a directly opposite character. The present belief is, that in- stead of producing an arrest of foetal development, and abortion, the use of mercury is calculated to prevent these evil consequences. APPENDIX. The following interesting case of recent occurrence, was kindly fur- nished me by Dr. S. L. Abbot, Physician to Out-patients of the Massa- chusetts General Hospital, too late for insertion in the body of this work. SECONDARY SYPHILIS COMMUNICATED TO AN INFANT BY AN ATTENDANT. April 25, 1859. — A little girl, one year old, was brought to me by her mother, presenting a well-marked syphilitic affection. There were numerous superficial ulcerations on the inner surface of the cheeks and lips, a slight impetiginous eruption on the outer surface of the lower lip and chin, and an abundant growth of mucous papules on each side of the anus, passing forward to the genital organs, and in both groins. The growth in the latter site was very remarkable for its almost perfect symmetry of arrangement; consisting of five or six circular, distinct, nummulated patches, each somewhat larger than a half-dime, rising from one to two lines above the surrounding surface, and presenting in their arrangement and grouping almost complete identity in both groins. There could be no question as to the nature of the disorder. What was its history and probable origin ? This was given me by the mother, who had every thing in her appearance to recommend her as a worthy, respectable, reliable person, as follows: — Early in the previous October the child was taken with scarlatina, and required the care of an extra attendant at that time, the mother being too much occupied with her profession, that of a dressmaker, to allow her to take exclusive charge of it. Her immediate friends and acquaintances were unwilling to expose themselves to the contagion of the disease, and she accordingly availed herself of the services of a woman living in her neighborhood, with whom she had but a slight acquaintance, but who was recommended to her by her extreme fondness for children. She had, it is true, heard disparaging remarks about her, but as she was the wife of a man, whom she considered respectable, she had not given much heed to them. The woman was a faithful nurse, very fond of the child, and was in attendance upon it more or less constantly for three months. During this period the child continued to be suckled by its mother. The mother observed at the commencement of the nurse's attendance that 427 428 appendix. she had a very sore mouth, the corners of it being greatly disfigured and covered with crusts. Apprehensive that some disorder might be com- municated to her child, although not dreaming of the possibility of any syphilitic contagion, she questioned her about her mouth, and was told in reply that the trouble was only " canker," to which the doctor was apply- ing caustic every day. She did admit, however, that some months pre- viously she had had a complaint of a venereal character, of short dura- tion, which she had taken from her husband. She had been well of this, however, for months. The natural caution of the mother, notwithstand- ing, led her to check her frequent impulse to kiss the infant; but in 6pite of this she frequently observed her disobeying her injunction, and imprinting her poisonous caresses directly upon the mouth of the little one. Her care of the child ceased at the end of three months. A few weeks after this, probably about two months, the child was observed to have sore mouth, which was not considered of any special importance by the mother, who looked upon it as " canker," such as young children are subject to. This continued three or four weeks without benefit from the domestic remedies employed, when the mucous papules made their appearance. These had existed three weeks at the time the child was brought to me. It seemed at once probable that here was one of those rare cases of the transmission of secondary syphilis, and transmission in a very unusual way. The most thorough and searching inquiry failed to elicit any evidence which should criminate the parents. Four other children of the same parents are living and perfectly healthy and have never shown any symptoms like those recorded above. The father admitted that he had had gonorrhoea fifteen years since, some years before his marriage. He was previously un- known to me, but the frankness of his manner, and the extreme solicitude of both parents in behalf of their little one when they learned the real nature of her affection, had great weight with me in satisfying me that they could not, knowingly at least, have had any direct connection with the infliction of this grievous disorder upon it. In order to supply all the evidence possible, the mother submitted most willingly to examina- tion, and not a trace of disease, recent or old, could be found on the external organs of generation, or by specular exploration of the vagina and uterus. No evidence therefore existed to implicate the parents ; it was highly desirable, if possible, to obtain an examination of the woman from whom the evil was supposed to have sprung. Luckily she was within reach, and without hesitation presented herself to me for exami- nation, and, judging from her semi-indignant manner of address, for acquittal from all suspicion. She admitted at once the fact that had been previously stated, of a venereal complaint of short duration, of which she recovered some time before taking charge of the child. The com- appendix. 429 plaint, she said, was a slight " running " from the vagina, which lasted but a few days. She was treated by her husband (who, according to her account, pleaded guilty to imparting it to her), he having had some ex- perience formerly in compounding medicine in an apothecary's shop. The occurrence took place soon after their marriage, and the disease in the husband was said to be the remains of a disorder contracted before marriage, of which he had supposed himself cured. Her mouth was still sore, she having tried various physicians without relief, all of whom called her disorder " canker." The angles of the mouth were ulcerated and swollen, bearing evidence of the long duration and treatment of the disease; — there was a superficial ulcer, as large as the nail of the little finger, and covered with lymph, on the inner surface of the lower lip, which she ascribed to the pressure of the teeth; just within the angles of the mouth on the inner surface of both cheeks were similar ulcers, with turgid, indolent edges. I unhesitatingly assured her that she had syphilis in its secondary stage. The ulcers were identical in appearance with those so often seen accompanying syphilitic sore throat, and which are so apt to continue, now better, now worse, for a tedious period. Her mouth, she said, was in about the same condition at the present time as when she had charge of the child. There was no affection of the throat nor any indication of former disease there; neither did I see any trace of cutaneous disease. The child's mother, however, had in- formed me that she noticed a scurf on her hands at the time she was in her employ. On farther inquiry, I learned from the woman that she had miscarried three times within a year, each time before the comple- tion of the third month of pregnancy. After one of these abortions, the occurrence of which she attributed to weakness, she lost her hair, owing, as she thought, to the subsequent fever. I did not make any further ex- amination, as information which I had received of her history subsequent to the time when she had charge of the child made any facts which mi^ht have been thus obtained of no special value. This, then, is the whole history, and I am unable to resist the conviction that the child de- rived its disease from her attendant who was affected with it at the time, probably, in a secondary form. The difficulty of obtaining final, irrefrag able evidence in such a case is, of course, extremely great, almost amounting to an impossibility; but if circumstantial evidence can insure conviction, we have here, I think, a very strong case. It may be said, granting the fact that the woman had syphilis, how do you know she did not have chancre in the mouth, from which the dis- ease was communicated to the child ? It is extremely improbable that she had for two reasons : first, the assurance of the mother and the wo- man herself that the disorder in her mouth is in the same condition now as it has been since it first appeared, a statement made of course 430 APPENDIX. without any knowledge of its professional significance, and according with the well-known facts in similar cases; and second, there is n6 evi- dence that the child has had any different affection of the mouth from that existing when I first saw it, and which did not appear until some weeks after all intercourse with the woman had been broken off. Furthermore, it is noticeable that the disease in the child is not the usual hereditary form. In the great majority of cases, that appears as roseola or psoriasis, with ulcerations, etc., and almost always shows itself within the first few weeks after birth. To be sure there are exceptions to this, but they are of extreme rarity. It should be remarked that the left nipple and areola of the mother were inflamed and slightly excoriated at the time the child was brought to me, and had been so for some days; and the mother stated that she nursed the child almost wholly from this breast. There was no fissure or ulcer, only an inflamed and superficially excoriated appearance. The facts in the case, then, may be summed up as follows: — 1. A previously healthy child is taken in charge by a woman who at the time has ulcerated lips and mouth. 2. This woman admits the previous existence of a venereal complaint (as likely to have been a concealed chancre as any thing else from her account), from which she had some time before recovered. She ac- knowledges repeated abortions and alopecia, — common enough results of constitutional syphilis. She still has, at the time of examination, indolent ulcers of the lips and cheeks, such as are so often seen in secondary syphilis. 3. The statement of the mother that, in spite of her earnest remon- strances, the attendant frequently kissed the child's lips. 4. The occurrence after a few weeks' interval of superficial ulcers in the child's mouth, followed soon after by mucous papules, and inflamma- tion and excoriation of the mother's nipple. Such are the facts, and their value will be different with different minds. I am willing to admit that I believe the child to have contracted syphilis from the impure lips of her attendant, she being at the time af- fected with secondary ulcers of the mouth, the first manifestations of the disease in the child having the secondary form. It remains to say a few words of the treatment of the case. The mother was advised to wean the child for fear of the consequences to herself; and until that was accomplished, to wash the nipple with liquor sod* chlorinatae, after each application of the child to the breast, and to wash over the excoriated surface daily, with a solution of nitrate of sil- ,ver, four grains to the ounce of water. Two grains of the chlorate of potash were directed to be given to the child three times daily, the same solution of nitrate of silver to be applied once daily to the condylomata, APPENDIX. 431 and black wash to be kept constantly applied to them. The mother's nipple was well in five days, and at the end of two weeks the child was greatly improved. The change of diet had been any thing but prejudi- cial to it, and the mother expressed her astonishment at its rapid increase of flesh and strength. The papules had become very pale, and had subsided about to the level of the surrounding surface, and the mouth was nearly well. The treatment was directed to be continued until re- covery should be complete. INDEX. Abbot, Dr. S. L., secondary syphilis communicated to an infant by an at- tendant, ..... Abrasions, superficial, on the tongue, Accidents from iodide of potassium, " secondary, contagious, .... Acid, chromic, as an escharotic, " nitric, as an escharotic, .... " " in sloughing phagedaena, " " in sloughing ulcers, " " danger in applying it to the pharynx, Acid Nitrate of Mercury as an escharotic, . Alopecia,........ Ammonia, carbonate, in phagedenic chancre, « " with iodide of potassium, Anaesthesia, or deficient cutaneous sensibility, Arseniate of iron in herpes praeputialis, . « " and quinine in herpes praeputialis, Average time for the healing of indurated chancre, Babington, method of prescribing mercury, .... Balanitis,.......... " pseudo,......... " causes of,........ " treatment,........ Baldness,.......... Balsam of Copaiba, •....... « " eruption produced by, " " injection,...... u « first employed by Professor Chapman, Behrand, Mr., on potassio-tartrate of iron in primary syphilis, Bennett, of Edinburgh, a non-mercurialist, " on contagiousness of secondary syphilis, " cases reported by him, Benzoin, compound tincture in sloughing Bladder, irritable, .... « " treatment, Blennorrhagia,..... " causes of, " diagnosis, . . • " usual period of latency, " symptoms, " contagion, " treatment of in the male, ulcers, 427 357 323,357 282 154 184,235 235 362 362 184 351 237 325 268 89 89 208 202 59 60 61 62 351 24 12 29 24 234 197 281 281 363 95 97 1 2 12 14 14 16 19 433 434 INDEX. Blennorrhagia, cathartics in,........ 19,24 " hot fomentations,........ 20 " injections of nitrate of silver,..... 21 " " " fatal effects of, in, . . 23 " capsules of copaiba,....... 28 " cubebs,.......... 30 " various injections,....... 41 " treatment at Chelsea Hospital,...... 40 " in the female,........ 155 " " " diagnosis,.......157 " in young female children,...... 159 " situation of the complaint in the adult female, . . . 161 " varieties and symptoms,...... 161 " treatment,..........163 " " local,........ 164 " of the uterus,.........168 Blisters in gleet,........... 52 Blood in syphilis,...........191 " contagion from syphilitic,........ 277 Boek, Professor, on syphilization,........193 Bones and periosteum, diseases of, ...... 402 Boston Society for Medical Improvement, on contagiousness of secondary syphilis,............282 Bougie,............ 54 Bubo,.............243 " d'emble'e, ........... 243 " on same side as the chancre,........243 " from indurated chancre, rarely suppurates, ..... 244 " true syphilitic, usually indurated,.......244 denotes the system is poisoned, .... 244 " " treatment,.........248 Vidal's opinion,....... 248 patient should keep still,......248 " counter irritants,....... 249 Malapert's method of blistering, etc., . . . 249 " method at Paris Hospitals,..... 249 " Guy's Hospital,.....249 " compression objected to,..... 251 fatal results from,.....251 " indolent or chronic,......... 251 " sloughing,...........253 Buchu in blennorrhoea,....... . „4 Buckingham, Dr., anomalous cases,...... g Busk, Mr., on composition of gummy tubercles, .... 391 Calomel to mucous tubercles,....... 33g Camphor in painful erections,...... 45 Castration in spermatorrhoea,...... i2g Cazenave, on contagiousness of secondary syphilis, .... 282 Cerebral syphilitic affections,....... 404 Chancre, indurated,........ 177 2Q5 " microscopical examination of,...... 177 INDEX. 435 Chancre, Hunterian, rarely met with,.......177, 209 " " never forms on glans penis,.....180 " " rarely on os uteri,...... 226 " " abortive treatment,.......181 " " views of Dupuytren, ...... 182 " " Vidal,.......182 • " local applications,......184,218 " " constitutional treatment, ...... 188 " masked, or concealed,........180, 222 " " rarely met with,.......• 223 " " produces great mutilation, ..... 223 " " treatment,.........224 " " on os uteri, and vagina, . ... . . 223,225 " " treatment,.........225 " inflammatory,......... 227 " " how induced,.......227 " " treatment, ....... 228 <« " Mr Key, sarsaparilla and lime water, . . . 228 opium, 228 " phagedaenic,..........230 " " progresses rapidly,...... 231 " " seldom produces constitutional syphilis, . . 232 " " treatment, ....••• 232 Chancres in women,..........241 Chordee, .... ....... 46 " treatment, ... .... . 46 " " lupulin,......... 44 " " camphor,......... 4!* Circumcision,........... Cod liver oil, as a tonic,..........32° " chocolate, and jelly,..... • 32° Compression of testis,.......... Condylomata,..........• 336 Contagion of secondary syphilis,........282 Coote, Holmes, on secondary without primary symptoms, ... 282 Cubebs in gonorrhoea,.......... " eruptions*produced by,........ 12 Cullerier, of Paris, on bichloride of mercury,......211 Davis, Dr. C. A., treatment of blennorrhagia,..... 40 Deafness, syphilitic, case of,........ Diday, on contagiousness of secondary syphilis,.....282 Discussion at Boston Society for Medical Improvement, ... 282 Dura Mater, syphilitic tumors on,........405 " " iodide of potassium for,....... 406 Eczema praeputialis,.......... « " treatment of,....... 92 ■Ro-an. Dr., on the use of mercury,........200 194 Emunctory organs,...... ... 69 Epididymitis,.......... Erections, involuntary and painful, ...... 44 436 INDEX. Ergot in Spermatorrhoea, .... .....123 Erichsen, Professor, on simple and mercurial treatment, ... 198 Eruptions, papular,...........296 " " diagnosis,........ 297 " " treatment,.........30° " " squamous,........ 311 " " treatment,.........319 " " from iodide of potassium,..... 323 " " tubercular,........328 " " treatment,........ 331 " pustular,...........340 Excoriations,........... 100 Exostosis syphilitic, ..........412 Ferruginous remedies and iodide of potassium in the constitutional treat- ment of nodes,.......... 409 Fissures or rhagades on the tongue,........358 Fomentations in blennorrhagia,........ 20 Francis, Dr. J. "WP, on bichloride of mercury,......211 French Council of Health, statistics of different methods of treating syph- ilis,............. 197 Fricke of Hamburgh, a non-mercurialist,.......196 Fumigations,........... 302 Gamberlini, Dr., of Bologna, on iodide of sodium,.....327 Gargles,............ 366 Gleet, sometimes communicable,........ 18 " and matrimony,......... 17 " . . ........... 48 " microscopial appearances,........ 50 " treatment,........... 51 " blisters,........... 52 " injections,........... 53 " constitutional treatment,........ 56 Gonorrhoea, causes,........... 2 " diagnosis,.......... 12 " period of latency,......... 14 " treatment of, in the male,....... 19 " in the female,.........155 " diagnosis,.......... 157 situation, varieties and symptoms,.....161 " treatment,......... J63 Grassi, M., analyses of syphilitic blood,.......191 Gummy tubercles,.......... 385 diagnosis,.........386 " " cases,......... 387 " give rise to the " horse-shoe " or serpiginous ulcer, . 387 " " have been found in muscles,..... 389 " " " " in the heart,......390 " " " in tendons,..... 390 " " " in epididymis, testicle, liver, lungs, brain, 390 " " their composition,....... 391 INDEX. 437 Hancock, on buchu in gonorrhoea, ..... . 34 Hebra and Sigmund of Vienna, on mercurial inunction, . . . 203 Haemorrhage, urethral,.......... 46 Herpes praeputialis,.......... 83 treatment,......... 88 Hosack, Dr. David, on bichloride of mercury,..... 210 Hyoscyamus and camphor in spermatorrhoea,......125 Incubation of the venereal poison,....... 180 Infantile syphilis,...........413 Infrequency of indurated chancre,....... 177 Injections of nitrate of silver,......... 21 " objections to those of high power,..... 23 " fatal effects from,......... 23 " in blennorrhagia, ........ 41 " in gleet,........... 53 " in uterine blennorrhagia,....... 171 Intoxication, iodic,...........324 Iritis, syphilitic,........... 375 " diagnosis,...........377 " " treatment,......... 379 Iron, arseniate,........... 89 " citrate of and quinine,........ 208 " iodide of, . *...........332 " potassio-tartrate,.......... 207 " in phagedaenic ulcers,......233 Irritability of the bladder,......... 92 " " treatment,....... 93 Jackson, Dr. James, on lupulin,........ 122 Johnson, Dr. James, on sarsaparilla,.......216 Julep of ammonia for habitual drinkers,...... 347 Key, Mr., iodide of potassium in sloughing buboes,.....253 Labia majora, abscesses in,......... 168 Lawrence, Mr., of London, on syphilization,......194 Lee, Mr., of London, trephining in certain cases of chronic syphilitic ostitis, 409 Leucorrhoea as a cause of gonorrhoea,....... 5 Lichen, varieties,........... 297 " diagnosis,...........297 " passes into tubercle,......... 298 Locker, of Vienna, use of bichloride of mercury,.....212 London Lancet, on " " " "..... 212 Lupulin, in chordee and erections,........ 44 in spermatorrhoea,........ 121 Marsdcn, Dr., treatment of secondary eruptions at the Royal Free Hospi- tal, London,.......... 305 Massachusetts General Hospital, cases of venereal disease arising from in- fantile syphilis,.......... 278 Menstrual fluid exciting gonorrhoea,........ 3 Mercurial fumigations, . ........ 302 37* 438 INDEX. Mercurial inunction,........* 203 Mercury, . .......... 195 " should be taken on a full stomach,......202 " not useful in pustular syphilitic affections, .... 349 " " for sloughing or phagedaenic ulcers, .... 238 bichloride,.......... 210 " " one hundred years ago,......212 " " a favorite of Dupuytren,..... 213 McGrigor, Sir James, reports cases in British army cured without mer- cury, ............ 196 Methods of treating syphilis,.........195 Milton, Mr., blisters in gleet,........ 52 Mouth and throat, secondary lesions,.......355 Mucous tubercles,.......... 335 " " treatment,.........338 Nitrate of silver, injections in blennorrhagia,..... 21 " " as a caustic to chancres,......184 Nitric acid to sloughing ulcers, ... .... 362 Nodes,.............403 " intra-cranial,.......... 404 " diagnosis,...........407 " constitutional treatment,........ 409 " local treatment,..........411 Nose, syphilitic diseases of,......... 370 " " " treatment,........372 Nurses, inoculability by syphilitic infants, and vice versa, . . . 279 Ophthalmia, gonorrhoeal,......... 12. " etiology of,.......129 diagnosis,....... 133 treatment,........134 Neonatorum,...... 139 " treatment,.....140 Opium in irritability of the system,.......228,233 Orchitis,............. 69 " statistics by Sigmund,........ 71 " symptoms,........... 71 " treatment,.......... 73 " mercurial ointment,......... 74 " iodide potassium ointment,........ 74 " extract of belladonna,........ 75 " tincture hyoscyamus,......... 75 " syphilitic,........... 397 " belongs to no particular stage of syphilis, . . . 397 " diagnosis,......... 399 " pathological appearances,......399 " " treatment,......... 399 Ormerod, on iodide of potassium and mercury,.....326 Os tincae, chancres on, ........ 223 " infrequency of,........226 Ostoscopes, syphilitic,........ 402 diagnosis and treatment,...... 407 I INDEX. 439 Pains tertiary, iodide of potassium in,....... 408 " urethral,..........* 105 " treatment,......... 106 Papillomata,..........• . 153 " treatment,......... 153 Papular eruptions,...........296 " " diagnosis,........ 297 Paralysis from intra-cranial syphilitic nodes,......406 Paraphymosis,........... 66 " treatment,.......... 67 Peaslee, Professor E. R., on nitrate of silver as a caustic, ... 184 Penis, bony hardness of, ........ 46 Period of latency between primary and secondary symptoms, . . 256 " longest recorded,.....*.....257,259 " shortest, ".......... 259 Periosteum and bones, syphilitic,........402 Pharynx, sloughing ulcers,......... 359 " " " treatment,.......361 Phymosis............. 63 " treatment,............ 63 Potassa fusa, as an escharotic, ........ 184 Potassium bromide of, in spermatorrhoea,.......125 " chlorate of, as an injection,....... 166 " " in stomatitis,........219 " iodide of, in sloughing buboes,...... 253 " " no standard dose,........325 " " singular effects of,....... 323 " " in tertiary syphilis,......348, 387, 391, 408 " " useless in primary syphilis,...... 395 " " " early secondary syphilis,.....395 Potassio-tartrate of iron,......• 207,218 " " in phagedaena,.......233 Pregnancy and syphilis,......... 426 Prepuce, its uses,........... 59 Prostitutes, cause of their sterility,....... 168 "uncturing tunica vaginalis testis, and epididymis..... 77 Purpura co-existing with rupia,........ 343 Pustule plate,............336 Pustules syphilitic,.......... 340 " " treatment,....... . 346 Reeve, on intra-cranial affections,........405 Reid, " " "........ 405 Relapses in gonorrhoea,.......... 35 Rest, its importance in gonorrhoea,....... 27 Rheumatism, gonorrhoeal,..........143 " " diagnosis, ....... 145 " " treatment,........145 Rhus Glabrum in stomatitis,........ 220 Ricord, on caustic applications to chancres,......183 " on experiments without mercury,...... 198 Roseola syphilitica,...........292 440 INDEX. Roseola syphilitica, diagnosis,........ 294 " " treatment,......... 295 Royal Free Hospital, treatment of secondary eruptions, . . . 305 Rupia syphilitica,...... .... 343 " two varieties,........ 343 " " treatment,........ 348 " " iodide potassium,....... 348 " " tartrate of iron and potassa,......348 Salivation never necessary,.........201,211 " or stomatitis,..........219 " chlorate of potash in,........ 219 " muriatic acid in,.........220 " rhus glabrum in,......... 220 Salter, Dr. R. H., large doses of iodide potassium,.....326 Saponaria officinalis,......... 215 Sarcocele,.............69, 397 " treatment,..........73,399 Scrofula and syphilis,.......... 383 Secale cornutum in spermatorrhoea,........123 Secondary symptoms without primary,...... 270 Seminal fluid may communicate syphilis,.......277 Sigmund, on mercurial inunction,....... 203 Skey, Mr., his method of treating gonorrhoea and gleet, .... 43 Smith, Dr. J. L., on syphilis from a nursling to a nurse, . . . 281 Sodium, iodide of,.......... 327 Speculum uteri,........... 155 Spermatorrhoea,...........108 " causes,.......... HO pathological appearances,.......115 " treatment,......... 115 Syphilis,.............. 175 " time between exposure and symptoms,..... 181 " blood in,......... 191 " secondary,........ 255 " hereditary,......... . 413 " infantile,.......... 413 " prognosis,...........417 " symptoms,.......... 417 " diagnosis,...........421 " treatment,......... 424 Syphilodermata,......... 262 Wilson's nomenclature,...... 264 Willan's system,........265 " diagnosis,......... 265 color of skin,.........265 insensibility of skin,....... 268 cicatrices,..........269 Syphilization, artificial,......., |92 " disasters from, . . . . . . . 193 Swan Alley sore,......... 241 " not contagious,........242 INDEX. 441 Tendons, nodes or gummata in,........ 390 Tertiary pains,............4^7 " syphilis,........... 383 " " in young infants,........4i4 Testicle swelled,........... 69 " " compression,......... 78 " " " best time for,...... 79 " " " Ricord's opinion,..... 79 Teeth, artificial, sores from,......... 357 Tinct. Benzoin, comp. for sloughing ulcers,.....334, 335, 363 " iodine as an injection in vaginal blennorrhagia, ... 166 Todd, syphilitic diseases of dura mater,.......4°5 Tongue, affections of,.......... 356 " " " treatment,........358 " swelled, in stomatitis,........ 220 Transmission of infantile syphilis,........278 " " " Trousseau on,..... 279 Travers on Sarsaparilla,..........216 Trephining in certain cases of chronic ostitis,..... 409 Tubercula gummata,...........385 " " diagnosis,........ 386 " " cases, ......... 387 " " produce horse-shoe, or serpiginous ulcers, . . 387 " " are found in the heart, testicles, lungs, muscles, brain, etc.,...........390 " " treatment,........ 391 " " their composition,.......391 Tubercles lupoid, ... ....... 330 Tubercule muqueux,..........336 Tumors mucous,........... 335 " treatment,....... ... 338 " intra-cranial, syphilitic,........ 405 Tunica vaginalis, puncturing,......... 77 Turenne, M-, on artificial syphilization,...... 192 Tyrrell, Mr., scarifications in gonorrhoeal ophthalmia, .... 135 Ulcerations about the toes and the nails,.......-350 " on the tongue,......... 356 " sloughing in the mouth,........359 « « " " treatment,.....361,368 Ulcers, serpiginous,...........330,334 " phagedaenic,..........234>329 Urethral blennorrhagia in the female,.......172 u